A Fairer Evaluation System to HOs

Weeks before I left, I received this warm message from one of the house officers (HOs) from my ward. I am glad that he had a fruitful posting in Nephrology. No, this is not a "self-kembang" post, but more about "HO evaluation" - what is our role, as a senior, when a HO is posted under our supervision?

Just to elaborate more - I'm often asked why am I not "harsh enough" to HOs. In fact, I hardly even raise my voice to them. Am I not a strict senior? Certainly I am, I actually supervise them closely although it might be indirectly. I wrote my concern about them years ago. There shall absolutely be no compromise in the way we train them, but I am just saying, the feedback can be done in a fairer and more professional way.

I came from the time that HO could be shouted at with the voice as loud as across the entire ward. Morning ward rounds were stressful and could even be a "live show" to the patients and relatives. Remarks such as, "Are you sure you have graduated from med school?" "If you can't manage this, you're worse than a medical student!" are often heard. A HO could be chased out from the ward just because the specialist said, "I don't like to see your face." However, when these were mentioned to senior, the reply is commonly, "Well, (shrug shoulders) during our time, a casenote could be just thrown to your face. It is considered better now."

Surely, things have changed with time. There are less glaring scenes during ward rounds nowadays, partly also because of prevalance of social media. The complaints have shifted to facebook/ whatsapp etc., where a particular HO can be "openly" discussed in the group without him/ her knowing. Let's pause for a second and think, is this a fair evaluation to them?

During my fellowship training, I was exposed to a different evaluation system and just to share:

1. During each posting, a resident will be evaluated by 2 supervisors - one on the knowledge part (by conducting mini viva in between and the end-of-posting exam) and one on the working efficiency part (the ward consultant that he/she is under). In this way, the evaluation covers both academic and work output parts.

2. "360 evaluation" - every 6-monthly, evaluation forms will be sent to your seniors, peer colleagues, juniors and nurses on your professionalism, interpersonal & communication skills and patient care etc. This evaluation is to get a more all-rounded and objective feedback of the resident.

3. "Self-assessment" - a self-check on your competency level, strengths and weaknesses. To be discussed with supervisor on how to further improve.

4. Finally, the evaluation system is mutual and you do get a chance to evaluate your ward seniors. Are they approachable? Motivated to teach? Do you find their rounds useful? How is the leadership?

Yes the paperwork can seem overwhelming, but it is undeniably a fairer evaluation system with less potential biases as compared to evaluation done one-way.

IMHO, If you're an evaluator or becoming one in future, what we can try to do or think about:

1. Focus your assessment on the right attitude and how safe/ professional is the HO, rather than knowledge alone. The latter can be learned. The fact that seniors know more simply because of "lead-time bias" i.e. we have worked longer. It is therefore our reponsibility to teach and guide them, not demoralize them!

2. (Try to) Get rid of the thinking of "New generations of HO are getting hopeless". This contains sense of grandiosity to some extents, I often think that it is either you're underestimating them, or overestimating your performances "during your time". Given time and proper training, they will just shine as well or even outperform us.

3. Avoid too negative or personal remarks. This is neither professional nor helpful. E.g. When they are unsure of an answer, "Can you go back and read, and share with the team tomorrow?" is definitely a more positive approach.

4. When the performance is not progressing as expected, before labelling as "acopia - i.e. failure to cope" or "failure to thrive", it would be more reasonable to first find out what difficulties are they facing, or is there any family/ personal issue behind impairing the learning.

5. Deal with error professionally. No medical professionals will say that there is no single error in their entire career. When it occurs, the discussion can range from personal feedback to larger channels such as M&M meetings - the key is to learn from mistake and avoid the next occurrence.

Finally, one of my mentors used to say, "In work, practise intelligent and efficient medicine, the emotional shouting part is not going to help. Why kill someone's interest in their earliest phase of career? It is a vulnerable group, give them a good training environment so that they can grow and be better than us."

Don't you feel the same way? :)