Feedback is a gift

I was in the OR today with an attending who calls it how it is. He tells you what you are doing wrong while you are doing it. He does not soften it, he does not wait for the end of the rotation, and he does not let a sloppy rep slide because the case ended fine anyway.

I left that room tired. I also left better at something I was worse at that morning. Those two things show up together often enough that I have stopped calling it a coincidence.

Real feedback is expensive to give. It takes attention during a case the attending could be doing faster himself. It costs him a few minutes he does not have. And it risks the resident walking out thinking he is difficult.

Silence costs nothing. "Looks good" costs nothing. Most people, most days, take the free option, and I understand why.

Timing is the other half of the price. A written evaluation 6 weeks later that says "great resident, keep it up" is not usable. I cannot remember which case it refers to, which decision it is grading, or what I would change. Feedback has to arrive while my hands are still in the wound.

Surgical training used to run on volume. Instruments thrown across the room, screaming, students humiliated in front of the whole table. Any of us who trained under people who trained under that have heard the stories, and some have lived a version of it.

That is leaving, and it should. Humiliation never taught anybody a screw trajectory. It taught people to hide their errors, which is the exact behavior you least want in someone learning to operate.

Specific correction and public humiliation are two different acts. One of them can be delivered quietly, at the table, in a normal voice, and still be completely direct.

Here is what I watch for now. When a program corrects for the old culture by removing the discomfort entirely, it usually removes the correction along with it. Everyone gets a "nice work." Every eval says the resident is progressing appropriately. Nobody says the thing that would change how you operate.

A resident who is never corrected graduates at exactly the ceiling they walked in with. That is a worse outcome than a hard day.

And the bill comes due somewhere. The retractor I am holding wrong, the closure I am putting under tension, the angle I am cutting from habit rather than from the deformity in front of me. If nobody names it now, with an attending 3 feet away, it gets named later by a wound that will not close.

I want attendings who will tell me the thing. Not louder. Specific, immediate, and unbothered by whether I enjoy hearing it.

The ones who do it are teaching a second lesson at the same time: that being wrong out loud is survivable and normal. That is the lesson that makes a resident willing to say I don't know in front of the room, which is the whole ballgame for the next 30 years.

Two audiences, and the second list is shorter because most of the work belongs to the person receiving it.