Creating a Culture of Feedback, with Acknowledgements

I tried to attend a Department of Psychiatry Grand Rounds presentation recently titled “Creating a Culture of Feedback” by my colleague Dr. Allison Williams, MD. I say “tried” because only a few minutes into the presentation, I got paged out. That’s what I get for being a psychiatric consultant to the general hospital. I couldn’t get back to the presentation but Dr. Williams sent copies of the slides as email attachments.

Feedback is on my mind a lot, only partly because of the Maintenance of Certification (MOC) processes which include peer and patient feedback activities that I and thousands of other physicians are required to personally solicit in order to satisfy the American Board of Psychiatry & Neurology (ABPN). It’s a mandate, which I don’t need and which I would like to reform, or more correctly, see rescinded. Philosophically, I don’t believe you can mandate self-reflection in physicians. We have to believe in it and practice it by choice.

The presentation was about feedback by faculty for the benefit of resident physicians, though. It reminded me how hard it is to get honest feedback just from my peers and patients. I’ve posted about this:

The Results So Far of My ABPN Peer Feedback – The Practical Psychosomaticist

Soliciting Patient Feedback both for the MOC/PIP and Patients: How Am I Doing? – The Practical Psychosomaticist

I can’t speak for anyone else, but I’m badly in need of more practice and guidance about how to give useful, kind, and targeted feedback to learners. I have painful reminders about my style every time I attempt it. I hardly ever get feedback, so it’s tough to know how to deliver it myself. Oh, I get a lot of “Hey, great job on that fill-in-the-blank–but that’s not feedback. We have a system of regular, required peer review that’s mandatory for fulfillment of Joint Commission standards.

But I never get those returned to me, so I don’t know what’s in them.  And I can’t learn from what I don’t hear. I am aware of my shortcomings–I think. I often sound just like Dirty Harry, more related to repeated episodes of laryngitis from being required to stay on duty, sick or not, as an intern for rounds, 30-plus hours on call, and regular abuse from senior residents than from innate grittiness. That kind of “Go ahead; make my day; do you feel lucky–punk?” verbal insensitivity doesn’t play well. But it’s what doctors in my day were routinely taught. Some might consider whether doctors-in-training back in the day were vulnerable to Post Traumatic Stress Disorder (PTSD) in that kind of environment. Many physicians might reply with “I don’t have PTSD. I cause PTSD.” Now repeat that back to me. No that’s all wrong; lower your voice. Go practice in front of a mirror and don’t come back until you get it right.

See how that works?

OK, so I’m exaggerating…a little. I hope that someone from the Federation of State Medical Boards (FSMB) is reading this. This is called brutal reflective self-assessment, one of the three components of effective life-long learning in medicine and part of the framework of Maintenance of Licensure (MOL) currently being rammed down our throats. Hey, I can do this by myself, OK? And I do this because I want to do it and because I believe it’s the right thing to do. That’s the only way reflective self-assessment works. For the sake of completeness, the three components are:

1. Reflective Self-Assessment (What improvements can I make?): Physicians must participate in an ongoing process of reflective self-evaluation, self-assessment and practice assessment, with subsequent successful completion of appropriate educational or improvement activities.

2. Assessment of Knowledge and Skills (What do I need to know and be able to do?): Physicians must demonstrate the knowledge, skills and abilities necessary to provide safe, effective patient care within the framework of the six general competencies as they apply to their individual practice.

3. Performance in Practice (How am I doing?): Physicians must demonstrate accountability for performance in their practice using a variety of methods that incorporate reference data to assess their performance in practice and guide improvement.

OOPS! It looks like “brutal” is not a part of the first component.

Once, when I was a junior resident, a faculty supervisor said to me, “You’re going to piss somebody off…” or something to that effect. I waited for something else, a little more detail, maybe some advice. I didn’t get it, in more than ways than one, apparently. I think he tried to “learn me hard”, but something got lost in the translation.

So I was eager to get something new from “Creating a Culture of Feedback”–but got paged out. That’s what it means to be a psychiatric consultant in an 800 bed hospital. On the other hand, I could glean something from the presenter’s slides.