It is the last afternoon of a month's rotation with the resident team. Post call, the intern is trying to discharge her patients before the weekend. You enjoyed your month and felt that the intern had a solid fund of knowledge and connected well with her patients. Occasionally, however, she overlooked details and you caught several mistakes before discharge. Overall patient care did not suffer, but the process could have been more efficient. The hospitalist decides to give the intern this feedback.
The intern sits down at the nursing station with her attending. He says “You have been doing a great job, but I am concerned that you are forgetful. Three weeks ago you made a few mistakes on discharges.” The intern looks around at the other interns in the area, becomes tearful and then quiet. She sits with arms folded, and after many long silences or one-word responses to further questions on her self-assessment, she stands and says “OK I have to go now. Is there anything else?”
This case raises several questions:
- Was this the best time and/or setting to give feedback?
- Did the hospitalist learn anything about the learner's self-assessment?
- How could the hospitalist have received feedback on his own teaching?
In this example, the process of providing feedback was not perceived as constructive. The intern received negative feedback in a public place, at the end of a post-call day, when she was tired and under stress to finish her work before the weekend. Once she felt humiliated before her peers the intern likely heard nothing more and could not absorb or reflect on what transpired. The hospitalist lost an opportunity of identifying extenuating circumstances that might have affected this intern's performance. The intern probably would not have informed him of any psychosocial stressors, illness, or personality conflicts in front of others. If identified, the hospitalist had a responsibility to communicate true concerns to the program director.
Perhaps the hospitalist could have provided feedback to the intern earlier in the rotation, so that it did not come as a surprise on the final day. “Forgetful” also seems like a judgment on this intern as an individual. Instead, specific examples of what was overlooked immediately after the initial events would probably have been more actionable. The hospitalist also did not take the opportunity to elicit specific feedback about his own performance, or about the learner's experience as a whole.
This case demonstrates how important it is to provide feedback in a nonjudgmental manner with careful attention to the timing and location, so that the learner can have the space and time to absorb and reflect. The feedback is also not timely or specific.
In this particular example, the hospitalist probably should have checked to see if this was an appropriate time to give feedback. “I know you are post-call and have a lot to do before leaving. Do you have time to meet today? I would like to exchange feedback.” If not, rescheduling to a later date is likely appropriate but do not leave the rotation without a scheduled time and place in hand or at least a plan to check back on a certain date. This is akin to the patient being discharged without a follow-up appointment: it is much more challenging to arrange later!
During the session, he could have begun with: “How do you think this month went for you? Do you feel you met your own learning goals?”
Once the learner has shared her self-assessment, the hospitalist could then have shared his observations: “I observed the way that you explained Mrs. Smith's heart failure regimen changes to her and to her family. You gave a clear explanation about why we discontinued hydrochlorothiazide and added furosemide and lisinopril to her regimen, and you patiently answered her questions regarding her other heart failure medications. I was concerned that some details were overlooked during the discharge process. On two occasions patients were discharged without ACE inhibitors.”
After a pause to allow her to digest the information, “May I ask how you typically reconcile medications on discharge? How can we come up with a method to help remember key medications?”
After core suggestions are discussed, “May I ask for some feedback? How did my communication style work for you? Was I available enough? What could I have done differently?”