Insights on Residency Training

Joseph Cooper, MD, is a Chief Resident in Internal Medicine at Geisinger Medical Center in Danville, Pennsylvania.

Here are some questions that are still on my mind as I approach the tail end of my chief year. I’m thinking about the best ways to offer constructive feedback.

• What is the best way to approach a struggling learner?
• What is the best way to give guidance and feedback without being perceived as a tyrant or overbearing?
• How can I maximize the potential of my team members and the trainees with whom I work, based on performance evaluations?

A senior colleague surely did not lie when he told me that his year as chief resident was “one of the best years of my life.” Our institute might be unique — I have an unrestricted medical license, I function as a teaching hospitalist for 11 weeks of the year, and I precept in the outpatient general internal medicine clinic 1 day each week teaching residents. So, I might have the perfect transition from resident to “junior attending.” But these activities come in addition to the teaching responsibilities, leading of daily morning reports, troubleshooting, and being the mediator between the residency administration and the residents that are the essence of being a chief.

Governors Island. New York City, NY. My own work. Iphone.

I think about the great mentors I’ve had throughout my training, and I try to emulate the feedback given to me (whether direct or indirect) when I interact with the learners under my tutelage. But during my short time as a “junior attending,” this year, the above plan is a lot easier said than done.

The trick is to emulate mentors who thought about the 3 questions at the top of this post, and NOT to fall into the trap of saying what trainees want to hear. For example, I remember feedback sessions with attendings who would say: “You’re great, you’ve done everything right, only thing to improve is that you should read more.” Read more? Read more? I always got a bit upset by this, because we all should read more. Medicine is life-long learning, for medical students coming out of basic science to the seasoned triple-boarded subspecialist/physician scientist. So again, back to the original questions at the beginning of this entry. How do clinician educators and mentors provide actual “constructive criticism,” that is appropriate, non-threatening, and useful in the future?
I’m by no means an authority on the matter, but here are some helpful hints on that seem to have worked well this year:

1. Set the stage: Provide clear expectations. Sometimes this requires going the extra mile and providing a written document rather than verbally setting expectations at the beginning of a rotation/week on service. I have drafted my own “expectations,” that I email to all learners prior to coming on service. This step is key to providing useful feedback at the end of a rotation, because the learner can’t say “well, I didn’t know I was supposed to do XYZ.” Setting the stage also applies to the environment in which feedback is given: in a timely manner, and one that is private, protected, and confidential.
2.  Ask open-ended questions: You can never go wrong with this. With patients or with learners. This is a skill most of us accept as important, but often fail to use correctly. Beginning a feedback session by allowing the learner to self-reflect on his or her successes will usually allow for an easier transition to discussion of areas where the learner needs improvement. A simple introduction such as: “So, what did you think of the past week?” is non-threatening, open-ended, and allows the learner to start and (importantly) control the dialogue.
3. Use the “sandwich” technique: This is only a bit different from the infamous “breaking bad news,” dialogue, but the sandwich technique is an effective way to deliver constructive feedback and promote change in the skills and behavior of the learner. To use the sandwich technique, first reinforce and give positive feedback on skills and behaviors that you directly observed. This fosters confidence in the learner, promotes positive reinforcement, and usually encourages the learner to seek feedback from others. After this step, ask the learner to identify deficiencies and areas in which he or she thinks improvement is needed. If the learner has already identified areas that need improvement (in the open-ended dialogue in step 2 above), you already taken the first step. Provide them with specific examples on how they can improve and in the behavior/skills that you directly observed that could be refined. When giving positive feedback, it is best delivered immediately, while “on the spot.” When giving constructive feedback, I’ve found it best to keep a log, and review situations at a formal feedback session near the end of the learning experience.
4.  Seek confirmation and end with a plan: The goal of a constructive feedback session is to be non-confrontational and to give the learner tools and skills to facilitate change. At times, these sessions may be emotionally charged, and the learner may take the feedback personally and feel “singled out.” Following steps 1-3 above will help avoid this angst. Finally, have the learner make an action plan before leaving the session. (E.g., exactly how to approach a patient and care plan.) Have the learner give you their summative assessment and then facilitate and form an action plan for moving forward.

Educators should continue solicit guidance from mentors and institutional leaders about how they provide constructive feedback to learners. Lastly, the educator should always solicit feedback from their learners, confirm constructive feedback, and have an action plan to improve deficiencies.

On that note, I will leave you with a“throwback” New York City photo, in preparation for my return to the “big apple.”

Garment District Rooftop. New York City, NY. My own work. Iphone.