I do like a good milestone. So, while I may or may not make any resolutions for the New Year, I think it’s important to pause, reflect, and refine. This year I used Sahil Bloom’s annual review. The first question was, “What did you change your mind about this year?”
At first glance, I wondered, “Did I actually change my mind about anything?” But, just like anytime we give our brains space to answer and reject the initial “I don’t know.” or “Nothing.” the answers began pouring out.
One that is fresh on my mind as I’ve been coaching residents and faculty in various family medicine residency programs is that of evaluations and consensus. I like a good progressive reveal, so let me dig back to my earliest memories to highlight a few stories that fit this reflection.
Case Study 1: I was an intern on my inpatient medicine block, taking call with an R2 IM resident. I had heard rumors from faculty and residents alike that they were worried he was clinically “weak.” (Way to soothe my anxiety on my first night of cross-coverage for four medicine teams and new admits! 😅 )That night was busy.
In the midst of several common diagnoses, we admitted one rather sick younger patient. He had anemia and acute renal failure. We decided he needed a vas cath in preparation for urgent dialysis. The senior spent the night looking up information in the Washington Manual and Ferri’s Lab Handbook. (This was back in the day when you had to remove the spiral binding and thread a leather shoestring in its place so it would fit in the white coat pocket.) At one point, he grabbed both volumes of Harrison’s between phone calls to attendings. He led us through stabilizing the patient and the diagnostic plan that eventually led to the diagnosis of paroxysmal nocturnal hematuria.
On the day team, with my regular senior and attending, it was great to see how impressive an impact we were making in this young man’s medical course. It wasn’t long before our attending asked the daytime senior and me to consider writing it up as a case study. (I wrote up my section and handed it in, I have no idea where the process stalled).
Looking back, I’m not sure anyone credited the on-call senior whose competence had been questioned. I don’t recall anyone asking me how calmly and methodically he handled the situation. I felt very much supported that night as it progressed, and I gained respect for him. I also wonder, on this side of it, why I heard faculty (not just residents) comment on his abilities as an intern from another program.
Case Study 2. Fast forward several years when I was new core faculty. We had an intern who it was clear didn't have a solid baseline medical knowledge. We discussed it as a faculty frequently. He wasn’t my advisee, so I was peripheral except for a few short clinic interactions and a few night calls. Nothing earth-shattering in my interactions.
The stakes grew higher when he was asked to repeat the year. And then it became an almost additional year-long process of trying to get him up to speed. From a faculty standpoint, it took extra manpower to have someone assigned to work with him one-on-one, more meetings, discussions, IEPs, and evaluations (this was prior to a CCC being formed). It was exhausting, and we all lost much of our admin time.
From his point of view, he was under the microscope. His every thought, decision, and action were under tight scrutiny -- to a level, no other resident was held. And he became frustrated that he was the subject of many faculty meetings. Understandably, his emotions became unmanageable under such pressure. It became apparent that he could not make up his clinical deficits in that atmosphere, and he eventually left. (A few years down the road, he became a board-certified family physician loved by his patients).
I wondered if we could have done it better.
Case Study 3. There were other residents who were in difficulty during my time as core faculty. One ended in non-renewal of contract, one resigned, and the others successfully graduated. In each case except one, I was on the periphery of the process, though I knew many of the intimate details. The one in which I was more integral to the remediation process was fascinating. When there was enough time to chat and the resident felt safe enough to be open, they conveyed that they knew much more than they could express in clinical inquiries. They walked me through concrete examples. The resident expressed that they liked to be more thoughtful and deliberate in answering (i.e., slower), which was easily misinterpreted as not knowing. They also expressed that being scrutinized and asked questions on the spot hindered their ability to articulate their clinical thinking. They explained what was going on in their mind – what they were considering, self-editing, etc. – trying to say “the right thing in the right way.” Once we supported them with this lens, with less pressure and more time to express their thoughts and reasoning ("thinking out loud"), the faculty could see he was on track.
I wondered how we could create an environment where residents could overcome their self-doubt and actually dialogue about their thought processes.
Case Study 4. As on-call faculty, I now miss out on the conversations in faculty meetings and am not privy to revelations of the CCC. There have also been more extensive overhauls of what things are discussed about trainees and with whom – essentially, narrowing the circle of who is aware of any issues. This threw me for a loop when I was contacted to work with a senior resident in difficulty that I had precepted just a few weeks prior. She had been on the radar of the CCC for some time, and they wanted an external person to work with her. I was shocked they hadn’t let us on-call faculty know the concerns – and I expressed such. When asked how it would have changed anything, I retorted that I would have asked her more questions, dug more in the charts when supervising her, and slowed her down despite her trying to improve efficiency. It felt valid at the time.
Though I have to admit, I did wonder the actual necessity of it.
Case Study 5. This past year, my mind changed. I worked with a resident outside of his program. He found out several months ago that the faculty had been discussing his progress and concerns on evaluations at a faculty meeting. This was long before he was aware of any issues as most of the evaluations he’d seen seemed fine to him (which is a whole other challenge). When asked, he wasn’t sure if it came up as a routine, periodic review or from some incident or evaluation. He was unaware that all programs must undertake routine reviews of residents. But he was unnerved that he was being discussed behind "closed doors" without knowing about it.
It happened again when a student gave non-written feedback to an attending, even though that student had reported positive feedback in person to the resident. He was called into the advisor's office for a meeting (with the surprise guests of the PD and BH faculty). He learned that the attending had interviewed the entire team in preparation for this meeting. This, again, was before the resident knew anything about the contrary verbal feedback. To him, it felt like there had been a judge, jury, and a verdict before the alleged culprit had been notified. The level of mistrust, insecurity, and feeling blindsided was overwhelming. I believe this would be the same for almost anyone. However, his experience was amplified through his life experiences dealing with bias and blatant racism.
Now, my job as the coach isn’t to judge the program or take sides (clearly, I don’t have all the details). Nor is it to tell the resident how they should handle it. I partnered with him, and he uncovered his best way forward to address the feedback in a growth-mindset manner. He decided to take what was useful feedback from the second-hand student report and let go of what wasn’t. He decided what needed to be communicated to the attendings involved and what he could allow people to be wrong about. He ultimately also decided that because he felt unsafe and unsupported by the manner of the meeting and how the feedback was handled, he would document more. He planned to talk with his advisor about how he experienced that meeting and what would have felt more supportive. And he ultimately decided he would have low expectations that the program would make any changes and that at this point in his life, it was not his to bear. Wow! The maturity and kindness this resident extended are admirable.
But these two incidents with that resident, plus reflecting on the ones I mentioned above, have changed my mind about the need for all to know. There is a tension that exists - the best approach to faculty being informed for optimal supervision vs. resident evaluation and review privacy. While as a younger core faculty, I wanted to know everything about everyone - in part I told myself to do the best job and to be a support - I suspect there was also just a level of curiosity that didn't need to be filled. And in fact, full transparency with resident reviews and evaluations may prime faculty to find deficiencies.
There is a balance here that I suspect is one of those situations in which a rigid rule won’t solve. Many residencies have written rules (and follow them) for the CCC to disclose information to others not on the CCC. Advisors are usually looped in. And when there are concerns the PD must be notified. So, maybe now it's not a matter of the process for many programs so much as it's about the transparency of the process, the order of notifications, and honoring the system in place. But I do believe there is room for all of us to evaluate our process and have the flexibility to adapt to unique situations.
Next week, I’ll unpack a bit more about psychological safety in such settings and offer my perspective and suggestions for best practices. In the meantime, feel free to email or message me your experiences, articles, or suggestions.
Until then, Have a Joy-filled Week! Tonya
If you have a resident in difficulty that would want to opt-in to coaching, I'll be happy to work with them as a safe, confidential thought partner to help evaluate the feedback, gain insight, formulate plans and navigate the emotions that come up in such difficult times. Learn more HERE