Chair's Column: Optimizing Teaching Effectiveness and the Learner Experience – The Value of Feedback

Clinical teaching is, fundamentally, about forming strong, trusted relationships and communication between teacher and learner. These trusted relationships are particularly important in the stressful times we are in right now.

What we have done

Our department deeply values the contributions of our teachers and educators. Our faculty members contribute to fulfilling our education mandate, across all academic titles, (e.g., Clinician Scientist or Clinician Teacher). To support the enormous contribution our teachers and educators make to this mandate every day, we have put many processes in place to ensure that those interacting with learners:

• are fully equipped to do so,
• understand the expectations of them and,
• have opportunities for professional development and further enhancement of their teaching skills throughout their academic careers.

Demonstrated teaching effectiveness is critical to faculty members’ success at all major milestones in their academic careers. For this reason, all new faculty members are assigned a formal mentor and, during new faculty orientation, the policies that govern and resources available to support a physician's role as a supervisor of medical learners are shared and discussed. We review all faculty members’ teaching effectiveness 1.5 years into the initial probationary faculty appointment period, at Continuing Faculty Appointment Review (3-year review), and at consideration for academic promotion. Throughout a faculty member’s appointment, we continuously track teaching evaluations provided by learners. Evaluations are flagged when overall teaching scores are equal to or less than 3.75/5 (which represents the 10th percentile for DoM teaching scores) and when any one score is less than 3. Importantly, all low teaching scores are reviewed for associated comments, as these are critical to understanding the learner’s concern and may inform next steps.

We are proud that our faculty members are routinely recognized by learners to be committed, conscientious, expert, and supportive teachers who create a safe learning environment while upholding high standards of professionalism, collegiality, civility, and respect. However, in a minority of situations, concerns do arise that must be addressed in a manner that:

• is supportive of all parties,
• addresses power imbalances and fears of retaliation,
• is culturally sensitive and confidential, and,
• adheres to procedural fairness.

When this happens, we have a well-developed approach to investigating concerns in concert with the Temerty Faculty of Medicine (TFoM) and the relevant hospitals. A variety of actions may be undertaken depending on many factors, including but not limited to, the nature and severity of the behaviour identified, the individuals involved and the environment in which the incident(s) occurred. In sum, the feedback our faculty receive from learners is critically important.

In November 2020, the Royal College of Physicians and Surgeons of Canada (RCPSC) conferred a “Notice of Intent to Withdraw Accreditation” on our Core Internal Medicine (IM) residency program. One of two areas identified for improvement was residents’ perceptions that feedback about the program was unwelcome and could not be provided without fear of retaliation. To assist us in responding to the College’s report, we established an arms length IM Accreditation Task Force comprised of faculty and IM residents. In June of this year, they provided us 24 recommendations; one-third of the recommendations were related to how we give and receive feedback.

What we will do

While the practices outlined above have been in place for some time, feedback indicates we have not communicated them sufficiently. Further, there are many things we can do even better. To this end, we have made, and are continuing to make, changes in partnership with our learners and in alignment with our strategic priority of valuing the clinician teacher. This includes:

• Reinstating the annual IM external site review. Feedback received via these site reviews will be shared with the relevant PICs and hospital/departmental division heads. (IM Accreditation Task Force Recommendation #13, #18)
• Introducing education sessions on how to give and receive feedback in a respectful and constructive manner at resident orientations this past July 2022 and at New Faculty Orientation in September 2022. There will also be presentations on this topic at hospital Medical Grand Rounds this fall and winter. (IM Accreditation Task Force Recommendation #22)
• The development of heat maps to visualize rotation and teacher evaluation scores (RES and TES, respectively) by rotation. These have been shared and discussed with PICs and DDDs and are being used to identify and act on rotations requiring improvement, and to monitor for positive change. Here is a downloadable example. (IM Accreditation Task Force Recommendation #14, #19)
• Expressing support for the establishment of a Learner Advisor in the DoM – an individual that residents can contact to provide feedback or seek advice from. (IM Accreditation Task Force Recommendation #20)
• The creation of a guidance document outlining our policies and practice regarding Optimizing Teaching Effectiveness and the Learner Experience in the DoM. This document outlines how the DoM prepares, supports, and recognizes the excellence of its teachers, and how it collaborates with TFoM and our hospitals to ensure the safety and well-being of its learners. The document has already undergone extensive review by intradepartmental and TFoM education leaders (IM Residency Program Committee, Dr. Michael Elfassy, former co-Chair, IM Accreditation Task Force, Dr. Reena Pattani, Director of the Learner Experience Office, TFoM, Dr. Pier Bryden, Associate Dean, Professional Affairs and Clinical Values, PGME leadership and the DoM Executive Committee) with substantial edits made as a result. It is now undergoing re-review by the IM Residency Program Committee and the IM Accreditation Implementation Oversight Advisory Group, after which it will be circulated broadly and posted on the department website. (IM Accreditation Task Force Recommendation #15)
• We will continue to provide annual reports of the number of investigations conducted regarding learner concerns about faculty members and their outcomes. We will be recruiting additional administrative support within the DoM for this activity.

Moving forward together

Over the past 8+ years as DoM Chair, I have witnessed constructive learner feedback on physician behaviours and cultures result in responsive, meaningful change within the department. To be useful (actionable), feedback should be provided:

• In a timely manner
• In the most appropriate setting
• Based on specific behaviours that have been observed

Be specific, considerate, and non-judgemental – what we observe in the moment is not always an accurate reflection of someone’s wider experience.  Effective critical feedback informs, enlightens, and motivates.  It is not unkind or hurtful; rather, it’s a generosity we are able to offer and receive graciously.

The past few years have been incredibly stressful for everyone in medicine. As physicians, we continue to experience firsthand the immense pressures being placed upon our healthcare system. Under this shared weight, we must support one another; this extends to moments when feedback is offered or received. 

With reflection, coaching, education, and a variety of other resources, constructive concerns and feedback have been and will continue to be carefully and thoughtfully addressed. The pressures are high, and yes, we will falter at times - we are human after all. Let us do our level best to continue to be kind to one another. For that and your continued efforts amid chaos, I thank you.