By: Jolanta Karpinski
Stepping in to restore balance: cues for a coaching conversation
I have attended and provided lots of sessions on giving feedback; “How to give feedback” is one of the most, if not the most, common topics offered by faculty development programs. And, there’s lots of models out there: the classic feedback sandwich, the one-minute preceptor, R2C2, SPIKES…feel free to add your favorite to that list1,2. And, yet, in reviewing the resident assessments completed by my division members, I still perceive that we provide limited to no comments or comments of low value…like “read more”!
Feedback models help us develop an approach, a process, for a feedback session. But what if the supervisor’s challenge isn’t how to say it but rather identifying what to say ?
Competency based education (CBE) and workplace-based assessment ask us to be coaches3 – observing trainee performance and providing in-the-moment coaching that helps the trainee progress in their development; CBE wants us to use the clinical encounter as a learning moment. So as a supervisor, in that clinical encounter, how do I recognize the learning moment that will be meaningful for that resident with this case?
Lately, I have been thinking about that problem through the lens of the preceptor’s role in clinical supervision. We are asked to provide students and residents with appropriate autonomy so that they can work (and learn) in their zone of proximal development4 while simultaneously monitoring their actions so that patient safety and the quality of clinical care is maintained5. Using that balance of patient safety and learner autonomy has been helping me pinpoint the learning moment…and find the words to use in my coaching.
Have you ever felt that itch to take over a procedure the resident is performing… grab the scalpel or probing needle and ask them to step aside? Or, perhaps, as you’ve sat in on a discussion about a management plan or goals of care, you haven’t been able to stop yourself from butting in and rephrasing something the resident said so that it was better understood by the patient and family. Or maybe as you were listening to a case presentation, you felt the need to interject and ask for details the learner did not or could not provide.
Those are learning moments… inflections in the course of the clinical encounter where you as the supervisor felt that tilt in the balance of learner autonomy and patient safety and the need to “step in” to course correct. The events that led up to that moment were things the learner did well and should continue to do. At the moment that you felt the need to step in, you identified something that should be done differently, something that was missed, or perhaps even something that was incorrect and could harm the patient.
Recognizing that urge to intervene as the cue to a learning moment can help the supervisor identify what to focus on for the coaching session and can help them find the words to say. We can reinforce the aspects of the encounter that were well done, describe the specific moment that led to the urge to intervene and comment on what we observed at that time (or felt was missing). If we did intervene, we can talk about what was done that was different from what the learner was doing. And, we can apply any of the approaches and models that we have learned in faculty development sessions to provide that feedback.
Try it out!
- Pay attention to your “urge to intervene”
- Step in as needed for patient safety
- Use that moment as your focus for a coaching conversation
And sometimes, maybe they do need to “read more” – so they learn about the signs and symptoms of a presentation and can ask all the needed questions, or so they can broaden their differential, or so they can offer other treatment options. But by identifying the learning moment, our coaching can include that specific guidance that makes “read more about ….” a useful comment.
About the Author:
Jolanta Karpinski, MD, MMEd, FRCPC is head of the division of nephrology and a clinician educator at the University of Ottawa
References
- Orsini C, Rodrigues V, Tricio J, Rosel M. Common models and approaches for the clinical educator to plan effective feedback encounters. J Educ Eval Health Prof. 2022;19:35. doi: 10.3352/jeehp.2022.19.35. Epub 2022 Dec 19. PMID: 36537186; PMCID: PMC9842479.
- Natesan S, Jordan J, Sheng A, Carmelli G, Barbas B, King A, Gore K, Estes M, Gottlieb M. Feedback in Medical Education: An Evidence-based Guide to Best Practices from the Council of Residency Directors in Emergency Medicine. West J Emerg Med. 2023 May 5;24(3):479-494. doi: 10.5811/westjem.56544. PMID: 37278777; PMCID: PMC10284500.
- Norcini, J., & Burch, V. (2007). Workplace-based assessment as an educational tool: AMEE Guide No. 31. Medical Teacher, 29(9–10), 855–871. https://doi.org/10.1080/01421590701775453
- Eisner L, Wallin D, Vincent A. Education Theory Made Practical – Volume 2, Part 1: Zone of Proximal Development. Accessed January 28, 2025 at https://icenet.blog/2018/04/03/education-theory-made-practical-volume-2-part-1/
- Professional responsibilities in Medical Education. https://www.cpso.on.ca/Physicians/Policies-Guidance/Policies/ Accessed January 21, 2025.
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