Where the absence of criticism is the highest form of praise

Ole Kristian Losvik About the author

The path through the residency feels like running as fast as possible from one trench to another to avoid being shot.

Being a foundation doctor means being exposed to an experimental form of learning. From one day to the next, I try out various versions of being a doctor. When trying out various ways to perform diagnostics and treatment, I draw on the knowledge from my studies. I choose strategies based on my knowledge and prior feedback. If I err in my judgement, feedback sometimes ensues, most often in the form of a note in the records system.

As one of the last foundation doctors under the old scheme, I have now made it well past the mid-point (1). I rotate from one department to the other, and I have worked with hundreds of colleagues. The speech recognition system has learned to understand what I am saying, and not least, I have learned many new diagnostic codes that generate more income for the health trust.

Nearly all feedback that I receive is related to the absence of diagnostic codes in the patient’s medical history. The remaining feedback mostly states that a blood gas measurement should have been taken or that insufficient diagnostic imaging has been requested. In addition, I have sometimes been provided with a copy of the discharge summary of patients who have died during their stay in hospital.

«Elective ignorance was a great survival skill, perhaps the greatest» (2). This quote from Jonathan Franzen’s The Corrections provides a picture of the social corruption that has followed society’s «progress». Reorganisations, documentation requirements and time constraints result in moral stress in more than half of all Norwegian doctors, the youngest of them included (3). Elective ignorance became my method for disregarding feedback, messages that I found to be neither relevant, nor constructive for my work or training (4). It is in fact a rather immature mechanism for incorporating criticism.

I am far from the first person to ask for specific, relevant and constructive feedback (5, 6). Educators often use the health services as an example of a master-apprentice type of learning. Just as in the skilled crafts, skills, knowledge and attitudes are transferred from an experienced clinician to a young doctor. I am uncertain whether I should consider my appointed supervisor as my master. Perhaps it is the senior consultant who is in charge of the ward on a daily basis? At any rate, I have had a fair number of masters during my medical apprenticeship.

It has been shown that doctors are poor at self-assessment (7). Supervision and feedback are thus more than a matter of training, they also impinge on patient safety. I believe that corrections along the way are an essential part of the training of skilled clinicians. Unfortunately, my impression is that the provision of feedback in the world of the contemporary hospital has been reduced to pointing out errors. Provision of positive feedback would facilitate a far larger number of corrections, including praise when good clinical judgement has been exercised. Good practice goes far beyond the absence of malpractice.

The drive for efficiency in my university hospital has caused reporting to disappear. Before the blood samples and the x-rays have been taken I have already dictated the entry records on my recording device. The patient is followed up efficiently by the next doctor, without me needing to give it any thought. Thus, the need to confer has nearly disappeared. Gone also is one of the most common arenas for provision of feedback. Most of my patients I never see again. The duty of confidentiality bars me from knowing more or learning more, once my responsibility as a therapist has been completed.

Giving and receiving feedback is a skill with a theoretical framework that can be learned (8, 9). At its best, feedback gives rise to reflection. The best reflections will provide insights to both master and apprentice – provided that they have the time in our increasingly industrialised hospitals.

If employers and universities see the value of feedback as a method for training good therapists, they also need to put it on the agenda. Feedback and supervision cannot be something which is provided after all the discharge summaries have been completed well ahead of the seven-day deadline. Perhaps this could have a place on the curriculum, along with diarrhoea and microbiology?

Most likely, the life of a doctor is much like life in general; the finest words are spoken on the last day. Many fine words were uttered in the Department of Internal Medicine when I had completed my period there. In fact, I had heard words of praise even earlier: the nurses give you kudos if you discharge many patients; many were also very satisfied with my quick treatment of patients in the emergency reception. Once, my patient died, and then I received positive feedback in the morning meeting as well. A pat on the back for a lost battle.

1

Losvik OK. Ny turnustjeneste – ferske frustrasjoner. Tidsskr Nor Legeforen 2013; 133: 731. [PubMed]

2

Franzen J. The Corrections. New York: Farrar Straus & Giroux, 2001

3

Førde R, Aasland OG. Moralsk stress og faglig ytringsfrihet blant leger. Tidsskr Nor Legeforen 2013; 133: 1310 – 4. [PubMed]

4

Tunold O. Turnustjeneste er både læring og arbeid. Tidsskr Nor Lægeforen 2007; 127: 2118 – 20. [PubMed]

5

Bahar-Ozvaris S, Aslan D, Sahin-Hodoglugil N et al. A faculty development program evaluation: from needs assessment to long-term effects, of the teaching skills improvement program. Teach Learn Med 2004; 16: 368 – 75. [PubMed] [CrossRef]

6

Bing-You RG, Trowbridge RL. Why medical educators may be failing at feedback. JAMA 2009; 302: 1330 – 1. [PubMed] [CrossRef]

7

Davis DA, Mazmanian PE, Fordis M et al. Accuracy of physician self-assessment compared with observed measures of competence: a systematic review. JAMA 2006; 296: 1094 – 102. [PubMed] [CrossRef]

8

Branch WT jr., Paranjape A. Feedback and reflection: teaching methods for clinical settings. Acad Med 2002; 77: 1185 – 8. [PubMed] [CrossRef]

9

Ende J. Feedback in clinical medical education. JAMA 1983; 250: 777 – 81. [PubMed] [CrossRef]

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