In our baseline survey of UCSF internal medicine residents, we discovered a strong relationship between learner confidence and self-reported SBIRT skills practice, and this relationship was explained by the perceived barriers of lack of experience dealing with alcohol or drug problems and a discomfort in dealing with these issues (p<.001). These results provided us with a clear signpost to guide curricular development towards increasing experience and reducing discomfort. By providing residents with multiple opportunities for practice and observation with a standardized feedback protocol, we targeted those perceived barriers that were associated with lower confidence in SBIRT skills. We more finely tuned our curriculum to our learner’s needs and the overall outcome of increasing SBIRT behaviors in the future.
Our experience has several implications for others considering SBIRT curricular design. First, assessing characteristics of learners at baseline proved to be a valuable tool for tailoring the curriculum to target the specific needs of residents. Second, developing tailored curricula is an iterative process. Anticipating this during planning and putting in place procedures to evaluate learner responses will likely facilitate the magnitude of improvements at each iteration. Lastly, the exercise of developing a proficiency checklist is valuable, in and of itself, to help ensure alignment in curriculum and explicitly address and standardize practice recommendations that we make to residents. Overall, a body of related research and our initial qualitative data support the effectiveness of performance feedback as a core curriculum component in teaching SBIRT skills.
Observation with feedback is critical to the effective implementation of medical skills, particularly those that involve interpersonal communication (20
). Despite this, implementation of feedback in training curricula is insufficient, particularly in the area of addictions (21
). As early as 1950, Weiner drew poignant parallels between the critical role of feedback in medical education and rocket science, where the importance of reinserting performance information into the system via feedback is a necessary antecedent to the modification of behavior (1
). However, unlike rockets, which are designed with their own objective performance evaluation instrumentation (1
), health care providers, particularly those with minimal exposure to a given behavioral intervention, are poor estimators of their own skillfulness (22
). Arguments for the implementation of observation with feedback also have drawn parallels between interpersonal communication in medical interactions and complex skills from other areas, such as athletic or musical domains. Here providers’ struggles to accurately assess their own performance may be analogous to a golfer practicing with a blindfold on, or a pianist playing while wearing earplugs. Without a feedback loop, performance is unlikely to improve (20
Feedback has been referred to as the life-blood of learning, especially if it is provided often and in a learner-centered style (24
). A learner-responsive curriculum requires data gathering about learner deficiencies and resources and attitudes, as well as ongoing evaluation of and responsiveness to implementation challenges and successes. What we learned in the development, implementation, and modification of our SBIRT curriculum at SFGH parallels research from the broader field of medical education, where observation with feedback is a highly replicated essential strategy for enhancing intervention skillfulness. This teaching technique holds great promise for SBIRT curricula. Our experiences developing and implementing an SBIRT Proficiency Checklist and Feedback Protocol with UCSF internal medicine residents demonstrate that observation with feedback in GME clinical settings is feasible, well-received, and valued by the resident physicians. Qualitative feedback from housestaff supports the continued development, implementation, and rigorous evaluation of clinic-based observation with feedback. Continued research is needed to document the impact of observation with feedback on self-reported and objective measures of SBIRT-related provider behavior.