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Trainee Evaluations, Reviews, and Confidentiality: Building Psychological Safety

So far, in the current blog series, I have explained why I have changed my mind about resident progress and evaluation transparency. I have also offered a series of questions programs can utilize to improve the gaps (as I see them) that may exist. Today I want to provide a reminder of why it matters – which boils primarily down to psychological safety.


Psychological safety is a concept that gets more attention than it once did, and rightly so. A psychologically safe environment “encourages, recognizes, and rewards individuals for their contributions and ideas by making them feel safe when taking interpersonal risksIt’s one that is built on respect and permission” (Definition from Psych Safety)


Dr. Timothy Clark, an Oxford-trained social science expert, and author of the Four Stages of Psychological Safety, lists the progressive stages. In order, they are:


  1. Inclusion safety fulfills the need to belong and be connected. Note this is foundational to fostering the escalating levels of security. Because we are hardwired for threat detection (physical and social alike), effort needs to go beyond “we are happy you are here.” It’s a shift from, “You are lucky to be here” toward one that demonstrates, “We value you. Your qualities, and yes, even your differences, make us more whole.”


When trainees don’t feel they belong, they must keep the impostor mask of perfection up for self-protection. It causes undue stress.


What can you do as individual upper-level residents and attendings do to create a culture of connectedness and belonging? What can the program offer to foster the same? What must change?


  1. Learner safety fulfills the need to learn and grow. This is the POINT of residency training - an environment to learn. In this environment, trainees don’t face judgment or backlash for asking questions, not knowing the answer, or giving feedback. Human imperfection is normalized, and the individual receives helpful feedback for growth.


When it’s not perceived as safe, the mask stays up. They fear speaking up on rounds for fear of “looking stupid,” having a knowledge gap, or perhaps saying anything about an issue or situation they perceive as harmful. This impacts not only their education but team dynamics and patient safety.


How do you and your program normalize varying knowledge gaps from person to person? What approaches may exist within your program that could lead trainees to hold back? How will you change those?


  1. Contributor safety fulfills the need to make a difference. Once individuals belong and it’s safe to learn, the most natural step is wanting to add their value. Our trainees are like all humans – they desire to use their knowledge, skills, and experience to impact patient care, training quality, and hospital systems. A safe contributor environment allows for safety in making clinical decisions and participating in the plans, and the growth process continues. The trainees are free to contribute to the team, the residency program, to patient care in meaningful ways without the risk of public embarrassment or punishment.


This is where we, as supervising clinical educators, allow for progressive autonomy with guidance and encouragement in exchange for the effort and growth of the individual. While still occurring in many venues, micromanaging, dismissing ideas, or publicly embarrassing residents and fellows are damaging. Micromanaging leads to stunted independent growth and learned helplessness. Whereas, healthy guidance leads to self-efficacy and competent clinical independence.


How do you decide when to direct your accountability at the task, process, or outcomes level? What processes are you and your colleagues using to guide progressive autonomy? A coaching approach can help trainees realize how much they know (because many, by default, dismiss the knowledge they’ve gained), augment their clinical connections, and highlight knowledge gaps to fill. And you, as the supervisor, can use this information to determine the level of accountability. Whether you prescribe the exact medication, route, and dose or if you say, “let’s get their blood pressure down to more appropriate levels” or somewhere in between. If it feels unsafe for knowledge gaps to exist (no learner safety), then the attending’s questions can be perceived as “digging to find the weakness” instead of highlighting how far they’ve come. I wrote more about this subject of balancing autonomy with supervision HERE.



  1.  Challenger safety fulfills the need to make things better. We can create an environment that allows individuals to speak up if they see something that could be improved. It allows for various perspectives to be spoken. It removes the pressure of conforming to the status quo, which often needs to be tested in changing times. The voices are welcomed and considered, and the culture is such as the individuals don’t lose their standing or have other negative consequences for offering a different perspective. Dr. Clark describes it this way, “the safety matches the increased vulnerability and personal risk associated with challenging the status quo.”


How do you support trainees to speak their opinions without fear of retribution? In what ways is meaningful consideration given to those ideas? And in what ways can you encourage and provide opportunities for such? Many of you likely offer the opportunity through the ongoing program evaluation committee. In what ways are dissenting opinions handled and considered? Is there room for improvement? What approaches may exist to discourage trainees from sharing their views and questioning clinical decisions or system processes? What adjustments could be made?


Psychological safety takes attention at all levels. Lack of it creates a culture of emotional exhaustion, fear, and disengagement. When it does exist, our trainees are more fulfilled, engaged, and confident and perform at higher levels to reach their potential.


Next week, I’ll offer concrete steps for mitigating implicit bias in reviewing trainees for remediation, extension, promotion, and graduation.

Until then, Have a Joy-filled day!


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