Real-time assessmentand feedback of juniordoctors improvesclinical performanceGordon Caldwell, Worthing Hospital, West Sussex

Iwas sitting in the National

Association of Clinical Tutors’Autumn Meeting in 2004,

wondering why we assess ourjuniors in artificial circumstancesthat might not always not reflectreal work, and take up so much ofour time. I began to wonder whywe do not assess our juniors inthe real workplace, in the waythat a driving test examinerassesses learner drivers in realtraffic situations. I rememberedProfessor Janet Grant of the OpenUniversity saying that, if someauthority asks if you are doingsomething (for example, the

assessment of junior doctors),one should reply ‘Yes’, and thenfind out in what ways you arealready doing it! So I reasoned,‘Why not observe my juniors atwork on the post-take ward round,without the need for extra time tobe spent on assessment?’ On myway home from the meeting, Idesigned my first ‘team assess-ment’ form, and used it the nextday. I have modified the form overtime, and the ‘scoring’ systemtoo, because I have learned thatfeedback is ultimately far moreimportant to students than beinggiven a score.

THE PROCESS

I also wanted my juniors tolearn how to run a post-takeround. Before the round starts,we count the patients to beseen, and prioritise the round tosee the most acutely ill patientsfirst, then the night-shift pa-tients, and finally the day-shiftpatients. The juniors now pre-pare this list for me, and have itready before the round begins. Iask one junior, or nurse, toassess me during each round. Iassess each junior once after thefirst case he or she presents on

Feedback isultimately farmore importantto studentsthan beinggiven a score

Learningin theWorkplace

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the round, using a structuredformat (see Figure 1), empha-sising that this is a teamassessment (for example, thestudent’s score will be enhancedby ‘good’ prescribing by theSenior House Officer – SHO). Thefeedback is open and heard bythe whole team. Typical com-ments I might make are:

‘You chose suitable medica-tions, and to improve next timeyou should write the prescription incapitals. Also write your name incapitals, with your bleep number,after the name of the first drug.’

‘Your presentation was verythorough. I can now trust you tomake a briefer presentation,

emphasising the important posi-tives and negatives.’

‘Always report how ill thepatient appears, followed by thevital signs, including respiratoryrate and oxygen saturations.’

‘If you request a chest X-ray,you must write down the findings

Figure 1. Dr Caldwell’s post-take ward round instant team assessment.

At the end ofthe whole round

I ask forfeedback on my

performance

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before the ward round, or get thenight doctor to do it.’

‘You spoke with the SpecialistRegistrar (SpR), and I want youalways to speak to the patient’snurse, or a senior nurse, after youhave decided on a managementplan.’

Such feedback takes at mosttwo minutes per junior. At the endof the whole round I ask forfeedback on my performance. Myjuniors have, for example, askedme to write less and look at themmore during a case presentation;to summarise the problems listmore clearly; to challenge themmore on management; to pointout unsatisfactory care moreoften; and to explain changes inmedication more often.

OUTCOMES

I have used this new system onevery Thursday I have been onduty since November 2004, andduring every post-take round onSaturdays, Sundays and Mondaysafter weekend day admissions. Ihave never seen my juniors’behaviour change so quickly andso effortlessly. For example, alltheir prescribing is now written inlegible capitals. All patients haveadmission and follow-up vitalsigns recorded. The juniors speakwith the nurses after all admis-sions, which has improved com-munication and care. The clerkingnotes are all legible, with cleardates, times and signatures. Casepresentations are brief and per-tinent, and charts, electrocardio-grams (ECGs) and X-rays are intheir correct places. The juniorswork as a team to ensure thateveryone, from the student to theSpR, gets a ‘good’ score, and toprovide me with the information Ineed at the correct time. I canspend more time talking with thepatients and juniors aboutimportant issues, as well asteaching, and we even have timefor a coffee break. Recently wesaw 27 new admissions in three

hours without any feeling ofpressure, and still had time to goto the Coronary Care Unit (CCU) sothat the Foundation Year 1 Doctor

could learn about acute coronarydisease management. I had notbeen to the CCU for several years,so I was learning too!

I have neverseen myjuniors’behaviourchange soquickly

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Since starting this new post-take system, I have also changedmy behaviour on rounds. I nolonger keep and modify the wardround list, so I write less and talkmore on rounds. I have learned tobe more comfortable identifyingunsatisfactory care, and to pro-vide open feedback. I make itmuch clearer to my juniors nowhow I want the round to run. Ifind that I am enjoying roundsagain, and I have a much betterknowledge of my juniors and theirperformance.

DRAWBACKS AND BENEFITS

The process does require effort(but, on the plus side, it does nottake up much time). The juniorscan have a tendency to rush on tothe next patient rather than towait for assessment. However,their performance has improvedso much that at times it seemsunnecessary to use this system onevery round, but I still want togain more experience. It can be

hard to find new challenges, butin general the level of discussionincreases over time – for example,because the presentation is good,there is time to discuss the man-agement in more detail, ratherthan just to give straightinstructions. On the form shownin Figure 1 there is too little spaceto provide much feedback, thefeedback is not anonymous, andthere is no easy way to givewritten feedback to every teammember; however, I think the‘team’ aspect is valuable. Thinkingof the assessment rather than thepatient can at times distract me,and I would like the SpR or SHO totake over doing the assessments –and peer feedback might be evenmore powerful and challenging!

TAKE-HOME MESSAGES

I have learned:

• To make ‘WILF’ – ‘What I amLooking For’ – clear to myjuniors in areas of real clinical

practice; for ward rounds Inow have a sheet to describethis.

• To set clear and simple criteriafor assessments.

• To design structured assess-ment and feedback records.

• That in teaching, learning orcoaching, feedback is far moreimportant for improving per-formance than any score – infact, being too concernedabout the score can distractfrom useful feedback.

• That my juniors always wantto know how to be better, andalways want a new challenge.

• That my juniors can help me tochange in useful ways, and itis very reassuring and pleasingto get honest feedback!

BUT – I have not learned howto get anyone else to give this atry! Will you?

I think the‘team’ aspect is

valuable

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