Many years ago, when I was a trainee physician, a formal feedback to track my progress never materialised. Instead, late one evening, with no prior notice, I was marched into a room and told by a clearly enraged consultant that he wished I had never been selected into the training program. I was stunned when the monologue ended in this dire pronouncement, “Actually, I’d say you are a disappointment to medicine.” Looking back, this ambit claim should have alerted me to muster my internal defences right there. It was only the beginning of my training; in the handful of years I had been a doctor, I had not presided over a string of unaccountable deaths nor had I bullied interns or abused patients. I was like every other trainee – unexceptional but committed, aware of the difficult trek ahead but grateful for the opportunity. And while it may have been apparent to an experienced eye that I wasn’t destined for high glory, it seemed a bit rich to foretell a doctor’s lifelong contribution to medicine by the first few unremarkable years. But of course, none of this occurred to me at the time other than the sinking realisation that I wasn’t just a disappointment to medicine but a certified failure. It didn’t matter that the consultant had not got to know me; it didn’t matter that his intemperance was common knowledge; all that mattered was that he had seen further into me than anyone else and proclaimed me an early failure. I wish I could say that the claim was so entirely unfounded and so wildly exaggerated that I banished it from my head but in fact, his words sank into my marrow and stayed there for years and years to come. The ensuing years turned out to be far more interesting than I could have imagined. I became an oncologist and won a Fulbright award that transformed my life from a physician to a physician-writer and public speaker. Patients and colleagues complimented me but to me, those other skills felt like a feeble corrective to the unachievable goal, greatness in medicine. I felt like an imposter because someone in a position of knowledge and power had told me so. Still, the experience didn’t result in a crisis because I was shored up by good people – for that one abusive encounter there were other constructive ones. I also came to recognise how the hospital is a hotbed of competition and politics and how one rotten relationship has a domino effect on other, utterly innocent, people. Later, I learnt about the special irritation and impatience with others that comes from being the parent of children who won’t sleep, fall ill, or cause more serious grief. And then there were my dying patients, who reminded me that life is short and that we should forgive people, not necessarily because they deserve it, but because we deserve it. In other words, I came to intellectualise why a senior faculty might have behaved poorly. But what really puzzled me is how little this helped to erase the long shadow the diatribe cast over my career and why those ill-chosen words continued to play tricks with my self-esteem. Eventually, I became a supervisor, borne out of an aspiration that no trainee should have to undergo a ritual of humiliation to somehow emerge the secure and well-adjusted doctor that society deserves. If doctors were to be genuine healers, they couldn’t commence their career by licking their own wounds inflicted by their own colleagues. From the stories I still hear, we are not there yet. It’s a myth long perpetuated in medicine that trainees will only learn through “tough love”, but this tough love ignores constructive criticism, finding space to listen, providing room to grow, resting instead on public (or if you’re lucky, private) shaming. I have seen plenty of doctors destroyed by it but have yet to meet someone who blossomed through such cruelty. On the other hand, a veteran physician recently fretted that he had abandoned saying anything remotely critical for fear of being accused of harassment. In this heightened era of awareness of bullying and harassment in medicine, this is an observation worth pondering because a doctor who is given neither reason nor room to improve is being done a disservice. Most doctors strive to be better versions of themselves and are eager to find good role models. Being too quick to take offence will result in feedback crammed with platitudes and a piece of paper as meaningless as the encounter. One solution might be to have an independent observer present at feedback but the real mentoring happens not at formal sessions but through countless corridor conversations, timely compliments, tactful rescues, and after-hour phone calls. Every doctor knows that these incidental things form the scaffolding of a career. Many formal supervisors now undergo training which provides them a structure for giving feedback. This is one step towards being nuanced and sensitive to the changing face of medicine which boasts doctors who are pregnant women, young parents, former refugees, victims of war, as well as those tackling their own chronic illness or mental wellbeing. But I think the key to feedback (and to trainee welfare in general) lies in every senior doctor taking the responsibility more seriously. Medicine is a lifelong apprenticeship where a young doctor learns from a cast of hundreds. We promote continuity of care for patients but it should apply equally to the care of doctors. For far too long, feedback has been an automatic checklist and if you have not committed a grievous error, there is nothing to discuss. But constructive feedback means saying, “You could do this better and here is how.” It means showing vulnerability, “I have made the same mistake, here’s what I learnt.” Above all, I have found it means reassuring a struggling trainee concerned for her future, “I am here to support, not sink you.” But feedback isn’t only about castigation but also commendation. Praise is largely a forgotten concept in medicine; we are quicker to laud an alcoholic for showing civility than applaud a doctor for resolving a crisis. The control of medicine by bureaucrats has resulted in the eye being on the bottom line more often than the workforce. I have seen doctors wearied by a lack of recognition, or worse, broken by criticism, but I can’t immediately think of someone who went rogue after winning deserving praise. Changing these ingrained habits is a responsibility that should not be shouldered by supervisors alone. It’s a duty upon of all us to influence change. The doctor-patient relationship is sacrosanct but no less important is the doctor-trainee relationship. If there is nothing good about a trainee, it’s the senior staff who must look harder. Because when doctors genuinely care about doctors, it’s good medicine for society.
