Semi-anonymous? A QR code solution for providing feedback for residents

It is a ubiquitous problem in teaching hospitals: a staff doctor will grab a resident-supervising physician in the hallway and express a concern with a resident but doesn’t want to put the issue in writing. Telling the staff doctor to put it in an email where the contents will be seen by the resident doesn’t always work for a number of reasons—one being that some doctors worry that the resident might rate them poorly and that could impact their career. That may not happen often but during a session at the International Conference on Residency Education (ICRE) in Halifax in October, Dr. Holly Caretta-Weyer, associate residency program director and director of assessment at Stanford University School of Medicine, said even when it happens once faculty members remember it for years. At an ICRE panel titled “Would it stand up in court? Making defensible decisions for progression and readiness for unsupervised practice,” Dr. Caretta-Weyer outlined a solution she uses: she gives the staff doctor who catches her in the hallway a QR code and tells them they can leave their concerns semi-anonymously. That solution got interest from some attendees during the session, but some doctors were concerned about anonymous complaints about residents for a couple of reasons. Read: Stopping microaggressions in the clinical learning environment The QR code solution Dr. Caretta-Weyer said competition is so fierce the residents can be averse to criticism appearing on their permanent record. “(Some feel) ‘I can’t appear anything but pretty and perfect and unicorn-esque,’ instead of focusing on growth and development. ‘I have to check all my boxes to get my next job.’ That is something that is very, very difficult to address.” Scanning the QR code with the doctor’s phone, takes the staff physician to a spreadsheet form with asks for: Trainee name Your name Do you want to remain anonymous to the resident? (“I always tell them that’s sort of conditional,” noted Dr. Caretta-Weyer, that “‘I can’t protect your anonymity all the time.’”) A box for sharing thoughts. Staff doctors see value in making anonymous observations to the resident because their feedback is reported in aggregate, allowing them in many cases to give very specific information, Dr. Caretta-Weyer noted. “(Faculty) come up to me and say, ‘I worked with this resident today. I have these three specific cases where I’m running into concerns and am worried this might be a pattern. I don’t want to put this in writing for it to be on the resident’s permanent record if it isn’t something that you’re seeing over and over again,’” she said in an interview after the panel. Scanning the QR code and putting that in semi-anonymously is a space for specifics. “They’ll say, ‘I saw this patient with this presentation. Here’s what the resident did that I was concerned about.’” It might be a medical knowledge problem or communication issues with nursing staff. ‘Big girl pants’ While it's hard to give constructive criticism of residents, one audience member said she sees it as part of her job to “put on my big girl pants” and have a mature conversation about a problem she sees. Dr. Nathan Rider, a fourth-year resident the University of Calgary who attended the session, said in an interview the Medical Post that he can see both sides. “One issue is that trainees don’t actually have the feedback that they need in order to properly understand where they’re going wrong and how to fix that.” “The other issue is that there is a very large power dynamic between trainees and staff physicians,” said Dr. Rider, who is past president of Professional Association of Resident Physicians of Alberta. He said it's not impossible for a staff physician to be limited in advancement because of something that occurred with the trainee but the “but the reality is that the staff has infinitely more power in that relationship. And so I worry about that data being used to essentially build a case against a trainee without their knowledge and without the proper feedback for them to improve or change.” And, if there were a misunderstanding between the staff and the trainee, there is no option to discuss that between the staff and the resident, he added. “I know personally of cases where a staff has been upset with the trainee, but after they actually discussed the situation with the trainee, they realized why the trainee had acted a certain way and then believed that the trainee had actually not acted inappropriately.” Competency committee But Dr. Caretta-Weyer said it “used to be the case where someone just came up to me in the hallway and, just, word vomit. I was, like, what am I supposed to do with this if it’s not in writing?” The truth is, she said, faculty members are reluctant to put concerns in writing because “they’re worried that the resident will basically say, ‘You gave me bad feedback. I’m going to go and give you a terrible evaluation because you gave me that feedback.’” Dr. Caretta-Weyer said if she does see a pattern of concerns in the QR code notes (notably, they aren’t anonymous to her), “often I will go back to the resident and say, ‘Here’s what I’m seeing.’ Give them a bunch of cases from a bunch of different shifts and say, ‘Here’s all of the examples that I’ve heard of.’ And yes, they might be able to go back and say, ‘Oh, this was with that,’ but they’re seeing a preponderance of evidence as opposed to saying, ‘Oh, this faculty member is out to get me,’ or whatever.” She said the alternative to getting a record of concerns is that “you get into the competency committee meeting and all of a sudden everyone in the competency committee is saying, ‘Oh, I’ve seen that. Oh, I’ve seen that. Oh, I’ve seen it.” (And) I have no documentation of this!” The competency committee meeting cannot be discovery time, she said. “It is time to synthesize the data to give back to the resident to say, ‘Here’s our decision, here’s the feedback, here’s what we want you to work on.’ It’s not time to be like, ‘Surprise!’” The QR code system means hallway concerns are documented. “It has to be something that I can refer back to when the resident comes to me to say, ‘Well, you’re saying I’m not ready and that this is the issue. Where is the evidence?’ I now have the evidence to refer back to.” Dr. Caretta-Weyer added, “Again, if it’s something that I’m seeing a pattern on or if it’s something that’s very concerning, for example, lying about being sick just so you don’t have to go to work, I go directly to the resident. I don’t wait for the competency committee. I go to the resident and say, ‘What’s going on?’ Because a lot of times when they’re having more egregious issues, there’s some underlying problem. Something’s going on at home, there’s mental health issues. And it’s more helpful for me to get to that root cause. If it’s a pattern, then that actually tends to be something that probably needs remediation.” She noted that the input isn’t always criticism that is shared. “It can also be praise,” Dr. Caretta-Weyer “I get emails where faculty are like, ‘Your resident did this awesome thing.’ And I’m like, ‘Great. Put that in there, too.’ It’s just my repository for all the stuff that people don’t put in formal evaluations.”

Semi-anonymous? A QR code solution for providing feedback for residents

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