Performance appraisals are an integral part of an organization’s assessment of employee and trainee standing. Management and human resource literature is full of analysis and debate regarding how to best rate subordinates. Regardless of evaluation system utilized, some of the common goals of individual appraisals are to monitor progress, identify areas for growth, set goals, guide development, provide and elicit feedback through open communication, and document issues that may require disciplinary action or even alternative career guidance. Effective evaluation processes are transparent, objective, fair, predictable, valid (they measure what they are intended to measure) and reliable (the results are repeatable and demonstrate low inter-rater variability).
The Accreditation Council for Graduate Medical Education (ACGME) oversees all physician trainee programs that lead to specialty board certification. The ACGME outlines the mandatory components of a resident evaluation in its Common Program Requirements. Faculty are required to submit a “formative evaluation” in a timely manner for each rotation. Objective assessments of resident competence are to be provided in the areas of “patient care, procedural skills, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice” — all based on specialty-specific Milestones assessment tools. Additionally, evaluations are to be multidisciplinary — from a range of faculty, peers, professional staff, patients and even self (essentially, a 360-degree review).
How frequently a resident evaluation falls short of ACGME requirements is not known. Experience and anecdotal feedback from residents across the country suggest that evaluation noncompliance may be common. Given that residency evaluations heavily influence your advancement, remediation or even possible termination, these must be done right. We’ll discuss some ideas for promoting evaluation compliance in ways which advocate not only accuracy, but your progress.
Be familiar with the specifics of your evaluations. If you are not being evaluated routinely, request it of the faculty that you have recently worked with. In order to obtain timely evaluations, it can be very useful to request a mid-rotation feedback session with the attending(s) of the service. This serves several functions. It shows them that you are engaged in learning and improvement, begins to solidify for them the ideas about you which will end up in your evaluations, and perhaps most importantly, can identify problems or misunderstandings while there is time to address them. There is nothing like feeling sabotaged by an unexpected critical evaluation that shows up months after the rotation has ended — long after the time in which you could have learned from or repaired the issue.
It can be difficult to obtain objective evaluations given the historically heavy reliance on faculty physicians’ subjective opinions. That subjectivity can manifest itself in attending preferences, biases and even political pressures which may translate into a negative rating despite your performance being within safe and acceptable norms. An example might be that you perform a fascia closure as you were taught by one attending, but when using that same approach in a similar case with another attending, you are heavily criticized for your poor choice in closure technique that “should never be used” in such a case. Or perhaps you work over 80 hours in a week in order to take care of a busy service in which patients would not be appropriately cared for otherwise, but receive a negative “professionalism” rating for not having limited your hours. This is a Catch-22 in which requesting relief would also be considered unprofessional and culturally unacceptable (an unwritten, but undeniable, shirking of duty which would label you as “lazy”). Or perhaps, there is merely a personality difference for which you are disparaged.
Other evaluator pitfalls are the “halo” and “horn” effects, in which a single opinion or category of evaluation is generalized to all components — making the resident out to overall be an angel or devil based on a very narrow assessment or bias. Moreover, some attendings may not want to write an honest (and potentially uncomfortable) negative appraisal, or conversely, may not want to take the time to formulate an objective, detailed and accurate positive evaluation. Nonetheless, physician attendings are well-educated professionals who have accepted the job and must be capable of writing compliant trainee evaluations.
While there is no perfect way to address the subjective nature of evaluations, catching potential criticism early through communication and non-confrontational clarification with attendings can make a difference. Additionally, do your part to give them objective material to work with: do presentations, talk about patient outcomes, be punctual, volunteer for cases and meaningful tasks, facilitate workflows and team interactions. At the end of the rotation, let the attending know that you have enjoyed the learning opportunities (even if there have been frustrations) and that you would appreciate any final feedback or recommendations.
Multidisciplinary evaluations are rarely utilized in residency training, but they are an untapped gold mine. Consider the positive interactions and complex cases that you have shared with other professional staff: attendings, residents, and fellows on consult services; nurse managers; clinical PharmDs; medical students — even patients themselves. Leverage these positive experiences to your benefit. Ask others if they would be comfortable writing you a positive evaluation about your work together. If your institution does not have a formal system for 360-degree evaluations, these can be emailed directly to your program coordinator to be placed in your resident file. Evaluate yourself. If you find an evaluation with which you disagree, consider writing a polite, clarification rebuttal for your file, as well. When the Core Curriculum Committee meets to discuss your progress, make sure they have plenty of information to work with. You do not want their opinion being swayed by unopposed, subjective or inaccurate evaluations of you.
Resident evaluations are critical to your advancement. You can significantly influence them for compliance and accuracy, not only through the reporting of your own positive performance, but through your purposeful interaction with those that write them. As mentioned in a previous article, your residency training is a significant investment in yourself. Get busy protecting it!
Todd Rice is an anesthesiologist and creator, Graduate Medical Education Compliance Project.
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