Oct 27, 2015
By Alyssa G. Rieber, MD, and Robert A. Wolff, MD
Department of General Oncology, The University of Texas MD Anderson Cancer Center
Our hematology/medical oncology fellows have become experts in receiving feedback. They have successfully completed medical school and internal medicine training, with monthly evaluations and semiannual Clinical Competency Committee assessments. They have navigated 360 evaluations, continuity clinics, and Program Director (PD) summaries.
With this experience, one would assume that feedback during fellowship would be welcomed and straightforward. This is true for the majority of our trainees at The University of Texas MD Anderson Cancer Center. They expect their clinical skills to progress over time and to be well-respected by faculty and staff. Most fellows have confidence in their professionalism, patient care, and interpersonal communication. In general, our fellows quickly adjust to being “average” in a pool of overachievers who have been given positive feedback (and praise) most of their lives. Thus, feedback sessions are an opportunity to acknowledge strengths, reinforce the rewards of hard work, and encourage clinical excellence, while concurrently offering suggestions for improvement. During interactions in the ambulatory clinic or the inpatient service, immediate one-on-one feedback from faculty is expected. In addition, receiving feedback from as many providers and ancillary staff as practical is critical to the evaluation of the trainees.
Our 360 evaluations provide the most detailed information and can reveal concerning behavioral trends not discerned through other mechanisms. These evaluations are performed during the second year in the fellows’ general oncology continuity clinic. Over time, our clinic and research staff members have become comfortable expressing their perceptions of the fellows during the 360 evaluation, providing a well-rounded evaluation. Following these evaluations, the continuity faculty member meets with each trainee individually to review their performance in detail. During these sessions, faculty members are expected to highlight three notable strengths of the trainee, and using a constructive approach, provide feedback about three areas requiring improvement. Goals can range from returning pages in a timely manner, to courteous interactions with clinic staff, to enhancing their English language skills.
On occasion, deficiencies are identified in at least one core competency that require remediation. For some core competencies, such as medical knowledge, improvements can be measured with standardized tests and remediated through a structured plan. This feedback is usually direct and progress easily tracked. There is little drama associated with these sessions and the fellows appreciate advice about specific strategies to bolster their fund of knowledge.
Deficiencies in the more personal competencies require nuanced feedback. Professionalism and interpersonal concerns need to be substantiated from more than one source, unless truly egregious behavior is exhibited. We encourage our frontline faculty to make the first attempt at addressing small problems with real-time feedback to prevent future occurrences. Most faculty members are capable of addressing minor infractions, such as tardiness, miscommunication, and rotation-specific expectations.
Repeat offenses or complaints from several faculty members are communicated to the PD or Associate PD (APD). The trainee is then expected to meet with the PD or APD for a one-onone discussion. In many instances, this may be the first time the trainee has become aware of concerning behaviors and an emotional or defensive posture may ensue. During these meetings, fellows are encouraged to reflect on the feedback, not react to it. Fellows are then given the opportunity to remediate with a clear timeline and metrics regarding future evaluations.
When needed, fellows are removed from contentious situations, specific concerns are documented, and selfdirected solutions encouraged. We utilize our Employee Assistance Program as a resource for fellows in order to evaluate for impairment, including substance abuse or psychological disorders. Any underlying physical or psychological conditions could manifest themselves in unprofessional behavior and should be appropriately treated. Fellows are offered protected time to evaluate their personal situation and address any conflicts or problems in their personal life. After a time-out (usually lasting two to four weeks), we reconvene to formulate a specific performance improvement plan. Fellows are expected to take ownership of any deficiencies identified and work to address them. In our experience, those who acknowledge the need for improvement succeed in doing so. Those who resist continue to struggle.
In summary, providing feedback is an important component of fellowship training and most trainees welcome it. Giving frequent, timely feedback is encouraged among the faculty. Our 360 evaluation in Year 2 provides a valuable mechanism for uncovering deficiencies not easily identified in other settings. Feedback is best received when positive skills and attitudes are discussed in combination with areas in need of improvement. Fellows are advised to take a reflective, non-reactive approach to feedback sessions, with emphasis on our confidence in their ability to succeed.
Quick Tips for Evaluations
When giving feedback: When possible, try to give constructive criticism in the moment, in real time. Balance feedback about areas for improvement with feedback about positive attributes. Provide specific examples to illustrate both strengths and weaknesses. Be candid but professional.
When receiving feedback: Remember that feedback is a gift and everyone has room for improvement. Reflect, don’t react—take time to really think about the constructive criticism without taking it too personally. Take ownership of your areas for improvement. If not provided, ask for a clear timeline and specific metrics to track your improvement. Utilize Employee Assistance Programs to address personal challenges impairing your professional development.