Virtual Mentor. August 2005, Volume 7, Number 8.
Frame Feedback to Improve Professional Performance
Vignette 3: Colleague-to-Colleague Communication.
Commentary by Barbara F. Sharf, PhD
You are a radiologist in a hospital-based group practice. While one of your partners is on vacation, an internist calls you because your partner read a head MRI for one of his patients a short while ago. The internist is concerned because his patient's headaches are becoming worse, and she is now developing visual field deficits. Before considering a second MRI, the internist would like you to review the first one. When you get off the phone, you pull the patient's (Mrs. Kirk's) MRI; there is a suspicious "spot" in the pituitary gland that you think called for further evaluation. This difference of opinion has happened twice before with radiographic studies that were originally read by your partner and reviewed by you over the last 6 months. You think he is making some obvious omissions in his readings, and you recognize that something must be done. Patient safety could be at risk. You decide that the best course of action is to talk to your partner as soon as he returns from vacation. What do you say to him and how do you say it?
There's no getting around it—this is an unpleasant interpersonal situation, and one of ethical concern for patient well-being. Typically, physician colleagues enact a professional relationship of co-equal status and power. You have no authority to monitor your partner (Dr. M), nor do you have any desire to regulate your fellow physicians. On the other hand, the practices of clinical consults and second opinions have developed to provide a system of checks and balances in patient care so that the judgment of one practitioner is open to scrutiny, questioning, and feedback from others. The hoped-for result is the best care available for the patient. This situation with your partner is functioning like a second opinion. It is not unusual for physicians to differ in their judgments, thereby triggering dialogue and reconsideration of options. It is unusual to discover a pattern of obvious clinical errors; and, in this case, you feel ethically obliged to do something about this problem before it is repeated with other patients. But what constitutes "doing something"? Calling your peer to task looms as a distasteful event.
The first knotty question to be considered is: what is the goal of this conversation? Put another way, what do you hope to accomplish by confronting your colleague? An overarching goal is to get Dr. M's full attention and to mutually negotiate a constructive response. Examples of constructive responses might include a promise from Dr. M to conduct a supervised review of his work and to contact treating physicians if they've been given incorrect information. You may also have concerns about your colleague. While you have no more desire to be his therapist than his police officer, it would be useful to know to what he attributes this pattern of errors; if there is a difficulty beyond carelessness (eg, incompetence, depression, substance abuse, unusual stress, etc.), then it will become important to urge Dr. M to seek help for himself.
Such goals assume 2 willing participants engaged in civil conversation. What if Dr. M is defensive, angry, in denial, or otherwise unwilling to talk? The intimidating tape of a tense phone interchange between Dr. M and Dr. Y (alias, you) keeps playing in your head:
Dr. Y: Dr. M, this is Dr. Y. I'd like to talk with you about your findings on Mrs. Kirk, a patient whose MRI we both reviewed recently.
What steps can be taken to avoid this type of hostile exchange and to facilitate as productive an encounter as possible? There are no guarantees, of course, when it comes to dealing with individual personalities, but there are well-established guidelines for communicating feedback, including critical constructive or corrective feedback. Though these guidelines have been developed primarily in the context of educational and managerial settings [1,2], the practice of medicine has often been framed as a lifelong educational venture. Thus, it's helpful to realize that even seasoned practitioners can benefit from peer commentary and advice, if provided in a sensitive and thoughtful manner. So how can critical feedback be communicated constructively?
In the preceding imagined dialogue, Dr. Y had an appropriate instinct to meet with Dr. M personally to talk about Mrs. Kirk's case; a planned face-to-face meeting would have been preferable to an off-the-cuff phone conversation, which lacks many nonverbal, relational cues (an even bigger problem in e-mail messaging). However, Dr. Y didn't realistically assess the difficulty of setting up such a meeting, especially with the opening gambit of discussing "your" (Dr. M's) findings, which does not connote conjoint problem-solving. Timeliness was out of Dr. Y's control, since Dr. Y had already been contacted by the treating physician.
Even in this brief interchange, there is a good deal of evaluative language, in which Dr. Y labels Dr. M's work as error-prone. Had this meeting occurred in person, there would have been opportunity for these 2 To jointly examine the MRI (the firsthand data). Dr. Y may also have been more successful in engaging Dr. M had she expressed her personal concerns for both the well-being of Mrs. Kirk and Dr. M.
After having been negatively evaluated, rather than engaging in problem-solving for the benefit of the patient, Dr. M is focused on exiting this conversation—not on addressing potentially serious problems. There's been no discussion about making future positive changes.
Using these guidelines to inspire a dialogue that doesn't arouse defensiveness, let's imagine another possible exchange between Dr. Y and Dr. M:
Dr. Y: Thanks for agreeing to meet with me to discuss our differing interpretations of Mrs. Kirk's MRI. I'm glad we could find a mutually agreeable time.
Even though this conversation went very well, what should you do if Dr. M continues to make clinical errors? Reporting him to a quality assurance committee is always a final resort, but needn't be the first course of action. This case reveals a real and important tension between a physician's ethical obligation to ensure accuracy in patient diagnosis and treatment while providing corrective feedback to colleagues in a constructive, collaborative manner. Thoughtful communication that does not put colleagues on the defensive is most likely to result in improved performance.
Barbara F. Sharf, PhD, is a professor in the Department of Communication at Texas A&M University, College Station, Texas.
The people and events in this case are fictional. Resemblance to real events or to names of people, living or dead, is entirely coincidental. The viewpoints expressed on this site are those of the authors and do not necessarily reflect the views and policies of the AMA.
© 2005 American Medical Association. All Rights Reserved.