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Critical Feedback Is Actually Critical

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“OK, OK, one second, you did what?” There is a flurry of activity at the bedside of my ICU patient who is, simply put, not doing well. 

“I adjusted the vent … I increased the respiratory rate.”

I look at the resident standing across from me. She is visibly anxious. She has told me before that she looks up to me, and I know that I make her nervous. The patient we are caring for is very, very ill. She is a good resident, but the complexity of this particular injury pattern and the patient’s spiraling multisystem organ failure are simply above the normal skill set of a PGY-2. I slowly inhale as I figure out how to tell her that she’s missing the big picture without paralyzing her. There is much to learn from this case, and she is more than capable, but not if she feels incapable. 

“OK, yes, adjusting the vent may change the pH, but do you think that respiratory acidosis is truly the underlying issue here?”

She shifts nervously. The answer is not just one thing, and I want her to tell me that. The patient suffered a profound ischemic injury to his liver and kidneys during a period of hypotension when he first arrived as a level 1 trauma, leaving him incapable — hopefully, only temporarily — of clearing lactate hepatically or cleaning up the pH renally. What I want her to tell me is that he is developing compartment syndrome in his recently re-vascularized arm after successful, but time-consuming, repairs of his subclavian artery and vein, and that he needs to go to the OR, STAT. Despite her mask, I can tell that she has opened her mouth a few times to speak and then stopped herself before the words escaped. She doesn’t know what to say. I don’t know if this is because she doesn’t understand what is happening with the patient, or if she is too afraid of being wrong to chance it.

For the most part, the tantrum-prone surgeons of the past are extinct, or merely relics so close to retirement that they no longer have much to do with the day-to-day activities of the service. The types of abuse that I experienced or witnessed as a trainee are generally not tolerated by leadership, and residents are much bolder about reporting them when they do occur. This is undeniably a change for the better. But what has replaced explosive tirades is far too often silence. As a generation of surgeons trained in an era when outcomes unequivocally outranked demeanor, few of us have been taught how to deliver negative feedback well. Or if we have been taught, it was a presentation or two on constructive criticism, offering simplified lessons that stand in stark contrast to years of modeled behavior. The natural, easy move when unhappy with a resident’s performance is to avoid discussing the situation entirely. This is perhaps the most common maneuver adopted by surgeons who have been critiqued for their style of critiquing. But simply overstepping the situation and jumping directly to your plan for the patient cuts the resident out of the intellectual exercise completely, demoting them to the role of a scribe rather than an active participant and apprentice. 

In my first few years out in practice, it became abundantly clear that the surgeons who had best prepared me for the real world demands of this job were the ones who were consistently hard on me, regardless of their mode of feedback delivery. This job can be brutal. This job doesn’t care if you are having a rough day, or if your child is sick. The doors of the ED don’t close when you are tired or burned out or overwhelmed. Local bad actors don’t check in on your schedule before they decide if they are going to shoot or stab others. You must be ready, no matter what. You have to compartmentalize the rest and focus on the patient in front of you. You must perform under pressure regardless of the magnitude. That, for better or for worse, is the job. I am grateful that I trained in an environment where there was no such thing as an acceptable excuse. It prepared me for the real world, which holds me to that same standard. 

I sigh a little into my mask before I jump into this one, but I jump nonetheless. “The one thing this patient does not have is respiratory acidosis. Try again. Think about it.” There is a long pause and I let it linger for a bit. “What other reasons might this particular guy have to be tanking his pH? You can’t really treat anything well unless you know why it is happening, or at least have a starting differential.” 

We talk about it for a bit and she starts to pull the pieces together as we delve into the details. It feels good to hear the concepts and strategy coming out of her mouth rather than mine. There are some awkward pauses and uncomfortable moments as we work through it together, but it’s all worth it. One day in the very near future, that resident is going to get called at 3 a.m. for an incredibly challenging case. It is my hope that when that happens she’s ready, and that she looks back on today as one of those moments that made her so. 

How has the way feedback is delivered changed in medicine? Share your experiences in the comment section.

Dr. Danielle Pigneri is a Trauma and Acute Care Surgeon practicing in the Dallas-Fort Worth metroplex. When not working, she enjoys her other job, being a mom to two sweet young children. Dr. Pigneri is a 2022-2023 Doximity Op-Med Fellow.

Image by Alphavector / Shutterstock

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