In March of 2105 I returned to Mayo Clinic and switched from 18 years of seeing patients in a private setting to overseeing residents and medical students in an academic setting. It’s been a big change. I am learning to be a better teacher and to provide better feedback.
A key tactic to improve learning is to provide post-shift (or post-case) feedback. It’s a great time to review what has happened and it is ideally done privately with careful consideration. Unfortunately, I have a difficult time remembering what happened 9 hours ago and perhaps even 5 minutes ago.
When a resident asks, “Can we debrief? How can I do better?” It is not uncommon for me to draw a blank. And “drawing a blank” in such an instance is not a good teaching practice.
Therefore, in an attempt to improve my ability to provide feedback I created the following post-shift (or post-case) mnemonic to remember topics for clinical debriefing.
The mnemonic for clinical feedback topics is DREEM.
We all dance through our clinical experience and an empathic analysis of the moves of the day from a colleague who has been in the arena is helpful. This is just one attending’s feedback for one day. Take from it what is most helpful for your own personal and professional growth. Discard the rest. No worries. We have all been there.
This is a huge part of our job as clinicians. Invariably, however, residents and medical students get little feedback on the volumes of histories, physical exams, and medical-decision-making that they document.
This is how we communicate with patients and colleagues, how we create a compliant legal record for our care, and how we bill for our services. Each of these components is a prime opportunity for education and development.
How we get along with others greatly affects our own well-being and impacts the effectiveness of our teams. What is noticed in the interactions with nursing, or colleagues, or patients?
“I noticed [the following tone, facial impression, gesture]:
- during your phone call with [this person].”
- when you are approached [in this manner].”
- as you gave orders during [this situation].”
In what ways are interpersonal dynamics affecting their work? Do they feel safe? Are they flourishing? How are relationships impacting patient care?
Throughout our training and indefinitely beyond we find gaps in knowledge and skills. On the other hand, there are cases that we own with a depth of understanding and experience.
Sometimes the differential is too broad or too narrow. A clinical sign may be missed or adroitly identified. There are procedures where improved preparation or practice in technical skill are needed or supremely evident.
This is probably the most familiar topic for discussion and in many ways it is the most subjective. Patients present differently. Attendings have various approaches. The science is changing. All good stuff for discussion.
Multitasking is a myth and healthcare processes are complex. There are things that we can do to improve the efficiency of patient care and there are things that we do that create a wake of questions, uncertainty, and waiting.
- “I noticed that [these people] were repeatedly having to ask you for [next steps].”
- “You are very efficient in keeping up with the needs of each of your patients when [you do this].”
- “Instead of [doing it] in this order, you may want to try [doing it] in this order.”
M: State of Mind.
So much of how we experience our day depends upon our state of mind. At the same time, as our day progresses our state of mind changes. We may start the day on a high note and somewhere in the middle get knocked down.
For example, “I noticed that your level of energy changed during [this case].” This invites the discussion of how emotions come to play during our experience. “Your positive vibe had this effect,” or I sensed “a negative vibe,” and noticed the following results.
Sometimes there are difficult cases. A patient dies or pulls through. We attempt to satisfy the needs of someone. A case reminds us of something that happened in the past.
Sometimes it is our physiology. We are hungry or tired. We need to pause.
Sometimes there are things happening at home, we receive an email, or someone messages us.
As their attending, I can witness the experience, reflect it back, and help them connect it with their state of mind.
DREEM gives a roadmap for topics to discuss. It provides a grounded way to consider what has occurred and how we may improve. It can be helpful in not only providing feedback to others, but also in considering how we may best improve.