The other day I witnessed one of my partners talking to another. One was explaining to another how he had seen a patient who had ben evaluated a couple of days earlier. The patient was doing worse and required admission to the hospital and the “consultant” was “shocked” that the patient had been sent home on the first visit. The conversation occurred at shift change. It was in a public area. The physician giving the feedback felt the need to pass along the information and point out the error the other physician made. The physician giving the feedback used the consultant’s opinion as leverage. And, he was not open to listening to the other physician, constantly cutting him off, and asserting that the care was not adequate. Needless to say, the conversation did not go well.

I spoke with both the physicians after witnessing the conversation: 

  • Feedback giver:  “You agree right? It’s clearly wrong, right? He shouldn’t have sent her home… I was just trying to tell him about it. It’s my responsibility to tell him right? “
  • Feedback receiver: “What’s with that guy? We trained to send those people home in residency. We do it all the time. The patient did well, looked great… this consultant is practicing old school medicine. This is ridiculous. Who does he think he is to give me feedback anyway?”

Giving anyone feedback is a learned skill. In fact, in 2017, the European Respiratory Society published an excellent article discussing how to give and receive feedback in healthcare, in its journal Breathe1. Most people view this process as one filled with conflict and want to avoid it. But, avoiding feedback is detrimental to you, wether you are the supervisor or the provider. If you are the provider and you receive no feedback your assumption is that your performance is good (otherwise someone would have said something). If you are a supervisor and you avoid giving feedback because you shy away from conflict, then poor performance continues and is reinforced as something that a provider should do, which can lead to their termination. 

But, before we get into the details of how it’s done, here are some caveats to keep in mind: 

  • Feedback is not conflict. It is an expected part of any employment. Most people WANT to know how they are doing. Avoiding it results in actual harm to a provider’s career and patients.
  • Feedback is not just negative. Positive reinforcement is just as important. 
  • Feedback is necessary. Improvements in patient care and safety can’t be made without it. 
  • Feedback is not correcting an error.  Errors should be addressed immediately. For example: a physician orders 1 gram when it should have been 1mg. 

So how is it done correctly? Here are 10 things that will help guide delivery of feedback. 

  1. Give the feedback personally, not to a group, and avoid generalities. 
  2. Find the right time: not on shift, not in the midst of a terribly busy day, not when you both don’t have time to devote to the conversation. 
  3. Find the right place: a quiet office, physician lounge, a corner of a coffee shop. Not a hallway. Not a public stairwell. 
  4. Know yourself: Account for how you are feeling before starting. Make sure you are calm,  you are ready for an unexpected reaction, and you have time. 
  5. Know the facts: Do you have all the details? Have you read the chart? Have you spoken to the consultant? Have you done any research into the topic or revisited your protocols? Passing along someone else’s words without doing the digging is NOT helpful. It may be the complaint originator who needs the feedback.
  6. State the problem and wait for the response. Explain the facts and your conclusion. Ask if they draw the same conclusion? Be specific ! 
  7. Don’t interrupt. It isn’t a race. 
  8. Listen and acknowledge. You don’t have to agree, but acknowledge what the person is saying.
  9. Have recommendations: Put yourself in their shoes, and have a suggestion on how to proceed. Offer some advice on how to move forward. 
  10. Write it down. As a supervisor, your feedback is important. Your corrective feedback should be documented. You don’t need a court stenographer present, but you should keep a record of the conversation, and let the person know it. This is not hostile, it’s just the process. That way you can say “ we talked” and “you are doing much better and have improved”

With practice, you become more comfortable with the setting, timing, and process. In addition, providers become comfortable with your process. That is when everyone begins to benefit.

References:

  1. Hardavella G, Aamli-gaagnat A, Saad N, Rousalova I, Sreter KB. How to give and receive feedback effectively. Breathe (Sheff). 2017;13(4):327-333. PubMed , Full Text
  2. Dossett LA, Kauffmann RM, Miller J, et al. The Challenges of Providing Feedback to Referring Physicians After Discovering Their Medical Errors. J Surg Res. 2018;232:209-216. PubMed , Full Text
  3. Kaye AD, Okanlawon OJ, Urman RD. Clinical performance feedback and quality improvement opportunities for perioperative physicians. Adv Med Educ Pract. 2014;5:115-23. PubMed , Full Text 
  4. Pozen, Robert C. The delicate art of giving feedback. Harvard Business Review. March 28, 2013. (Link)
  5. Maguire, Phyllis. The art of giving feedback. Today’s Hospitalist. September, 2008. (Link)
  6. Oregon Health & Science University. Giving and receiving feedback. (Link)

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