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Until relatively recently, becoming a physician was a process in which the student began as an apprentice to an already skilled clinician. Eventually, both university- and hospital-based schools became part of the process, but an apprenticeship component persisted. In 1910, with the release of the Flexner Report, medical education here in the United States was revolutionized with a shift toward a more academic and scientific model already in use in Europe. While the path to becoming a physician grew more rigorous and science based when the students moved from the classroom and laboratory to the clinic and bedside, the process necessarily returned to its old one-on-one mentor-learner roots.
The venerable maxim of “See one — Do one — Teach one” that dominated my residency may still occasionally be whispered in the quiet corners of teaching hospitals, but I suspect concerns about risk management have discouraged its frequent application in hands-on situations. The development of artificial intelligence–driven mannequins may have finally relegated this remnant of an old cowboy (and girl) procedure-acquisition strategy to the dusty closet of medical education history.
However, when it comes to non–procedure based learning in clinic and hospital settings, the process continues to be one in which the inexperienced are expected to learn by observing their more experienced (sometimes only slightly more experienced) mentors. There may be some mini “lectures” on the fly during rounds explaining the rationale behind what the learner is observing, but “teaching” is still dominated by “Watch this — Try it when it’s your turn — Then we’ll tell you how you did.”
A recent survey in the journal Hospital Pediatrics reviewed in AAP News suggests that there is a problem with feedback, the final step in this three-step process. The investigators surveyed 52 residents and 21 fellows using a scale developed for industrial applications and found that, with the exception of delivery, the fellows scored better than residents in the feedback process. In interviews with a small subgroup of eight residents, the researchers learned that the two consistent impediments to obtaining feedback were 1) that the hectic pace of patient care placed a limit on opportunities (not surprising) and 2) a culture emphasizing “a positive, nurturing environment may have led physicians to avoid giving constructive criticism because it might hurt resident’s feelings.”
I have a friend who has held human resource (HR) positions in two good-sized teaching hospital systems. He certainly agrees with the time limitations component. He has also been involved in several cases in which trainees have accused senior physicians of harassment and unprofessional behavior because learners took issue with the manner in which they had been given feedback on their performance. One wonders if the institution(s) surveyed in this recent study had already experienced similar cases of discontent and have reacted by being so polite that feedback now lacks a feel of authenticity. This was a very small study, and it is hard to know how applicable the findings would be in a national sample, but I suspect there are more than a few teaching institutions in which kid gloves have become fashionable attire.
As my friend pointed out to me, substantial “generational differences” exist in many work places. Different generations may hold competing value systems when it comes to how feedback should be, and should not be, delivered.
None of us were trained in how to deliver a performance evaluation and feedback regardless of whether it was with one or two rushed sentences on a sprint from room to room on morning rounds or a more relaxed sit-down at the end of a rotation. We tend to lean on our own experiences of receiving feedback from our parents, from coaches, and most often from the models we observed as we came up through the hierarchy of medical training.
I found it refreshing to learn that at least one small population of the trainees may be willing, and even eager, to receive honest feedback even though it sometimes may come with a hard edge.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.
Until relatively recently, becoming a physician was a process in which the student began as an apprentice to an already skilled clinician. Eventually, both university- and hospital-based schools became part of the process, but an apprenticeship component persisted. In 1910, with the release of the Flexner Report, medical education here in the United States was revolutionized with a shift toward a more academic and scientific model already in use in Europe. While the path to becoming a physician grew more rigorous and science based when the students moved from the classroom and laboratory to the clinic and bedside, the process necessarily returned to its old one-on-one mentor-learner roots.
The venerable maxim of “See one — Do one — Teach one” that dominated my residency may still occasionally be whispered in the quiet corners of teaching hospitals, but I suspect concerns about risk management have discouraged its frequent application in hands-on situations. The development of artificial intelligence–driven mannequins may have finally relegated this remnant of an old cowboy (and girl) procedure-acquisition strategy to the dusty closet of medical education history.
However, when it comes to non–procedure based learning in clinic and hospital settings, the process continues to be one in which the inexperienced are expected to learn by observing their more experienced (sometimes only slightly more experienced) mentors. There may be some mini “lectures” on the fly during rounds explaining the rationale behind what the learner is observing, but “teaching” is still dominated by “Watch this — Try it when it’s your turn — Then we’ll tell you how you did.”
A recent survey in the journal Hospital Pediatrics reviewed in AAP News suggests that there is a problem with feedback, the final step in this three-step process. The investigators surveyed 52 residents and 21 fellows using a scale developed for industrial applications and found that, with the exception of delivery, the fellows scored better than residents in the feedback process. In interviews with a small subgroup of eight residents, the researchers learned that the two consistent impediments to obtaining feedback were 1) that the hectic pace of patient care placed a limit on opportunities (not surprising) and 2) a culture emphasizing “a positive, nurturing environment may have led physicians to avoid giving constructive criticism because it might hurt resident’s feelings.”
I have a friend who has held human resource (HR) positions in two good-sized teaching hospital systems. He certainly agrees with the time limitations component. He has also been involved in several cases in which trainees have accused senior physicians of harassment and unprofessional behavior because learners took issue with the manner in which they had been given feedback on their performance. One wonders if the institution(s) surveyed in this recent study had already experienced similar cases of discontent and have reacted by being so polite that feedback now lacks a feel of authenticity. This was a very small study, and it is hard to know how applicable the findings would be in a national sample, but I suspect there are more than a few teaching institutions in which kid gloves have become fashionable attire.
As my friend pointed out to me, substantial “generational differences” exist in many work places. Different generations may hold competing value systems when it comes to how feedback should be, and should not be, delivered.
None of us were trained in how to deliver a performance evaluation and feedback regardless of whether it was with one or two rushed sentences on a sprint from room to room on morning rounds or a more relaxed sit-down at the end of a rotation. We tend to lean on our own experiences of receiving feedback from our parents, from coaches, and most often from the models we observed as we came up through the hierarchy of medical training.
I found it refreshing to learn that at least one small population of the trainees may be willing, and even eager, to receive honest feedback even though it sometimes may come with a hard edge.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.
Until relatively recently, becoming a physician was a process in which the student began as an apprentice to an already skilled clinician. Eventually, both university- and hospital-based schools became part of the process, but an apprenticeship component persisted. In 1910, with the release of the Flexner Report, medical education here in the United States was revolutionized with a shift toward a more academic and scientific model already in use in Europe. While the path to becoming a physician grew more rigorous and science based when the students moved from the classroom and laboratory to the clinic and bedside, the process necessarily returned to its old one-on-one mentor-learner roots.
The venerable maxim of “See one — Do one — Teach one” that dominated my residency may still occasionally be whispered in the quiet corners of teaching hospitals, but I suspect concerns about risk management have discouraged its frequent application in hands-on situations. The development of artificial intelligence–driven mannequins may have finally relegated this remnant of an old cowboy (and girl) procedure-acquisition strategy to the dusty closet of medical education history.
However, when it comes to non–procedure based learning in clinic and hospital settings, the process continues to be one in which the inexperienced are expected to learn by observing their more experienced (sometimes only slightly more experienced) mentors. There may be some mini “lectures” on the fly during rounds explaining the rationale behind what the learner is observing, but “teaching” is still dominated by “Watch this — Try it when it’s your turn — Then we’ll tell you how you did.”
A recent survey in the journal Hospital Pediatrics reviewed in AAP News suggests that there is a problem with feedback, the final step in this three-step process. The investigators surveyed 52 residents and 21 fellows using a scale developed for industrial applications and found that, with the exception of delivery, the fellows scored better than residents in the feedback process. In interviews with a small subgroup of eight residents, the researchers learned that the two consistent impediments to obtaining feedback were 1) that the hectic pace of patient care placed a limit on opportunities (not surprising) and 2) a culture emphasizing “a positive, nurturing environment may have led physicians to avoid giving constructive criticism because it might hurt resident’s feelings.”
I have a friend who has held human resource (HR) positions in two good-sized teaching hospital systems. He certainly agrees with the time limitations component. He has also been involved in several cases in which trainees have accused senior physicians of harassment and unprofessional behavior because learners took issue with the manner in which they had been given feedback on their performance. One wonders if the institution(s) surveyed in this recent study had already experienced similar cases of discontent and have reacted by being so polite that feedback now lacks a feel of authenticity. This was a very small study, and it is hard to know how applicable the findings would be in a national sample, but I suspect there are more than a few teaching institutions in which kid gloves have become fashionable attire.
As my friend pointed out to me, substantial “generational differences” exist in many work places. Different generations may hold competing value systems when it comes to how feedback should be, and should not be, delivered.
None of us were trained in how to deliver a performance evaluation and feedback regardless of whether it was with one or two rushed sentences on a sprint from room to room on morning rounds or a more relaxed sit-down at the end of a rotation. We tend to lean on our own experiences of receiving feedback from our parents, from coaches, and most often from the models we observed as we came up through the hierarchy of medical training.
I found it refreshing to learn that at least one small population of the trainees may be willing, and even eager, to receive honest feedback even though it sometimes may come with a hard edge.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.