The GMC has published ‘Good conversations, fairer feedback’, a research study into the impact and value of feedback for trainee doctors. Authors Dr Catherine Walton and Dr Alice Rutter were clinical fellows at the GMC when their work was conceived, and here they explain how the project came about and the impact it’s had on them.
In August 2019 we began as clinical leadership fellows at the GMC, working in the team supporting the Caring for doctors, caring for patients review. This experience, coupled with the opportunity to understand healthcare from a broader and more strategic perspective, triggered a conversation between us.
Another GMC report, Fair to refer?, highlighted the disproportionate numbers of doctors from black and minority ethnic backgrounds who are referred to the GMC for fitness to practise concerns.
Trying to understand the causes of this, in a system that we were part of, was uncomfortable. We realised how limited our own perspectives were on what it meant to be a medical trainee in today’s NHS.
A theme common to both reports was ‘feedback’ and its impact on individuals’ training, competence and sense of wellbeing. The link between feedback and wellbeing particularly interested us, so we designed and refined a research project that we hoped would shine a light on that connection.
We set the wheels in motion. And then the true magnitude of the COVID-19 virus became clear.
For a time, submerged in uncertainty and with an urge to hasten to the front line, it felt impossible to invest our time into something so apparently trivial as a research project.
But, as the smoke cleared and we adapted to the new reality, it became apparent that the wellbeing of healthcare staff was more important than ever. So, we revisited our research and pulled together our report.
Our motivation was our certainty of the need to build an NHS that is compassionate to staff as well as to patients, that that desire was shared widely, and that feedback is a crucial factor.
Feedback is defined by dictionaries as information offered with the purpose of improvement. Yet a simplistic definition masks the immense influence and impact of the moments when feedback is shared.
Our research showed that, for doctors, feedback from someone who has their respect can alter the course of a career. Feedback builds trust, and is a means of building relationships that allow us to feel safe learning from mistakes.
But the counter is also true. Poorly-delivered feedback can be used to belittle and criticise, and can be taken as a signal that the recipient is not ‘part of the gang’. It can be a way of delivering a public dressing down. It can even amount to bullying.
A lack of any feedback can be equally damaging. As one trainee doctor put it, they were left feeling like they were ‘swimming in this big ocean not sure if going the right direction’.
No feedback, or poorly-delivered feedback, leaves trainees feeling isolated, and with the sense of being an outsider. This feeling was most acute among doctors who qualified outside the UK, or who did not identify as being white British.
There was a stark difference between those who had studied in UK medical schools and international medical graduates (IMGs) who qualified elsewhere. IMGs described how they lacked knowledge of an ‘unwritten code’ to be able to ask for support and to be confident of receiving it.
Recent community movements, such as Black Lives Matter, have raised awareness of differential experiences of life opportunities, and encouraged our exploration of our own privilege. The weight of history is not something we can ignore, and nor can we simply write off unintended wrongs as social blunders. It is not enough to blame a system and declare ourselves powerless to change it.
Our research showed us that these biases are rooted in our culture. We need active participants to bring about change, and our research also points towards ways that can happen.
Many of the experiences our IMG participants told us about were echoed in a King’s Fund report in July 2020. The NHS has one of the most ethnically diverse workforces in the public sector yet there are measurable inequalities in career progression and opportunity, and limited ethnic minority representation at senior levels.
Where do we go from here? From the perspective of feedback, we have demonstrated that it is not just about that offhand interaction or comment to a junior while hurrying to the next patient. There is so much more, or at least there should be.
Feedback forms part of a wider conversation, and the way we go about it raises questions about our unconscious biases and attitudes.
It is also a component of building inclusive cultures and psychological safety. Trainees who don’t feel psychologically safe, or don’t feel part of an inclusive culture, cannot sense check feedback and are unable discuss negative experiences with colleagues.
Feedback needs to become a conversation, a dialogue in which participants play equal parts. And we need to consider how doctors new to the NHS are enabled to understand their right to ask for feedback.
Our training teaches us that all doctors are leaders, often in the hardest moments of patients’ lives. At the core of engaged leadership is the understanding that our perspective is only one of many. By listening to other voices leaders can use their experience and wisdom to move others forward.
This art of listening to others, a curiosity about a range of views and a willingness to challenge constructively is the foundation for effective feedback and building trusting relationships.
Training both trainers and trainees about what feedback conversations should be, and setting attainable goals, would be a step forward.
As the last 18 months has shown us, we must examine each and every one of our interactions. We won’t get it right every time, but now is not the time to bury our heads in the sand or to look the other way.
Good conversations, fairer feedback: A qualitative study into the perceived impact and value of feedback for doctors in training, by Dr Alice Rutter and Dr Catherine Walton, is available online.