Episode 95:


Whether it’s inadequate note taking, or if something is missing here or there or mistake, or some kind of habit, let’s face it. Not all doctors are very good, at coaching mentoring, or teaching some of them are very [abrought 00:01:07] in some cultures and specialties. They pride themselves in being mean to each other. You’re going to have criticism, the question is how do you handle it.

What I like to think of is to make the criticism constructive. It may not come across to you, in a way that’s constructive. It’s your job to find out what can I do different, what can I learn from this, what process do I need to change in order to make this improvement in this area. You’re going to put a positive spin with the tangible handle, something physically different that you’re going to do.

Make it action based, very much like the book Getting Things Done with David Allen. I highly recommend that audio book while you’re straightening at your office, and cleaning up your house. Especially if you’re going through a massive inbox, or making new files, anytime you’re organizing. The bottom line there is that instead of putting somebody on a to do list, that just says paint the house.

Break it down to the next physical, tangible step in that big project and put something like, go to Lowe’s and look at different paint colors, or something like that. Something that you can break down, in the simple action task. You’re going to do the same thing whenever it comes to criticism you received on clinical rotations. Let say for example, and I bring this up now because I just got a criticism.

I wasn’t putting enough information in my HPI, in my History of Present Illness section, okay. It happens sometimes I think it happens when you start getting a little [inaudible 00:03:12] that’s still a little bit early but regardless the straight forward, and wrote simple to me now and they want me to kind of write a little bit more. Most in this don’t. That’s a good side bar here is criticism you may get maybe just one person’s opinion and you might be getting prices in that same area from everybody else.

It could be just that one person, that’s giving you the criticism. Take it with a green assault, it doesn’t mean you’re a bad person. Remember the difference between shame and guilt, it just doesn’t mean you’re a bad person, it means you could improve in this area, your job is to turn it into a tangible handle. Look at that thing and say okay what specific task could I do different to change the process here, so that I can improve based on this criticism.

In other words how can I make this constructive. In this example, of not putting enough information in the history of present illness section. One thing that I could do different would be to before I’m done with my note, and complete my note. Go back and look and make sure that my note reflects all the substantiation and documentation require to make whatever diagnosis I’m suppose to make in the bottom, okay.

I normally do that, I made a mistake today. That happens, I can make more thoughtful effort. Let say I catch myself next week, doing the same thing again. I can realize, “Hey, just to have that memory, of I’m suppose to do this or that.” That’s not working, I need to adjust. What I need to do, maybe put a three by five card on their monitor something. I need to change something about my system or practice, make tangible handle.

Let me talk a minute about the dynamics with feedback, on the rotations. You get what they call the 360 degree feedback in a lot of places, some places have medical students billing out, reviews and performance evaluation on each other, and their attending, and their residence, and everyone else is doing it too. Everybody is providing written documentation and feedback on everybody else.

It could be you’re not in a system like that, that’s kind of where things are going, if they’re not already there it’s been like that for 10 years in the professional world. Outside the medicine it started in a business, and now they’re spreading the medicine. They think this is good for us, well I can say it’s probably good, though painful it’s a double edge sword. If it’s kept positive, and it has kept constructive.

Too often, people just file up negative documentation and I absolutely hate that. I would much rather say someone is doing good, good, good all the way down on the evaluation form. Then if I have an issue with him, go and talk to them about it first not just start filing up documentation because you have no idea who else documenting things about this person and you … Every time you’re going to document something negative, about somebody else.

You need to think what is the impact or weight that you want this to have. Are you intentionally trying to stack out documentation to possibly get somebody fired someday. Because it will look like that, if that ever comes happen in their life. I granted, that doesn’t happen in 90% of people. The 10% do face difficulty, do you want add fuel to the fire, or just go talk to them off line. I recommend talking them off line, or just letting it go.

I filled out a incident report against a nurse that improperly handle the patient that was having syncope, in front of the patients family while he was having altered mental status. He was very unprofessional, and dangerous. I filled out an evaluation report with the intent that I wanted to substantiate documentation that if she did indeed have a pattern like that, which she turned out she did after I’ve made my decision to do it anyway.

I intentionally wanted to contribute to her getting fired, if that were going to happen. In other words, don’t take criticisms lightly when you’re writing them for other people. If they are your buddy, that’s what I like about criticizing other residents. We have to evaluate each other in my program. I just put everybody, good, good, good, or excellent, excellent, excellent.

All the way down, I’m not putting anything negative. We’re all human beings and there’s plenty of negative things about all of us. The time and place is not for a performance evaluation. That gets people fired, it doesn’t get them promoted. They’re kind of on track as residence to get promoted anyway. Automatically, as, long as you’re meeting all your requirements showing up to work, working hard, and doing a reason to get job.

Your job with feedback about you, is to demonstrate that you are tangibly taking action on whatever it is, they’ve told you about. When you are taking notes about, in offering feedback on specific items you can change, write there during that feedback section. Then you write that down, you need to really come back the next time and demonstrate you listen. More important than how you handle the feedback in the moment is can they see a demonstrable difference in your behavior after they’ve given you feedback.

That by itself is an independent line item for review, they care about if you’re trainable, if you’re teachable. Of course being teachable comes down to humility, and there in lies the pain. The reason that it hurts, to get criticism is either because you’re afraid you might lose your job, which is not the case for most of us. Also, because it kind of pricks you a little bit because whether you realize it or not, you’ve gotten comfortable.

You are resting on your laurels, you’ve let your guard down, and you’re taking things for granted. When someone comes along criticizes you, you either already knew about it, and were doing it intentionally or you didn’t know about it because it was sneaking up on you. A third category you could be just antisocial. Long story short, you need to bounce back strong and have listened and demonstrate that you heard their feedback, you responded and you incorporate new information and feed back into your work flow and your processes.

Literally that is an evaluation. I’m involved with the residency training committee, and  my program, I sit in I always criticism of other residence, and disciplinary problems and issues that are going on like that, the area of professionalism. I think I’m hitting the nail on the head here when I say people get comfortable and relax and start taking things for granted, may or may not realize that they are getting cocky depending on their antisocial, or narcissistic traits.

Then they get feedback, and then it hurts, and they might even respond angrily. You need to let that anger kind wear off, and look for any shred of truth in what they’re telling you, so you can make tangible handles and demonstrate that you really are listening to what they say. I’ll finish up with a quick tip here, about the sandwich method. This is a method that’s frequently thought in medical education.

Medical students and the residence are really never thought how to teach, you don’t have a class in medical school on how to teach right. As soon as you are in upper level medical student or resident, part of your job description is teaching those that are coming up beyond, below you. It’s not thought, neither as leadership in any formal way that’s a separate topic. What often passes for training people how to teach medical students is what they call the sandwich method.

It’s a cop out for actual training on how to teach, okay. I’m really criticizing the whole medical institutions for not teaching residence and, medical students how to teach each other. It’s such a big deal, and then you go on to be attending, and so many maybe 40% stay in an academic center. Their job as attending is to grade and rate people.  I mean part of the whole problem with medical education process is no one ever thought how to teach.

You just simply know more and have more experience all of the sudden that makes you the senior, but you could be really, really be terrible at teaching and you probably seen examples like that, you probably have people in your minds eye right now, that you can think of, that are exactly like that. Let me give you the sandwich method anyway, because it often does suffice and that is if you have a negative criticism to give someone or constructive criticism.

What you want to do is sandwich that piece of information, it was something good in other words. The first thing you say is something positive as you notice. Some [inaudible 00:12:43] you continue doing, they do well that’s a strength then give them the information that they need to work on. Always say here’s something that you can work on, work on blah, blah, blah being more empathetic when the patients leg is about to fall of the table because it’s broken.

Rather than just grabbing it and jerking it, and thrown it back on the table when the patients is in obvious agony. Then finish up your constructive comment, with another positive with the end of it. You kind of making a sandwich, it’s really that simple. It go like this, “Hey, I really like your report with the patient today. You had kind of settle tone, I like the way you have them laughing there at first.”

I think what you could work on is making sure you review the vital signs, and their most up to date medication list on the patients for the next time before you present. Overall you did a great job, I think you’re going to be really good at this, and you might consider this specialty because you just may have an act for ti. You see how that wasn’t bad at all. Someone that wasn’t thought how to teach or doesn’t know about the sandwich method.

Will just come in and there and say “What do you mean you don’t know what the medications are? What do you don’t have the [inaudible 00:13:58]. Now I understand in some cultures that’s the way they teach, and by nature I have to admit, I am very soft spoken. Takes a lot to get me angry and then all of the sudden I’m like a fiery ball of fire when it kill. Okay. It takes a lot, that doesn’t happen even every year anymore.

Very rear that I get really angry, what I’m saying may sound a little too soft for the environment, too soft even for your personality. That’s fun, use your personality I’m just saying if your goal is to be mean, you don’t need my help. If your goal is to teach, then do it in such a way that tells them what they can work on in the future without being offensive and overly hostile.

Because most people will nationally hear the emotion in a negative tone, of their supervisor and they’re missing the message. Exactly the opposite of what I just told you about with having to look for specific constructive handles in a feedback. In other words you’re going to take the negative hostile tone from your attending. You’re going to demonstrate positive constructive things you done about it.

When you take over their job, and you get promoted and you’re the resident, or you’re the attending. You’re going to know about the sandwich method and not do it the way these old crusty doctors do being a bunch of jerks everywhere okay, that’s the bottom line. Treat people with respect and dignity, the way you wanted to treated in life will go well for you. This is the medical school podcast, I’m your host Dr. Dan.


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