Kristen Atkins, MD

 Five years ago, my residency program scored embarrassingly low on our ACGME survey with respect to the comment: “I am satisfied with the feedback I receive.”  It was so low that even though we’ve markedly improved that score, I still can’t bring myself to publically state what is was.  As the residency program director, it was my responsibility to improve that score.  After attending an ACGME-sponsored course on feedback and evaluation at Vanderbilt, participating in numerous workshops at my home institution, and reading books and articles on giving and receiving feedback I learned that most of us are terrible at delivering feedback.1-4  We start off general, talk around the issue, are too forceful or too gentle, or we don’t say anything at all…except to our colleagues (and then are we ever articulate).  To complicate matters, many of us are equally poor at receiving feedback.  The voice in our head is louder than the well-intentioned voice from the feedback giver.  This last year we doubled our ACGME survey score in this category, so feedback skills can be learned.  At the ASC Annual Scientific Meeting in Washington DC this last November, Heather Barnes and I ran a workshop for the Program Directors on how to implement activities into your training programs to make feedback easier for the giver and receiver.  The following are concepts and activities I found useful in promoting a better feedback environment.

Feedback comes in three main forms: appreciation, coaching, and evaluation.4 In education-speak, appreciation and coaching are two forms of formative feedback.  This is day-to-day, real-time (or very proximal to the activity), specific, and focused.  For example, you and your new fellow just finished doing a fine needle aspiration and you noticed her hands were shaking when she did the procedure.  So, afterwards you review techniques for mitigating this.  Formative feedback is what entrustable professional activities are but that is a topic worthy of its own article.

Evaluation or summative feedback is an assessment of someone’s overall competency at a set point in time.  It is based on a conglomerate of data points or smaller evaluations that occurred over a set period.  The milestones and your 6-month evaluations are examples of summative evaluations.  The same fellow mentioned above might be at a 3.5 on the milestones for FNA technique.  In a perfect world, there are no surprises in a summative session because the formative encounters have been frequent and specific.  In reality, it is incredibly hard for many people to provide and receive feedback.  If it is not difficult for you, I guarantee many of your colleagues are struggling (or avoiding) the topic altogether.
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Feedback has not occurred until the recipient knows what behavior s/he should continue, modify or extinguish.  Even positive comments like ‘Good job!’ with no further information is unhelpful.  Here are a few complete comments that were in trainees’ end-of-rotation comment section.  With each comment, imagine you are the recipient.  Do you know what behavior is being suggested to continue, modify or extinguish?

  1. Good job
  2. Is still in med student mode
  3. Stop using Google
  4. Great fellow

Here are modifications that now make the comment more constructive.  Each one took me 45 seconds longer to think about and write:

  1. Good job. She came to sign-out having previewed her cases and had questions about the reading she had done.  When we discussed a topic I saw her later reading about that subject.
  2. I would like to see Dr. X take cases instead of having the fellows assign them. He should read about aspirates he performs in addition to the assigned readings.  It is ok to independently contact clinicians when there is a delay in cases.
  3. I recommend that Dr. Y make a list of topics to read about at the beginning of the rotation and read from textbooks or faculty-approved on-line resources. He should review study sets that correlate with the reading. It will help him/her to have focus and gain deeper knowledge.
  4. Great fellow. The residents consistently tell me how communicative, calm and clear s/he is.  Her reports are error-free; she calls clinicians when there is anything unusual in a case.  I appreciate all the extra resident teaching she did when we were on service together and I had a cold.

A common problem with feedback is the recipient and giver must be in the same feedback mode.4 If your fellow was busy giving preliminary interpretations and had an unusually high volume for sign-out and you start coaching on one of his reports, then, as well-meaning as your words and intentions are, they will probably be met with silent frustration.  That fellow simply needed appreciation to the work he did do.  The report feedback can wait.

How do you know it is a good time for coaching?  It is infinitely easier if you set the expectation that feedback will be occurring.  When you start your week on service, take a minute to ask each trainee what s/he is working on and what aspects of their work they would like your feedback.  This is an ideal environment because the trainees are expecting feedback and words will not feel overly harsh.

If you make only one change to your approach to feedback, I recommend this: ASK the trainee first how s/he thinks s/he did.  For example, if the reports are poorly written and disjointed, ask the trainee how s/he approaches writing reports.  Follow up their response with “what part is hardest for you?”  In my experience, most trainees are spot on to where the problems are.  I am then magically in a position of helping rather than criticizing; and more importantly, the door is now wide open for coaching and appreciation.

The intervention that has been the most culture changing is having a book club and journal club with all of our trainees.  We used the book, Thanks for the Feedback by S. Heen and D. Stone.4  This book has an online PDF study guide for how to facilitate discussions.5  I did most of the talking at first, but with each session the trainees spoke up more and more.  The book teaches how to pull feedback rather than having it pushed upon you.  It also highlights the triggers humans do that sabotage feedback from being received.  Once you identify the defense mechanism you do that inhibits feedback, you can follow suggestions on how to quiet or at least soften the internal voices.

One slightly disheartening thing I have found is that someone (probably you as program director) has to be vigilant about keeping this topic a priority.  Your colleagues will grow a little weary of the word feedback.  I had 4 years worth of residents who had been through our feedback curriculum and we were making progress.  This last year I eased up and we all started falling back into our old habits.  But, I think the effort is worthwhile.  Some faculty colleagues are finally giving feedback (after 5 years of discussing the topic).  Our survey scores continue to improve; I think in large part because the trainees see we are trying.

Here is my action plan for improving feedback and references for your use.

  1. Educate myself: workshops, reading, discussing
  2. Integrate feedback lessons into faculty meetings
  3. Redesign end of rotation evaluations with faculty buy-in (this has taken over 2 years to complete)
  4. Book club for trainees (4 part series)
  5. E-mail faculty periodically about the importance of specific feedback. Remind them that poor performance reports should never be a surprise to the recipient.  I offer my help if they need to discuss it with the resident/fellow.
  6. 6 month check-in with trainees about feedback. Ask for bright spots – what has been going well.  I present this information to the faculty.
  7. Guest speakers
  8. Journal club on communication
  9. Repeat steps 1-8
  10. Spread the word to other program directors to help ease their pain and to help other trainees become more proficient at giving and receiving feedback.

References:

  1. Bing You R, Hayes V, et al Feedback for Learners in Medical Education: What Is Known? A Scoping Review Academic Medicine, 2017;92(9):1346-1354.
  2. Heen S and Stone D Finding the Coaching in Criticism Harvard Business Review 2014
  3. Patterson K, Greeny J et al Crucial Conversations; Tools for Talking When the Stakes are High, 2nd ed McGraw Hill, 2012.
  4. Stone D and Heen S Thanks for the Feedback; the Science and Art of Receiving Feedback well, Penguin Group, New York, New York, 2014.
  5. Stone D and Heen S https://gracelead.files.wordpress.com/2016/07/thanks-for-the-feedback-guide.pdf, July 2016.

 

Kristen Atkins, MD is the Residency Program Director at the University of Virginia.