In the last two posts (post 1, post 2) I introduced the fact that there exists a culture of ‘failure to fail’ in medicine. Faculty themselves have a large part to play and, apart from being too lenient, also unwittingly introduce bias during learner evaluations.In this final post I want to share my approach to trainee evaluation.
I believe that most clinicians already know how to make judgments about learners – they just don’t know that they know! Furthermore if you follow the six steps below I think you’ll start to make more effective judgments and provide more meaningful feedback to learners. Just maybe – you might even identify [and start the process of helping] a failing learner. Comments welcome.
Fact: Most clinicians already possess skills transferable to trainee evaluation
- ER docs routinely diagnose and treat conditions in the ER with little information
- We have the ability to quickly discern sick from not sick
- What’s more – (if you think about it) you also possess the right words to describe why … pale, cyanotic, listless versus pink, alert, smiling
- The same skills can be used to identify competence [introduced self, gave clear question to consultant, provided concise history] and incompetence [pertinent negatives missing from history, inability to generate basic ddx, brusque interpersonal interactions]
- Many clinicians also possess transferable “Soft Skills”. We use these daily in difficult patient interactions.
- Guess what? The exact same skills can be brought to bear in difficult trainee evaluations!
- listening empathetically
- breaking bad news
- dealing with emotions
- dealing with hostility
My 6-step Prescription for Evaluation Success:
I have tried to illustrate above that the same skills that make you an astute clinician will also allow you to discern whether a learner may be under-performing and then let them know. Why not stick to what works? Below is my six-step prescription for evaluation success. I am hoping that it is pleasantly familiar to you.
STEP 1: Take a history from the learner at the beginning of the shift.
The ED STAT course run by CAEP [link] teaches Faculty to understand where the learner is coming from at the start of the shift.
- Ask the learner about:
- Level of training
- EM experience
- Home program
- Provide an orientation to the ER
- Ascertain their learning goals
- Set expectations
- based on level of training
- that they will be receiving feedback about their performance
- [in fact – tell them about these six steps]
STEP 2: Examine the learner’s skills
Use the IPPA approach!
- Inspection: watch the learner
- taking a history
- performing physical exam manoeuvres
- giving the diagnosis/ddx
- giving discharge instructions
- Palpation: perform physical exams together to
- confirm or refute findings
- correct errors
- role model
- learn from them
- learners often remember all the special manoeuvres better
- they ask questions that challenge you to read up – like “which cranial nerve is glossopharyngeal?”
- Percussion: use your finely tuned senses to ‘tap out’ gaps in:
- clinical skills
- [Hint: the mnemonic KSALTs can help identify where the problem lies with the learner. Read this [link] to the ALIEM MEdIC case].
- Auscultation: listen to the learner
- during consultations
- during interactions with other providers
- [HINT: eavesdrop on their histories from behind the curtain]
STEP 3: Diagnose the Learner:
- Is the learner competent or not?
- Think about biases you may be introducing and try to avoid them – especially central tendency bias [link].
- Use my ABC RIMES approach:
- Attitude – make comments like “self-directed” vs “unmotivated”
- Behaviours – “procedural skills above peers” vs “poor attention to workplace safety”
- Competencies: [I use a modification of the RIME approach [link] with the addition of an ‘S’]
- Reporting – give feedback on history-taking, written communication and presentations
- Interpretation – give feedback on interpretation of Xrays, EKG’s and ‘putting information together’
- Managerial skills – give feedback on efficiency, multi-tasking, stewardship
- Educator/Expertise – give feedback on knowledge and teaching skills
- Soft skills – give feedback on communication, team-skills, honesty, reliability, insight, receptivity to feedback
- For those that are slavish to the CanMEDs brand try the MS CAMP mnemonic:
- Medical expert
- Communicator/ Collaborator
STEP 4: Provide your diagnosis
- Think of your favourite uncle or granddad – would you be happy with the care that they received? If so – great!
- Provide feedback using the ABC RIMES framework [here’s an earlier post on providing feedback].
- If the feedback is going to be negative – you need to prepare. Here’s more information on getting ready for a difficult conversation [link].
- If you’ve primed the learner at the beginning of the shift – they shouldn’t be surprised.
- Have the courage to practise tough love – trainees are adults, they should be expected to receive feedback like adults.
STEP 5: Document! Document! Document!
- ALL verbal feedback needs to be written down.
- Use strong descriptive terms rather than weak ones. Saying ‘good job’ is good for self-confidence, but learners need specifics.
- Use the ABC RIMES or MS CAMP framework – effective evaluation forms make this task easier.
- RANK THE LEARNER. They cannot all be ‘above average’ – some trainees are below average.
- Even though a learner may be having a bad day this needs to be documented so that patterns can emerge.
STEP 6: Consult them out!
Most of us feel that problem learners are “someone else’s problem” – you’re right! You need to consult them out. But like all consults – you need to give the consultant the right information [see above].
- Remediation is NOT your responsibility
- Issues need to be referred to:
- Rotation coordinator
- Program director
Most clinicians already possess the skills needed to made judgements about failing learners. Furthermore, they also possess the soft skills to give negative face-to-face evaluation. If all clinicians used these skills [together with direct observation and expectation-setting] we may identify more learners that need help. Ultimately we will achieve more success at graduating cadres 100% of whom are competent, caring physicians.
There needs to be huge emphasis on culture change. This is going to require:
- More faculty development and engagement. BOTH faculty and programs need to come together to do this. [I’d appreciate comments on how to bring faculty to the table because at my institution this is problematic]
- Learners themselves understand how to receive and act on feedback.