Whitney Fallahian, MD, and Elizabeth Townsend, MD, PhD, both Assistant Professors within the University of Wisconsin Department of Anesthesiology, developed a Problem-Based Learning Discussion that was presented at ANESTHESIOLOGY® 2023 to address the importance of providing feedback to residents.
“Oftentimes, intubating is the first task in their life that residents aren’t great at right away. It’s jarring to them when they can’t get it right on the first try, but it’s all part of the process. It can be a real turning point in their perceived self-value.”
The scheduling dynamic in health care and especially in anesthesiology complicates these discussions as well. It’s not uncommon to work with a resident one day, then not again for several weeks. When working in academic medical centers with critically ill patients, finding the right time to deliver feedback is never easy.
“Most attendings are short-staffed, responsible for more patients than ever before, and not able to spend as much time with residents,” shared Dr. Fallahian. “There’s often a critically ill patient in the next room and other clinical responsibilities waiting, so we spend less time conversing. The dynamic between attendings and residents is changing, and it can be difficult to give balanced feedback. Residents, like most people, tend to fixate on the negative rather than the positive, which causes attendings to shy away and only comment on what’s going well.”
The issue of burnout also comes into any discussion on why feedback isn’t occurring on the ideal timeline. Dr. Townsend commented on the increased demands on physicians’ time in terms of documentation. “This unfortunately deprioritized things like giving feedback to residents,” she said. “Even though it’s the heart of academic medicine, it’s not billable time that’s recognized by the institution or health care system.”
Personal histories of easy success
It’s also worth remembering that residents and medical students may be more sensitive to criticism than a lot of other young workers. As a cohort, these individuals are gifted and have had a lifetime of excelling in academics. Dr. Townsend observed that there’s very little teaching in medical school on being open to negative feedback.
“For this high-achieving population, hearing negative feedback requires a level of vulnerability,” she noted. “Using this information to improve has to come from an intrinsic drive to do better accompanied by a degree of personal insight.”
Anesthesiology can challenge even the best and brightest residents. “Oftentimes, intubating is the first task in their life that residents aren’t great at right away. It’s jarring to them when they can’t get it right on the first try, but it’s all part of the process. It can be a real turning point in their perceived self-value,” reasoned Dr. Townsend.
Setting the stage for critical conversations
These conversations with residents can be sensitive, so it’s important to find the right time and place to give residents feedback. Dr. Fallahian aims to offer daily feedback so there isn’t a negative connotation if she asks to speak with a resident at the end of the day. She champions the Pendleton Feedback Model, which involves:
- Asking the resident what he/she felt went well.
- Sharing what you feel went well.
- Asking the learner what he/she thinks could be improved.
- Telling the learner what you think could improve (Oxford: Oxford University Press; 1984).
It’s not uncommon for these feedback sessions to take an unexpected turn. Both Drs. Fallahian and Townsend note that residents are often harder on themselves and bring up issues that the attending might find unremarkable. “When this happens, it gives me a peek into how insightful the resident is about his/her own performance,” said Dr. Fallahian. “It is important to remember that feedback is not only about the negative, but about highlighting successes as well.”
Prioritizing patient safety
Dr. Townsend often circles back to the mutual focus on patient safety, especially in difficult conversations. “If there’s a patient safety issue, I tell the resident that I want him/her to learn from that experience while keeping the focus of the feedback on patient safety rather than resident performance. I say it’s a learning opportunity and, if you were perfect, you wouldn’t be a trainee. Our residents are always rightfully concerned about causing harm, so I will often conclude by reminding them that the patient is doing well in the recovery area.”
In high-stress situations, it’s almost always better to reconnect later in a controlled, private setting. However, if there’s an issue in the middle of the procedure, it’s not always possible to postpone the discussion. Dr. Townsend advises giving simple, clear instruction during a procedure. She acknowledges that sometimes the attending needs to step in during a high-stakes procedure. The postop debrief needs to focus on the situation, not the resident, because oftentimes there are systems issues that can be improved, not only individual performance.
Avoid relying solely on written feedback
These debriefing discussions are valuable in highlighting what went wrong at the end of the day so the resident can make immediate changes. Sometimes Dr. Fallahian even asks the residents what they’ll do differently next time or change about their care as a result. What she wants to avoid is the all-too-common pitfall of sharing written feedback a month later and losing the opportunity to affect change earlier.
In situations where negative feedback is warranted, Dr. Townsend always has a conversation with the resident so there are no surprises on the written evaluation. “It helps lessen the blow when I call the resident in ahead of time and say I have to include a negative comment on their evaluation, but I also reinforce what went well and how the resident improved,” she said.
Focusing on the positive is a mainstay for both physicians. When Dr. Fallahian offers negative feedback, she always includes something positive. “I never give negative feedback alone. Even if 90% of the day was not ideal, I still bring up the 10% that went well,” she noted.
If this philosophy is different than the bullying mentality prevalent in generations past, both Drs. Townsend and Fallahian believe that’s a good development. “People don’t need to be crushed during residency,” Dr. Fallahian pointed out. “The mutual goal is for them to be competent and able to safely care for patients when they finish residency.”
Robin Hocevar is senior content editor at Wolters Kluwer, ASA Monitor’s publication partner.