Realimentacion -Feedback

REALIMENTACIÓN
RETROALIMENTACIÓN

Sesiones
con/de/para
Medicina
Interna y
Radiología

Sesiones con/de/para
Medicina Interna y Radiología

Sesiones
con
Medicina
Interna /
Radiología

Abraham Verghese, MD.
Senior associate chair for the theory and practice of
medicine at Stanford, University, Stanford, CA.

Subha Ramani, MD.
Department of Medicine,
Section of General Internal
Medicine, Boston
University
School of Medicine, 715
Albany Street, Boston,
Massachusetts-02118,
USA,
617-638-7985, 617-414-
4676
sramani@bu.edu

Subha Ramani, MD.
is a general internist with a major
interest in medical education.
She is currently an Assistant
Professor, Department of Medicine,
at the Boston University School of
Medicine.
She completed Internal Medicine
residencies at the Postgraduate
Institute
of Medical Education and Research
(PGIMER), India as well as East
Tennessee State University, USA, and
a
fellowship in General Internal Medicine
at Boston University.

Vijay Rajput, MD.
MBBS, FACP, SFHM, is
Professor
of Medicine and Assistant
Dean
for Curriculum at Cooper
Medical School of Rowan
University in Camden, New
Jersey.
Head for Division of Medical
Education in the Department of
Medicine.

REALIMENTACIÓN
Feedback is one of the most
powerful influences on learning and
achievement,
but this impact can be either positive
or negative.
Hattie J and Timperley H.
Power of Feedback.
Review of Educational Research 2007;77(1):81–112

El gran descubrimiento de mi generación es que los
seres humanos pueden cambiar su vida, cambiando
la actitud de su mente.
WILLIAM JAMES

CARENCIAS,
RETOS PERSONALES
 Inteligencia emocional y social:
Formar parte de “algo” que es superior
a cada uno de nosotros.
 Lectura critica de información biomédica
 Destrezas sociales, de intercomunicación interpersonal
 Destrezas docentes

Dos “cosas” que los seres
humanos tenemos y
perdemos:
TIEMPO, imperdonable
y
VIDA, irremediable.

REALIMENTACIÓNThe Two-Minute Teacher.
aid to making the most of educational
opportunities as they arise on the fly at the point of care.
a) Haz, favorece la conexión,
b) Explora lo que el alumno sabe o conoce,
c) Genera una contrato de aprendizaje: education
is most effective when it is focused on what learners
most want or need to know.
d) Conecta con emociones y/o experiencias,
e) Favorece el espíritu de colaboración y de responsabilidad,
f) Promueva la atención centrada en el paciente,
g) Reconoce el desempeño laboral y colaborativo.
Gunderman RB, Bedi HS. The Two-Minute Teacher. Acad Radiol 2013; 20:1610–1612.

“La mayor parte del error médico proviene no del mal
raciocinio basado en hechos bien observados, sino del
buen raciocinio basado en hechos mal observados”.
BLAISE PASCAL
(1623-1662),
filósofo y
matemático francés

We are focusing more on deciding what the
best study is for a patient based on
evidence-based guidelines and the clinical
conditions they present with.

Quality is when a radiologist evaluates the
need to expose a patient to radiation based
on the patient’s condition, the patient’s age,
and the value of the imaging procedure.

Giving feedback is a critical skill for effective
teaching and learning, the “heart of medical
education” .
A recent review of the social science
literature defined feedback in clinical
education as “specific information about
the comparison between a trainee’s
performance and a standard, given with
intent to improve the trainee’s
performance”
REALIMENTACIÓ
N
Kruidering-Hall M, O’Sullivan PS, and Chou CL.
Teaching feedback to first-year medical students: Long-term skill retention and accuracy of student self-assessment.
J Gen Intern Med 2009;24(6):721–726.

Generally accepted characteristics of effective
formative feedback include aspects of
structure, content, and format. Structural
requirements encompass location, time, and
orientation of the learner to the process
and to the goal of the process.
REALIMENTACIÓ
N
J Gen Intern Med 2009;24(6):721–726.

Ideally, the provider and recipient are allies
and operate in a culture of mutual respect,
while feedback is co-constructed through
loops of dialogue and information and
reflective practice. As for the content of
feedback, studies have validated that effective
feedback is constructive, specific, and non-
judgmental. Useful formats for feedback
include oral, written, graphic, and video.
REALIMENTACIÓ
N
J Gen Intern Med 2009;24(6):721–726.

J Gen Intern Med 2009;24(6):721–726.

Teaching feedback to early medical
students resulted in improved skills of
delivering corrective specific feedback
and enhanced comfort with feedback.
However, students’ overall ability to
deliver specific feedback decreased over
time.
J Gen Intern Med 2009;24(6):721–726.
REALIMENTACIÓ
N

The feedback exchange model between
clinical supervisors and learners has shifted to
include the role of the learner in seeking and
accepting feedback
The feedback exchange process and resident
feedback-seeking are influenced by multiple
factors. Both faculty and learner roles require
attention
Delva D, Sargeant J, Miller S, Holland J, Brown PA, Leblanc C, Lightfoot K & Mann K.
Encouraging residents to seek feedback. Medical Teacher 2013;35:12, e1625-e1631.
REALIMENTACIÓ
N

Resident feedback-seeking activities appear to
be dependent on four – 4 - central factors:
1. learning/workplace culture/climate,
2. relationships,
3. purpose and quality of feedback,
4. emotional responses to feedback
REALIMENTACIÓ
N

REALIMENTACIÓ
N

Further research is needed to determine how
to reduce the tensions between faculty and
learner perceptions of the feedback exchange
process and how to encourage residents to
take an active role in seeking feedback
from their clinical supervisors.
REALIMENTACIÓ
N

I do not recall residents really coming
forward and saying,
‘Hey, listen, how was I?’
REALIMENTACIÓ
N

Ramani S, Post SE, Könings K, Mann K, Katz JT & van der Vleuten C.
“It's Just Not the Culture”: A qualitative study exploring residents‘ perceptions of the impact of institutional culture on feedback.
Teaching and Learning in Medicine. 2016 http://dx.doi.org/10.1080/10401334.2016.1244014
REALIMENTACIÓN
1. Does feedback provided by faculty facilitate
performance improvement?
2. What are the strengths and weaknesses of the
current feedback system in our residency
program?
3. Can you describe challenges encountered when
yo give or receive feedback?
4. Can you suggest strategies to improve the
feedback culture in our department?

Ramani S, Post SE, Könings K, Mann K, Katz JT & van der Vleuten C.
“It's Just Not the Culture”: A qualitative study exploring residents‘ perceptions of the impact of institutional culture on feedback.
Teaching and Learning in Medicine. 2016 http://dx.doi.org/10.1080/10401334.2016.1244014
REALIMENTACIÓN

St-Onge C, Martineau B, Harvey A, Bergeron L, Mamede S & Rikers R.
From See One Do One, to See a Good One Do a Better One: Learning Physical Examination Skills Through Peer Observation.
Teaching and Learning in Medicine, 2013,25:3, 195-200.
REALIMENTACIÓ
N
From See One Do One, to See a Good One Do a Better
One:
Learning Physical Examination Skills Through Peer
Observation.
Group learning activities that allow
students to observe their peers during
physical examination should be favored.

REALIMENTACIÓ
N
Ramani S & Orlander JD.
Human Dimensions in Bedside Teaching: Focus Group Discussions of Teachers and Learners.
Teaching and Learning in Medicine. 2013;25:4, 312-318, DOI: 10.1080/10401334.2013.827979
Human Dimensions in Bedside Teaching:
Focus Group Discussions of Teachers and
Learners.
Teachers and learners regard the bedside as a
valuable venue in which to learn core values of
medicine.
Strategies to preserve these humanistic values
and improve bedside teaching. These strategies
are essential for true patient-centered care.

Bedside teaching is valuable
but underutilized.
Including the patient,
collaborating with learners,
faculty development, and
promoting a supportive
institutional culture can redress
several barriers to bedside
teaching.
REALIMENTACIÓ
N
Williams KN, Ramani S, Fraser B, and Orlander JD.
Improving Bedside Teaching: Findings from a focus group study of learners.
Acad Med. 2008; 83:257–264.

Williams KN, Ramani S, Fraser B, and Orlander JD.
Improving Bedside Teaching: Findings from a focus group study of learners.
Acad Med. 2008; 83:257–264.

Bedside teaching:
Trabajo en equipo
Orientación del equipo
Discusión de casos
Destrezas de comunicación
Destrezas educativas
Educación de personal paramédico
Éxito del programa
REALIMENTACIÓ
N

EFECTIVA
Proveer al estudiante de información oportuna para
reflexionar en sus errores y aciertos, le permite
reconocer
las consecuencias de sus acciones y la permanente
superación.
Vives-Varela T, Varela-Ruiz M.
Realimentación efectiva.
Inv Ed Med 2013;2(6):112-114

REALIMENTACIÓN
EFECTIVA
Vives-Varela T, Varela-Ruiz M.
Realimentación efectiva.
Inv Ed Med 2013;2(6):112-114

REALIMENTACIÓN
Hattie J and Timperley H.
The Power of Feedback. Review of Educational Research 2007;77(1):81–112

REALIMENTACIÓ
N
1. Prepare the team before entering the patient’s
room.
2. Prepare the patient.
3. Listen and respond to the patient and the family.
4. Think out loud.
5. Find the teaching moments.
6. Involve nurses and other health care
professionals.
7. Feel comfortable saying “I don’t know.”
8. Let the patient share a personal story.
9. Explain the next steps involved in the patient’s
treatment.

REALIMENTACIÓ
N
1. Preparation is a key element to conducting effective
rounds and increasing teacher comfort at the bedside,
2. Draw a road map of what you plan to achieve at the
bedside for each encounter,
3. Orient the learners to your plans for the session and
negotiate goals and objectives for the session. Tell the
learners what is to be taught,
4. Introduce yourself and the team to the patient; emphasize
the teaching nature of the encounter,
5. Role-model a physician-patient interaction,
6. Stepping out of the limelight and keen observation is a
necessary part of learner-centred bedside teaching,
Ramani S. Twelve tips to improve bedside teaching. Medical Teacher. 203;25(2):112–115.

REALIMENTACIÓ
N

REALIMENTACIÓ
N
7. Challenge the learners’ minds without humiliating,
augmented by gentle correction when necessary. Do the
teaching.
8. Tell the learners what they have been taught,
9. Leave time for questions, clarifications, assigning further
readings, etc.
10. Find out what went well and what did not,
11. Think about the bedside encounter; evaluate what went
well and what went badly and what you would do the next
time,
12. Start your preparation for the next encounter with insights
from your reflection phase.

REALIMENTACIÓ
N
The physical examination is a critical component of
medical practice.
However, residents demonstrate considerable
deficiencies in skills deemed important by program
directors and during residency, and these skills do not
typically improve beyond those of senior medical
students.
McMahon GT, Marina O, Kritek PA, Katz JT.
Effect of a physical examination teaching program on the behavior of medical residents.
J Gen Intern Med 2005; 20:710–714.

REALIMENTACIÓ
N
Frequency of physical examination, although not the depth of
examination, can be increased through a skills based
educational
program delivered to medical trainees.
Important aspects appeared to be the use of expert clinician
educators, the recruitment of appropriate and willing
patients,
using small groups for the learning exercises, and the
creation
of a safe environment where participating residents could
practice their clinical and teaching skills and receive
immediate
McMahon GT, Marina O, Kritek PA, Katz JT.
Effect of a physical examination teaching program on the behavior of medical residents.
J Gen Intern Med 2005; 20:710–714.

N
Bedside teaching is declining in the medical curriculum.
Reasons include an increased patient turnover in hospitals, the availability of
high quality diagnostic other than physical diagnosis, and practical and
personal
impediments.
Bedside teaching has been found to improve certain clinical skills in
students
and residents.
Bedside teaching is still valued by patients, as well as students, residents
and
clinical teachers as a very useful teaching method.
Because of its value for students/residents, patients and medical teachers,
obstacles to bedside teaching should be overcome.
Solutions vary from practical guidelines to using residents and interns as
bedside teachers.
Peters M, ten Cate O.
Bedside teaching in medical education: a literature review.
Perspect Med Educ 2014;3:76–88.

N
La medicina, se aprende según algunos preceptos:
a) Aprender haciendo,
b) motivación basada en la responsabilidad,
c) Supervisión y asesoría,
d) Vinculación teoría-práctica,
e) Ambiente académico,
f) Investigación como estrategia educativa y
g) Experiencias significativas
Lifshitz A. Mentores.
Med Int Méx. 2017;33(2):147-149.

Miller’s Learning Pyramid is an often-cited guide to describe different
levels
of knowledge and skills acquisition which distinguishes four levels of
competence or training objectives:
1. Knows
2. Knows how
3. Shows how
4. Does
Accordingly, the first two levels describe cognitive aspects, i.e. the
acquisition of factual knowledge (level 1) and the application knowledge
(level 2).
The third and fourth levels refer to procedural skills.
Skills lab training takes place on Miller’s Pyramid’s 3rd competence
level,
in detail on the level “shows how”/“show as if”.
REALIMENTACIÓN

REALIMENTACIÓN
see one,
do one,
teach one.
Vozenilek J, Huff JS, Reznek M, Gordon JA.
See One, Do One, Teach One: Advanced Technology in Medical Education.
Acad Emerg Med 2004;11:1149–1154.
see one,
simulate many,
do one
competently,
and teach
everyone.
‘‘learning by doing’’

REALIMENTACIÓN
MOTIVACIÓN
En educación médica, la realimentación
constituye un instrumento que informa al
estudiante sobre su proceso de aprendizaje y
facilita los cambios necesarios.
Busca las propias percepciones del alumno
respecto a su desempeño y cómo mejorarlo,
desarrollando habilidades de aprendizaje
permanentes, vital para la práctica autónoma.

REALIMENTACIÓN
MOTIVACIÓN
Si se realiza de forma efectiva resulta útil para
mejorar el rendimiento, las habilidades clínicas
y de comunicación, y el trato hacia los
pacientes.
Si se entrega de mala forma produce
desmotivación y un quiebre en la relación
docente-alumno.
La relación interpersonal docente-residente,
cuando se basa en una colaboración y en una
apertura al diálogo, es fundamental para una
retroalimentación efectiva.

REALIMENTACIÓN
Bedside teaching is the process through which learners
acquire the skills of communication by
asking patients’ permission,
establishing ground rules,
setting time limit,
introducing the team,diagnosing learner, diagnosing
patient,
conducting focused teaching,
using simple language,
asking patient if there is any question,
closing with encouraging thanks, and
giving feedback privately.
Abdus Salam A, Halizah-Siraj H, Mohamad N, Das S,
Rabeya Yousuf3 Bedside teaching in Undergraduate Medical Education: Issues, strategies, and new models for better
preparation of new generation doctors. Iran J Med Sci 2011; 36(1): 1-6.

Bugaj TJ, Nikendei C. Practical clinical training in skills labs: theory and practice.
GMS Journal for Medical Education 2016;33(4):1-21.
REALIMENTACIÓN

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