Dear Director: One of our star docs, who’s also a good friend, has gotten a couple of complaints recently. I know I need to pull her into the office, but I’m dreading it, afraid it’s going to be very awkward. What advice can you offer for having a more comfortable “bad performance” talk?
Providing feedback to our providers is a critical component of our job. This difficult task is made even harder by the number of hats we wear at work. In many groups, the providers, including the chair, are friends. Additionally, many work side-by-side with the docs they must review. In the clinical area, you’re likely equals, and you may even look to your colleague to bail you out of a difficult airway. But as the chair, you’re expected to mentor and coach all of your providers, and from time to time, be the hard-nosed boss. This is necessary, and if done right, doesn’t have to be dreaded by either party.
Face it: being the chair requires providing feedback, and some of it will not be positive. No professionals should consider themselves beyond improvement—and many will actually welcome honest assessment of their work if done in a respectful, kindhearted way.
At the very least, chairs should be doing an annual evaluation of their providers. But this shouldn’t be the extent of our feedback. Even to our “good friends,” we owe feedback throughout the year. Regularly providing positive feedback and showing appreciation for a job well done goes a long way towards building our credibility and relationship with those we evaluate, which in turn makes giving negative feedback and sharing areas requiring improvement more likely to not fall upon a deaf ear.
In fact, research suggests that high performing teams receive and exchange more positive comments than negative comments (studies suggest giving 4-6 positives to 1 negative). The thinking behind this is that by giving more positive comments, you’re reinforcing the positive behaviors, thus making employees more successful. On the other hand, since the ratio of negative comments is much smaller, your feedback will be more impactful and your team that much more responsive. In other words, while you can’t always “eliminate the negative,” you can always work on accentuating the positive. In recent years, many teachers have adopted a PQP approach for classroom feedback, which stands for Praise, Question, and Polish, and it may be help with setting the right tone for colleague feedback.
Dr. J, my Vice Chair, is a great role model in our ED and a good friend, but none of us are immune to a bad outcome or interaction. For instance, if Dr. J had a negative interaction with a nurse that was brought to my attention by my nurse manager, it would be unfair of me not to have a discussion about the situation, provide the feedback and perception of nursing, and allow him the chance to reflect on the situation. As tempting as it would be to ignore the complaint because he’s a role model and a good friend, if there were other issues, not only would I lose credibility with my nursing colleague, the situation could escalate without him having the opportunity or knowledge to consider his actions. And that would be unfair to him. Over the years, it’s how we’ve built our professional relationship by discussing all the issues. As colleagues, but also as chair and clinician, we’ve that built the foundation of a relationship that allows for positive and negative feedback, and we recognize that, although we’re friends, we each have a job to do—and neither of us is always going to be above reproach.
While you don’t necessarily have the “history” of a relationship you’ve built with new providers, you typically have instant credibility and are often providing more frequent feedback to your new hires or docs who are closer to residency. I’m a little amused by how long it takes some new hires to just call me Mike (and stop calling me Dr. Silverman), but as they transition from residency, they’re used to a hierarchy and also used to getting regular feedback. It’s in these early months of new hires where you can build your “history” by providing regular feedback and advice on how to manage an ED. Initially, comments tend to be more coaching about how to make timely dispositions or prioritize tasks, but remind yourself that providing early positive feedback (usually relayed to me via nursing after a well run code, STEMI, stroke, etc…) helps to build their confidence and will give you the credibility to provide some negative feedback when it inevitably comes.
Right Time, Right Place
It’s important to time your feedback appropriately based on the message you need to send. The old cliché of “Praise publicly, criticize privately” holds true. While it works to tell someone they did a great job on a difficult airway while they’re working in the ED, you may not have their full attention if you do it while they’re on the phone with the ICU getting the patient admitted. Timing that feedback for a break or end of the shift, or even the next day would be better. You also want the opportunity to have a discussion with the doc if they want. Perhaps they have a question about back up airway devices or how would anesthesia have responded if paged.
The same is true when providing feedback that needs to result in performance improvement. If I’m anticipating delivering news that may not be well received (particularly regarding poor performance on metrics or a bad case), I definitely want to have time scheduled with that provider so we can meet privately in my office. Although there are lots of conversations I’ll have in my office that take five minutes and sometimes will do those during a provider’s clinical shift, providing negative feedback requires an adequate amount of time and also an understanding of how the doc might feel afterwards, so I’ll generally avoid doing this conversation prior to a shift. After all, who wants to start the day on a bad note? Our clinical job is hard enough, so spending a lot of time discussing negatives and expecting the doc to happily go work there shift afterwards is unnecessarily demanding. This is particularly true if there’s a bad outcome to discuss, a lawsuit that was just filed, or if I’m going to put the doc on a performance improvement plan. For these types of topics, I’ll schedule a meeting with the doc on one of their days off.
Starting the Conversation
The conversation starts by preparing well beforehand. Consider what behaviors you want to reinforce and what behaviors need improvement. Gather data if necessary, and then outline some talking points. It’s certainly reasonable to start a meeting like this with casual, friendly conversation. However, once you’re ready to go, take a deep breath, stay calm, and start with a transitional statement that will set the stage. This can range from a “You’re doing really well on productivity for a new physician,” to “I have concerns about the recent complaints you’ve received.” For your issue about complaints, the next sentence is critical. This is a professional colleague who is also a friend, so it’s important to balance the appropriate respect with your concern for behavior that you do not tolerate.
I usually want to hear their opinions of the encounter first, so I’ll ask them to simply tell me what happened. For the sake of discussion, let’s assume the complaint is legitimate, and the doctor won’t answer that the patient was crazy. Most doctors I’ve worked with have the ability to honestly reflect on a complaint and might be able to pinpoint what happened. Perhaps it was a busy shift that led to delays. Maybe your doc didn’t get to the root of the patient’s concerns. Perhaps your doc was just having a bad day or wasn’t feeling well, so they were a little less patient than usual. Needless to say, there are a lot of possibilities, and the goal is to try to find the etiology. Getting to the root cause leads you to the final part of the discussion: preventing similar situations in the future.
Over the years, I’ve had a lot of conversations about metrics, communication and behaviors. I’ve worked with doctors who recognized they overreacted and acted poorly, and I’ve had doctors scream at consultants and not realize they’re raising their voice. As a chair or a mentor providing feedback and coaching, I’ve found that it’s much easier to discuss and improve things that are related to time management and skill sets (several missed EKGs, there’s some great CME opportunities, etc…) than it is to tackle personality traits. Personalities rarely change with coaching, so when you’re providing feedback, try to stick with the things that are easier to influence and recognize that some people may not be able to change. Consider if an ER doc is naturally confrontational. That doc could have negative interactions with patients, clerical staff, nurses, hospitalists, and consultants. While you can tell someone that they come across as aggressive or confrontational, the conversation is not likely to go well nor are the odds in your favor of having productive action items. Keep in mind, however, that we all have some personality traits that sometimes cause us problems. While personalities do not change, if the physicians are able to acknowledge which traits sometimes get them into trouble, through awareness and some effort they might be able to mitigate their effects.
While an action plan sounds very formal (and is part of a Performance Improvement Plan that I consider a last official chance at redemption prior to termination), it may be a necessary to create a step-by-step plan for the doc to understand what’s expected of them going forward and then commit this plan to writing. We all need clear expectations of how our performance should change and the consequences if they do not improve. After these action items are decided upon, following up with the doc to touch base over the next couple of weeks is typically done as well.
There’s no way around the chair being responsible for providing feedback and addressing performance issues with docs in the group. Because we are fortunate that our groups are usually tight-knit and friendly, we may find ourselves in situations where we have to overcome personal conflicts. This can be accomplished by having built credibility over time as being fair and professional with your team.
As 80% of most physician problems are system problems the Chair or director must also reflect on their own actions, and the system malfunction that is leading to the individual physician issue. Asking that physician what could be done better is the key to success not just for the individual but for the ED in its entirety.
As for the writing itself, the article could have been edited down to the last two paragraphs, as the rest while entertaining is non-value added.
This is an important topic, and needs further discussion. Keep up the good work.