Thursday, December 10, 2009

Problems for Medicine as a Self-Regulating Profession

Professions are occupations that society believes (a) serve vital human needs, (b) require a high level of knowledge, judgment and skill, (c) place societal benefit ahead of personal interests, (d) adhere to a strong ethical code and (e) can be trusted with substantial autonomy because of their commitment self-regulation.

I've recently had several occasions to talk with residents about their experience giving and receiving critical feedback during residency training. Their reports suggest that we are not educating for professional self-regulation as well as we should. If this is true, the professional autonomy we physicians cherish so much is on shaky footing.

The big picture I got is that critical feedback oscillates between extremes. Sometimes it is given with a sledgehammer - as if residents will learn only if cudgeled into submission. Other times it is whispered (or not given at all) - as if residents are too fragile to hear anything negative about their performance.

The eruptive form of critical feedback can lead to the equivalent of putting in earplugs - residents begin to interpret critical feedback as a symptom of ill-will or flawed character and discount it. The unduly timid approach to giving critical feedback can lead to a "no news is good news" outcome - residents interpret the absence of criticism as a message that their performance is fine, even if it isn't.

The residents were concerned that they had not yet developed a repertoire of skills for giving constructive critical feedback to colleagues and were not being coached in how to do it. When I told a group about a resident who, while shadowing me in practice, (a) felt I'd made a significant mistake, (b) brought her concern to a seminar to see what others thought about the situation, then (c) told me her views in what I experienced as a very constructive spirit, they were (d) amazed at her courage.

It's not surprising that we physicians do a poor job of giving constructive critical feedback to each other. Two reasons stand out for me. First, since the 19th century, cannons of medical etiquette have taught that physicians should treat each other with courtesy. Criticism was seen as a symptom of professional rivalry, not a manifestation of collaboration for improvement. Second, medical mistakes can cause harm, even death. Giving critical feedback can feel like an accusation of incompetence, and receiving it can elicit shame and guilt.

When I did an initial literature search about giving and receiving critical feedback among physicians I came up blank. We do write about personal accountability, as in this article about "System Failure versus Personal Accountability - the Case for Clean Hands." And we've made lots of progress in understanding the value of acknowledging mistakes with our patients and more skill in how best to do it. But we've not done at all as well with the topic of how to give and receive constructive critical feedback in our relationships with each other. This is a serious flaw in self-regulation.

(For a previous post about etiquette in medicine see here.)

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