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After the Match: In Search of (Anonymous, Ego-Deflating) Candor

Cook, Thomas MD

doi: 10.1097/01.EEM.0000499528.11993.26
After the Match

Dr. Cookis the program director of the emergency medicine residency at Palmetto Health Richland in Columbia, SC. He is also the founder of 3rd Rock Ultrasound (http://emergencyultrasound.com). Friend him atwww.facebook.com/3rdRockUltrasound, follow him on Twitter @3rdRockUS, and read his past columns athttp://emn.online/AfterMatchEMN.

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All residents are required by the ACGME to suffer through a comprehensive evaluation of their performance every six months, including ones by faculty and peers. Each resident sits in his program director's office six times to review his performance over the course of his three-year training program.

No one likes going through these evaluations, and the anxiety is often palpable when the resident enters my office. The first evaluation is typically easy. Evaluators are looking to see if a sociopath has entered the program, and the comments are bland and generic (“nice addition to program”). The last one before graduation is also easy. Everyone tells you how great you have been to work with. It is the middle four evaluations, however, where you will take your shots. This is when your faculty and peers will tell you what they really think. Or will they?

Each of us sees the world from our own perspective, and to imagine how others see us is nearly impossible. Only through years of experience, reflection, and most importantly criticism, do we see how we really are.

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Selflessly Lead

Emergency medicine residents have received more praise from parents, friends, teachers, and society in general than 99 percent of humanity. But the most important skill you need to be successful in residency and your career has received comparatively little formal evaluation. That skill is your ability to work effectively with a varied group of individuals by developing your interpersonal communication and leadership abilities.

If you really think about it, most of your ascent to the lofty position you now hold is based on your ability to select the right answer on multiple-choice tests. Sure, you were evaluated on your clinical abilities during the third year of medical school. But this is often a watered-down affair in which you manage relatively few patients in scenarios with lots of downtime. What will you be like when its 2 in the morning, and the ED is blowing up? Will you be the one to volunteer for unpleasant tasks? Will you selflessly lead or seek to protect your own best interests? How will you respond when you are sleep-deprived and hungry, and just picked up a chart for someone allergic to all pain meds except Dilaudid?

The answer to this is feedback. Not a multiple-choice question, but just letting people write down what they think of you. Purely subjective and possibly based on anecdotes, this information can be completely inaccurate. Regardless, the words on the page can cut you like a knife and bring you to tears. In short, no one likes opening themselves up to this abuse, especially incredibly successful people like emergency medicine residents.

And just to make this even more unjust, what if these evaluations are anonymous? What if you do not even know who is trash-talking you? What if the “evaluator” does not even have to stand behind her criticism? She can literally write down anything. Maybe she has an ax to grind with you for something as small as stealing a procedure. Why should you put up with this?

Every few years, an EM program director will initiate an online dialogue about whether resident evaluations should be anonymous. Critics of anonymity argue that evaluators should be willing to stand behind their appraisals, thus giving residents the ability to modulate their performance for individual attendings or peers. The counter-argument is, however, that if you really want candor about how you annoy others, evaluators need to be able to tell you what they think without fear of retribution. This is the reason ACGME requires anonymity for residents evaluations of the program's faculty members each year.

Residents may fear the unbridled comments of their attendings, but the most important critique will come from peers, the people from whom they most desperately seek approval. Unfortunately, receiving real candor from your peers may not be possible. Identifiable criticism is a tough sell for physician peer relationships. They are so delicate that the potential for generating acrimony creates incredible stress in the work environment, and residents will seek to avoid this at all costs.

And yet, it is your peers' opinions that are the most important for you to hear. You are only subjected to the scrutiny of your attendings for three or four years. Understanding how nuts you make your colleagues will affect your life for the next three to four decades. Residency is the only time you will get this feedback. I have been reviewing evaluations with my residents for 15 years, and I can tell you that the peer comments make the biggest impression. Many times they are really painful, but they also generate the most important changes in behavior that lead to future success. Having a large percentage of your peer group tell you to change your ways is not pleasant, but they will be doing you the biggest favor of your residency.

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