Reward or punishment in medical training

Like many of my colleagues, I teach and supervise students, residents, nurses, and respiratory therapists. I’m also the medical director of a PICU. Overall, I’ve been teaching and doing administration for over 30 years. And, like most of my colleagues, I never received any formal instruction at all in how to do these things. To some extent I got help from my own mentors, primarily by watching what they did, but basically I learned on the job. I hope I am reasonably good at it, but really, I have little way of knowing if I am. So I’ve always had an interest in whatever tidbits I could pick up in teaching theory that might be useful. One particular topic that’s always interested me is the opposing pros and cons of reward versus punishment. I use those tools to train my horse – rebuking bad and praising good behavior. What do we know about applying them to people?

The practical problem, one faced by most teachers, is what to do when a student does a poor job. The tradition in medical teaching, certainly when I was in training, was to lean heavily on the rebuking, punishing side of the equation. Public ridicule was common, and there was more than a little yelling involved. Did fear of that help me avoid doing the wrong thing next time?

A while ago I was reading one of my favorite group blogs, Crooked Timber. Most of the contributors are professors of one sort or another, and the topic of effective teaching comes up now and then. This whole reward/punishment tension was the topic of a post there. The situation it describes involves military flight instructors, who universally believed that yelling at fledgling pilots when they made mistakes was much more likely to make their next attempt better than was praising a good action. Here’s what one instructor had to say about it:

On many occasions I have praised flight cadets for clean execution of some aerobatic maneuver, and in general when they try it again they do worse. On the other hand, I have often screamed at cadets for bad execution, and in general they do better. So please don’t tell us that reinforcement works and punishment does not, because the opposite is the case.

It’s a military example, but training doctors has traditionally been done using that sort of get tough model. I was aware of a statistical principle called the regression to the mean, but this example applies it to teaching in a way I hadn’t thought about. The argument goes like this.

If a given student does a bad job at something, that is more likely to be a low point for them, below their average. Statistically speaking, they are more likely to do better on the next attempt no matter what the teacher does. So the teacher is likely to think whatever he or she did – screaming, for example – as causing the improvement. On the other hand, if a student does an exceptionally good job, the same regression to the mean makes it likely the next attempt won’t be as good, so whatever the teacher does – in this case praising – tends to cast doubt on the usefulness of praise.

For myself, I think praising, in the long run, works much better. I’d be interested in what any professional teachers think about this.

In the comment trail to the article, the classic The Art of Raising a Puppy was cited as a useful source. I found that very interesting. After all, to those of us with more than three decades in medicine, medical students are a little like puppies. We want to give them a sound foundation and train them without hurting them.

Christopher Johnson is a pediatric intensive care physician and author of Your Critically Ill Child: Life and Death Choices Parents Must Face, How to Talk to Your Child’s Doctor: A Handbook for Parents, and How Your Child Heals: An Inside Look At Common Childhood Ailments.  He blogs at his self-titled site, Christopher Johnson, MD.

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  • Anela Izadi

    Even the smartest and the best of medical students and residents will not fulfill their potential if their environment is not conducive to learning. Yelling or public ridicule are nothing more than bullying – cleverly disguised as a teaching method.

  • Alex Huh

    Yelling or a hightened tone is a challenging teaching mechanism to employ because it is harder to develop a dialogue that addresses what went wrong, how to change it next time, and to be specific, how do you train your mind to avoid doing it (if it is a habit) when the opportunity arises. Nobody likes to get yelled at, and people usually develop some animosity in response to the yelling (“Why the &@%# do you have to yell at me? It’s a mistake…jeeze”), which makes them focus not on the issue, but the person who is yelling at them. It doesn’t seem that efficient.

  • Karen Sibert MD

    It depends on what kind of mistakes we’re talking about.  Technical errors are part of the learning curve in mastering any procedure; if you’ve never caused a pneumothorax, you probably haven’t put in enough subclavian central lines.  There’s no point invoking any kind of punitive measure for that unless there was real carelessness involved.

     However, if students or residents are clueless or inattentive or not reading, and aren’t taking good care of their patients, we’re doing no one any favors to spare them criticism lest we injure their self-esteem.  They seem to have quite enough self-esteem.  Too often these days, people are afraid to write honest evaluations about poor performance for fear of litigation. 

    The desire to avoid sharp criticism can be a good motivator.  Perhaps there is value in watching a fellow resident squirm under an attending’s rebuke on rounds. The rest of the team may be more inclined to go home and hit the books in order to avoid the same treatment tomorrow.  What we do in medicine actually matters, and there’s a point when OK isn’t good enough.  Some errors are NOT system errors; they’re individual screw-ups for which individuals need to feel responsible.  Just saying “my bad” doesn’t cut it.

    • Christopher Johnson

      You make a good point about attitude. I agree the teacher needs to make a judgement about the student’s basic attitude. If the student is in “whatever” mode, some sharp, needling words can be useful.

      On that point, though, I think a teacher’s previous reputation and attitude make all the difference. If a teacher is perceived as fair and respected, the occasional castigation is even more potent. I know that for me I would do anything to avoid disappointing teachers who I greatly respected. So I think it’s important to save the hammer for when it will be most effective. If we yell all the time it’s ineffective.

  • Anar Mikailov

    As a medical student who has been on the receiving end of various teaching styles, praise of a job well done is a huge motivator.  Furthermore, when pupils get questions wrong, or don’t approach a patient’s medical care properly, one of the best teaching methods to address this deficiency is to ask the pupil to give a presentation on the same topic.  A 5 minute talk with a one page handout during the next days teaching rounds.  This is a great tool!

  • Anonymous

    I really like your references to horses and dogs.  In fact, last summer I saw a documentary titled, Buck, about a real “horse whisperer,” and I picked up something that has been of great value in my teaching people to take care of patients: Observe, Compare, Remember.  Also the Dog Whisperer, 50 % exercise (let them do a lot of work), 25% discipline (run a tight ship), and 25% affection(be nice).  I was taught by a very popular professor that I must give three praises for every criticism – never been able to live up to that.  That said, I’ve always thought one has to be tough to be a doctor. Performing under fear of public humiliation probably has value in measured doses.  It should make us tough, able to withstand whatever it takes to get the job done right.

  • James Otis

    Like the post. As a residency director I have to deal with residents who sometimes underperform, whether due to inexperience, fatigue or lack of knowledge. It is key to identify the cause so you can develop the response. Returning to school has made me realize how difficult it can be to acquire new knowledge and how a good teacher can make all the difference,notably one who figures out what it is that is keeping the student from learning. “Teaching Smart People How to Learn” a classic B-School reading, has made me rethink how to give feedback and deal with with residents who need to be taught to “think outside the box”

  • Arthur

    Enjoyed the post. As an associate professor in a urology training program, I have been teaching residents for over 10 years. One thing that we fail to recognize is that the “character” of residents has changed. The resident of 2012 is different from the resident of 2002. Residents now demand more with “less” training hours given the new resident work hour restrictions. There is also a certain sense of entitlement amongst residents today that was not evident in the past. As one of the previous posts suggested, it is important to identify reasons that residents are underperforming. Some of simply not capable but the majority who underperform, in my experience, are lazy and lack motivation. A little tough love is OK once in a while. Regardless of whether you praise residents or not, most will praise themselves anyway

  • Jenny Walsh

    Students learn better when they get good initial information and then get feedback that refines their understanding and behavior.  Feedback ideally promotes the behavior you want and helps students steer clear of the behavior you don’t want.  I’ve seen learning occur at home, school, church, work, and volunteer organizations, and I’ve noticed that a giant rant or harsh punishment may teach someone to fear their teacher/parent/superior officer/boss/leader, but not necessarily convey the message about the improvement desired and therefore prevent meaningful improvement.

    Before students attempt something, giving them a guideline, overview, or sample, the reasons behind that approach, pitfalls to avoid, etc. can do much to prevent a lot of frustration on everyone’s parts.  Giving a dry run for something–from introducing themselves to suturing–promotes establishment of good baseline skills before it gets used on real patients.  The teacher normally wants the student to succeed as much as the student does.  The preview/orientation/skills workshop/backround lecture gives a map to that success.

    Praise specifically–even descriptions portrayed positively feels like praise.  We’ve all been learning a long time and what worked in 1st grade still works today.  “Everyone–look how Joey outlined the black lines with his crayon so neatly and then smoothly colored each area in the same direction.”  Now the whole class has a better idea of how they could improve their coloring.  So, think about rounds–”Thank you Gretchen.  You not only presented all of the vital signs, but you knew that the tachycardia was immediately post-op and has not recurred in the last 15 hours.”  “Did everyone notice the detailed yet non-superfluous HPI Jaren presented?  He gave pertinent positives and negatives for congestive heart failure which include …”  “Thank you for meeting the patient before surgery without a reminder.”  “I think Mrs. J really appreciated how you explained her medications to her.  Great job!” 

    Provide critiques with specific things that were noticed and particular things to improve.  Do you think anyone wants to fail, especially at patient care?  Don’t you realize we yell at ourselves if we hurt someone or forget something important?  We got into medicine being incredibly conscientious and caring. Do you think we want to hurt someone?  Do you think we, who were the top of our class for so long before med school LIKE feeling stupid and ridiculous?  Give me a break.  We want to do well.  Guide us to be the best doctors we can be.  “Next time, you’re going to tell me whether this patient has pre-renal, renal, or post renal causes for acute kidney injury.”  “Go find out now whether the chest x-ray has been read.”  “We’re going to redraw the patient’s blood together and make sure we use the red top tubes this time.”  “For your next presentation, I want you to present the information in this order instead, and then practice it in the mirror 3 times so you are prepared to tell me about the patient.”  “Watch me as I show you how to pull the auricle to make it easier to see the tympanic membrane.”  “I noticed you were holding the reflex hammer awkwardly.  Here’s how to hold it so it can swing better and illicit a better response.”  “Slow down as you intubate this patient, so you can see the landmarks.  You went too fast and went down the esophagus instead last time.” 

    I think medical students want to get better.  Why not treat them that way and give them the tools to achieve it?

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