I recently sent an email to our medical supervisors with just this one word in the subject line: Feedback. I asked them to reflect on the primary emotion and first thought when they saw the subject header in their email list. What did the word 'Feedback' bring to front-of-mind? It may have been: what do I need to know? Who said something about me? Have I done something wrong?
Feedback is a critical part of our development: it aids adaptation, learning and improves performance. Yet, for many doctors, the prospect of feedback is feared. For some, this is based on previous experience of receiving feedback in a harmful way. A negative critique in public, or a focus on personality or character rather than behaviours and skills to be developed.
Many doctors – even senior ones – experience Imposter Syndrome: recurrent self-doubt, despite clear evidence of academic and clinical success. Even outstanding performers can struggle, and medical culture perpetuates the incorrect assumption that those doing well know they are doing well.
As the current generation of supervisors, you can change the medical culture for the better. By taking an intentional approach to feedback for your trainees, they grow more quickly in clinical skills and self-confidence even if you have corrective advice to give.
Formative feedback
This is the day-to-day, week-to-week feedback we all need to guide our work practice. Experienced practitioners understand that feedback comes from many sources, but junior doctors often don't recognise this. We hear that feedback was not forthcoming, yet it was clear that supervisors did provide guidance – it just hadn't been explicitly labelled as feedback. See the box for an example of formative feedback. Formative feedback is more immediately relevant for learners – given the proximity to recently performed tasks and behaviours.
Empowering feedback
Feedback is most useful when it becomes part of a daily or weekly practice – set the expectation that you will give feedback to help the trainee grow. We need to create a positive learning culture and encourage learners to develop an interest in receiving feedback. Feedback is most useful for learners when it fulfils the following criteria:
It takes place close to the time of the learning event and in private
It's a two-way conversation.
Alignment with the learner's pre-established goals and objectives – the Term Orientation Form for interns.
It promotes reflective learning.
It avoids personal comments and judgments of character.
It concentrates on behaviours that can be changed and skills that to be developed.
It includes positive re-enforcement – even if there is no corrective advice to give.
Radical candour – care personally, challenge directly
Sometimes it can be difficult for supervisors to give feedback if the learner finds it challenging or even awkward. Kim Scott describes the need for 'radical candour' – guidance at the intersection of caring personally and challenging directly. Scott calls the x-axis shown here the 'willing to piss people off' axis, and the y-axis is about how much you care.
Radical candour in our interactions doesn't always come easily. We've grown up learning that if you don't have something nice to say, then don't say anything at all. Of course, it's easier to let these opportunities slip by, not to build a mentoring relationship. However, as supervisors, we have a moral obligation to those in our charge.
Note the alternatives to radical candour. Consider the aggressive doctor who berates the RMO in front of the ward round, the registrar that criticises the nurse at the patient's bedside. Feedback for these doctors must centre on both the inappropriate challenge and the lack of care; else, they slip into manipulatively insincere behaviours. Many supervisor omissions occur in the quadrant of ruinous empathy. No one wants to tell the person that they have a problem; they may care about the individual but don't have the courage or skills to confront them openly about what's going on.
Summative Feedback
This takes place at the end of a rotation or course of study and provides a final performance assessment. Summative feedback is the End Term report that Doctors in Training need to have completed. Although there should be no surprises by the time of the End Term report, it is essential to take the time to provide this summative feedback in person and give attention and ratings to the various domains of practice. Please complete the free text comments as trainees particularly value this qualitative feedback.
Summative feedback is an excellent opportunity to correct inappropriately low self-assessments of trainees. The consequences of failing to support the unconsciously incompetent doctor are well recognised. What is less clear is the detrimental effect of failing to recognise and support the unconsciously competent among us. I expect this is the cause of much self-doubt and may form the basis of the Imposter Syndrome described earlier.
Danny Tucker