Jarrod Shapiro, DPM
Practice Perfect Editor
Assistant Professor
Dept. of Podiatric Medicine
Surgery & Biomechanics
College of Podiatric Medicine
Western University of Health
Sciences, St. Pomona, CA

The Post-Training
Experience Debriefing

Residency training is a highly complex endeavor in which many of us in podiatry participate. For me, as a new residency director, the concepts of assessment and feedback are constantly on my mind.

According to the CPME 320 document, standard 6.0, the current definition of a podiatric residency is "a resource-based, competency-driven, assessment-validated program that consists of three years of postgraduate training in inpatient and outpatient medical and surgical management" .¹ It's those first few words, "competency-driven, assessment-validated" that is the real crux of the issue.

This definition goes beyond the current residency requirements of "minimum activity volume," that base number of certain procedures podiatric residents must do to graduate. For much of my training during school and residency, I was provided assessments of my performance (mostly via examinations and some verbal feedback). However, much of this feedback was unstructured and somewhat random. What did not occur was the debriefing.

Most of us are aware of the concept of a debriefing as it relates to the military or government. When a spy returns from a field assignment he or she is "debriefed", which usually means they tell their handlers what happened in the field. This also occurs during military simulation training, where exercises occur, and, upon completion, the trainee is given direct feedback on how he did, including strengths, weaknesses, mistakes and correct actions.

Debriefing after simulation training has become an increasingly important action in surgical training. Since simulation is a mandatory part of general surgical training, it only makes sense that trainees would receive some form of formalized feedback. This is how training should be. Odd it is that our residency programs are "competency-driven", yet the profession indicates a minimum volume of cases is all that is necessary for graduation and practice. Doesn't sound so competency-driven does it?

Despite this inconsistency, our residents seem to be thinking this way. A study in this month's Journal of Foot and Ankle Surgery by one of my Western University partners, David Shofler, DPM and colleagues, demonstrates the importance of feedback in assessment. Dr. Shofler performed a nationwide survey of residents and residency directors, looking at various educational components. Among the interesting results, Shofler, et al. found direct feedback immediately after surgery as the most valuable learning resource reported.² This result makes perfect sense. What better method is there to help a trainee improve than to receive rapid immediate feedback during and/or after their training experience?

Tonight's Premier Lecture is
Biopsy Techniques
Tracey Vlahovic, DPM

Debriefing After a Training Experience

It behooves all of us who train students and residents, then, to understand how to provide the best feedback to our trainees. Essentially the question is, how do I debrief a trainee after a learning experience?

Funny you should ask because I have just the resource for you!

Arora, et al. published a useful study in the journal Annals of Surgery.³ This study sought to validate an objective test assessing a method of debriefing surgical trainees. Essentially, they were assessing the assessors. As part of the study and creation of a validated assessment tool, the group performed a literature review of debriefing methods.

Nice of them to do that, huh? Saves us some time!

The researchers found eight key features of an effective post-training experience debriefing, which are the following:³

1.	Approach – feedback should be constructive and supportive, rather than judgmental.
2.	Learning environment – quiet, nonthreatening and immediately following the activity was best appreciated by trainees.
3.	Learner engagement – active participation of the learner is key. The facilitator should do this by using open-ended questions, silenceand active listening.
4.	Reaction – a short period of time to gauge the learner's emotional reaction. A short period to absorb the emotional aspect of an experience may be necessary before learning may occur.
5.	Reflection – take a moment to consider the activity and what occurred. Thinking about it for a moment is helpful to frame a discussion.
6.	Analysis – the trainer should help the learner develop an analysis of what occurred, including the reasons and consequences of their actions.
7.	Diagnosis – the trainer provides direct feedback, directed at specific actions or behaviors that can be improved in the future.
8.	Application – the learner should consolidate what she's learned, and come up with a specific action plan for future practice and improvement.

Debriefing our trainees is not an easy process. It requires us to first break down the particular skill into its component parts, assess how the trainee performed those parts and then provide immediate, focused, constructive feedback for improvement. Considering these eight aspects of the debriefing can help provide a framework for improvement, and give our residents what they've told us they want. Perhaps this will move us one step closer to the goal of competency-driven, assessment-based podiatric residencies.

Best wishes,

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]

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References

Standards and Requirements for Approval of Podiatric Medicne and Surgery Residencies, Council on Podiatric Medical Education website, July 2015. Last accessed August 2, 2015.
Sholfer D, Chuang T, Argade N. The Residency Training Experience in Podiatric Medicine and Surgery. J Foot Ankle Surg. 2015 Jul - Aug; 54(4):607-614.
Arora S, Ahmed M, Paige H, et al. Objective structured assessment of debriefing: bringing science to the art of debriefing in Surgery. Ann Surg. 2012 Dec; 256(6):982-988.