Training in Neurology: Objective Structured Clinical Examination Case to Teach and Model Feedback Skills in Neurology Residency

Introduction

Providing and receiving feedback is integral to education, particularly in academic medicine, a field that requires integration of knowledge, procedural expertise, and interpersonal skills.¹ The value of feedback is amplified because both learners and experienced practitioners can be inaccurate when assessing their own performance.^2,3 Provision of feedback, therefore, serves a critical role to facilitate improvement and growth.

Building on previous efforts to teach feedback skills,^4,-,6 we aimed to use an experiential, simulation-based approach to develop feedback skills for neurology residents by designing an Objective Structured Clinical Examination (OSCE) case at the New York Simulation center. This OSCE case permitted neurology residents to practice feedback communication skills in an immersive learning environment modeled on a common scenario encountered in residency. Previous research has identified that effective feedback should be specific and actionable, be delivered by a credible source, and emerge from a collaborative approach.^1,4,7 Therefore, an inherently collaborative feedback method, the Ask-Tell-Ask method,⁶ was used to provide residents with immediate feedback after the OSCE case. This allowed residents to experientially learn the feedback delivery method and provided specific, actionable feedback on their communication skills.

Problem Statement/Objectives

OSCEs have been widely used in professional training, such as in the delivery of communication skills for end-of-life discussions⁸ and in practicing teaching skills.^9,10 In this article, we show the feasibility of a feedback training initiative targeting neurology residents by describing the administration of the OSCE case, resident perceptions of the OSCE case, and standardized medical student (SMS) assessments of the residents' performance. The resident learners' objectives were as follows: (1) to develop communication skills by taking part in a simulated feedback scenario and then receiving individual feedback about their performance; and (2) to learn about the Ask-Tell-Ask method by receiving feedback delivered using this method and by subsequently receiving instruction on this approach during a group discussion session.

Description of Program

A team of neurology faculty worked with the New York Simulation Center for the Health Sciences to design an OSCE case in which a neurology resident (the learner) interacts with a SMS (an actor) in a mock feedback session. Overall, 58 residents from the Adult Neurology, combined Neurology-Psychiatry, and Pediatric Neurology residency programs at the NYU Grossman School of Medicine participated in this OSCE case across 3 academic years. Twenty-five residents were in their third year of neurology training (postgraduate year [PGY]4), and 33 were in their second year of neurology training (PGY3).

The resident learners received no formal training in feedback provision before the OSCE. They were instructed to provide feedback to the SMS, with the premise that they had been working together on the neurology wards for 1 week. The learner was advised that the SMS was enthusiastic, well-liked by patients, and frequently stayed after hours to help the team; however, the SMS was often late to rounds and gave disorganized presentations in which he read a resident's note aloud.

Before the OSCE, the single SMS was trained for 2 hours by a neurologist and simulation specialist to provide standardized responses to a variety of approaches (eAppendix available from Dryad, doi.org/10.5061/dryad.280gb5mpx). He was instructed to portray an eager medical student who felt overwhelmed by the amount of knowledge presented and had difficulty with time management, resulting in tardiness and disorganized notes. The SMS was instructed to provide reasons for each of these areas targeted for feedback and to appear mildly nervous though eager to improve. For example, if his tardiness was addressed, he would explain that he was late because he spent extra time with patients on prerounds. Last, he was told that if the learner gave him an opportunity to ask questions, he should inquire about learning strategies, time management skills, and how to give better presentations. The same scenario was used for all residents.

The encounter was observed by a neurology faculty member through a 1-way mirror. The learner had 10 minutes to provide feedback to the SMS, followed by 5 minutes for feedback from the faculty member and SMS. For this feedback session, the faculty member used the Ask-Tell-Ask method. In the Ask-Tell-Ask method, the learner is first asked to reflect on their performance, then given specific observations on performance, and finally asked to outline strategies for improvement.⁶ This promotes active discussion among both parties and encourages a collaborative experience. The postcase feedback accomplished 2 educational objectives: (1) providing specific, individual feedback and (2) teaching the Ask-Tell-Ask method by demonstrating its use. The SMS assessed the learner's performance with 28 items on a behaviorally anchored checklist using a “well done,” “partly done,” or “not done” scale and with an additional 3 items with a “not recommend,” “recommend with reservations,” “recommend,” or “highly recommend” scale. Last, the learners completed a survey to evaluate the OSCE case using a Likert scale of 1–5 (from least/worst to most/best) and free text responses. After all residents in the group completed the OSCE station, they participated in an informal group debriefing session to further discuss the Ask-Tell-Ask method.

Program Evaluation and Outcomes

Lessons Learned and Future Directions

We have demonstrated that an OSCE case designed to develop feedback skills is feasible, provides individualized learner assessments and feedback, and is valued by residents. Providing feedback can be challenging and awkward, and a lack of experience may lead to fear about damaging the teacher/learner relationship or regarding hurting the feelings of the feedback recipient.¹ There has been relatively little research analyzing different methods of teaching feedback skills; the optimal method remains uncertain. The approach we have described, comprising an immersive feedback scenario, immediate faculty feedback modeling the Ask-Tell-Ask method, and a subsequent group discussion session, was judged to be effective by residents. Residents found the entire OSCE, including this case scenario, to be so helpful that they requested for the session to be moved to an earlier stage of residency training; this has been performed.

There are limitations to the use of an OSCE for practicing delivery of feedback. A simulation center is not accessible to every program and can be costly. However, it is feasible to develop observed encounters in which residents practice feedback in the absence of a simulation center. In addition, some residents noted that the OSCE format introduces cognitive strains that do not exist in real-life feedback sessions, such as following the instructions for the encounter, recalling details of the scenario, and monitoring the passage of the allotted 10 minutes. In response to these concerns, the instructions for the OSCE were shortened and placed inside the simulation room in 2019 and 2020. In the future, we will also provide advance instructions in the Ask-Tell-Ask feedback method so that residents can approach the case with more preparation. All residents interacted with the same male SMS, so we are unable to comment on any potential impact of sex. Further studies are needed to assess the longitudinal effects of this OSCE case. The current approach used resident surveys; ideally, future studies would use both surveys of resident perspectives and objective evaluations of residents' ability to give feedback before and after the OSCE. This could provide more objective evidence for efficacy in feedback skill development. Last, it is important to note that a number of different factors contribute to good feedback, some of which cannot be addressed in an OSCE; these include factors extrinsic to the session itself, such as the learner's confidence in the feedback giver and the duration of direct observation before feedback.⁷

Using a simulated, structured encounter to train residents to provide feedback is a feasible, valued, and easily implemented method to teach, practice, improve, and assess the provision of feedback. This approach could serve as a model for neurology residency programs seeking to provide an opportunity to practice feedback skills in a safe environment while being observed and provided with their own feedback. Further research is needed to address whether this approach leads to better neurology resident feedback to learners in real time and may serve as a future direction for our study.