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Dealing with conflicting feedback


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I am a FM R1 resident doing a hospitalist rotation. 

It’s been quite a frustrating rotation as I constantly get conflicting feedback from different preceptors. I work with a different preceptor almost every other day. 

For instance, one thought my assessment plan was too detailed and wanted me to become more concise

Another preceptor told me to be more detailed. 

Even prescribing medications, one preceptor does it one way, another one does it another.

For instance, I was taught to give a range for opioids, aka “hydromorphone .25-0.5mg po q4h prn” by one preceptor. She said this allows patient to   easier titrate their pain med needs. 

Today, I had a preceptor say, “NEVER PROVIDE A RANGE, just stick to one number and adjust as needed” . He said it makes it easier to figure out how much prn is taken and you adjust as needed.

Both ways make sense to me and I get criticized choosing one over the other.
 

It seems like whatever I choose there’s going to be someone  unhappy about it.

So at the end of the day, I just feel like I’m always doing it wrong and hearing the constant criticism is hurting my confidence.

I feel like crap. Sigh :(.

Any advice on how to navigate this?

 

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I'm still only at the applying to med school stage, but as a non trad that is a manager in a different industry I have some generic advice that may be useful. Humility and allowing superiors to save face goes a long way. Even if they are wrong they are still human. No one likes being corrected, so the game is to get them to correct themselves without realizing you led them there.

1. Always be kind and respectful to everyone, but pleasing people that have no long term influence on your career is completely optional. Don't need a reference or performance review from this person? Smile, nod, and then you are free to move on without incorporating their advice as soon as they leave the room.

2a. When there is enough time for discussion you can approach managers/supervisors with a question phased as "The advice you gave on how to do X makes sense, but I was also told Y in a situation that I thought was similar. Can you help me understand how I can think about Y differently?"

2b. If the conflicting advice came from the supervisor's direct superior you can straight up say "Dr. Boss told me I should be doing Y. Obviously, you both know more than me, but I need some guidance on how to determine which approach applies here." 

3. When presenting to superiors, open by asking if they want all the background details, the highlights and recommendation, or just the recommendation. Have a rough time estimate for each approach incase they ask. Letting them pick the format makes them feel comfortable and in control. 

4. Unless it's an emergency, never outright disagree with your supervisor infront of "out group" people. For you I suppose this would be patients, family, department chairs, and perhaps nurses or support staff. If it's a non emergency then you ask questions privately and from a place of pseudo-ignorance "I was studying for boards last night and the book said X about Y. Do you think that makes sense for us here or am I thinking about this the wrong way?" With this phasing, you aren't some know-it-all correcting the boss, you are a dutiful student asking the wise teacher how to apply books to real life.

5. Observe the actions of people that are what you want to be. The senior colleagues with the personal and professional lives most like the one you want are good role models. They might even give confusing or bad verbal advice, but their actions are almost always worth emulating.

Some of this may feel a little fake or disingenuous. However, sometimes you really will get a good reason why the textbook or Dr. Boss doesn't apply to your specific situation. Other times it will become clear that your supervisor isn't staying current with the industry standard. As the junior colleague, it's not your job to do anything about that unless it is a serious risk to patient safety or it is in some other way so egregious that you have an ethical obligation to report it as misconduct. 

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The above answer is fantastic. The only thing I will add is that some things in medicine are right , some things are wrong  and for some things it's a matter of style.

An  example is a person has had an MI and you decide not to give them aspirin. This is a wrong decision. Another example is someone has sepsis and you decide to treat them with antibiotics. This is a right decision. This is a right decision.

For the examples that you mentioned above, they are neither right nor wrong decisions but a matter of style. It's difficult for some people too be able to differentiate the things that are stylist versus right or wrong decisions. Oftentimes with attendings they will have a certain style and if you deviate from that they think that what you're doing is wrong which is not the case.

What I have started to do over the years is If I didn't really care about the outcome or the decision, I would just nod,  smile and say okay. If I did care I would usually say something along the lines of what the above poster mentioned in 2a and 2b. 

What I've also done is sometimes I'd just laugh and be like that's funny, the other i worked with told me to do this but I guess it's just a difference in practice. This works well with doctors I already have a relationship with and who I know would laugh with me.

 

 

 

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This happened to me as a clerk.  I'd also suggest to consider being pro-active/prophylactic at the beginning of the shift/day - i.e. briefly ask them their preferences wrt x (?more summary or detailed assessments) or y(as needed mentioning having received conflicting feedback), etc.. I realize that it could seem like overkill, but I think it can be easier than dealing with criticism later on when their expectations are not being met.  It also shows that you are keen and eager to "improve".

 In general, I'd suggest trying to read their style as much as possible and quickly adapting to whatever preceptor you are with (with respect to investigations,  management..) as often in medicine there's more than one "right" approach.  It's often more about "attitude" even if x is doesn't according to their preferences how do you react to criticism.. etc..    

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11 hours ago, Butterfly_ said:

I am a FM R1 resident doing a hospitalist rotation. 

It’s been quite a frustrating rotation as I constantly get conflicting feedback from different preceptors. I work with a different preceptor almost every other day. 

For instance, one thought my assessment plan was too detailed and wanted me to become more concise

Another preceptor told me to be more detailed. 

Even prescribing medications, one preceptor does it one way, another one does it another.

For instance, I was taught to give a range for opioids, aka “hydromorphone .25-0.5mg po q4h prn” by one preceptor. She said this allows patient to   easier titrate their pain med needs. 

Today, I had a preceptor say, “NEVER PROVIDE A RANGE, just stick to one number and adjust as needed” . He said it makes it easier to figure out how much prn is taken and you adjust as needed.

Both ways make sense to me and I get criticized choosing one over the other.
 

It seems like whatever I choose there’s going to be someone  unhappy about it.

So at the end of the day, I just feel like I’m always doing it wrong and hearing the constant criticism is hurting my confidence.

I feel like crap. Sigh :(.

Any advice on how to navigate this?

 

Everyone has unique idiosyncrasies to their practice, unfortunately this is the reality of residency where you will frequently find yourself pulled in different, even opposite directions.

Part of residency is growing a thicker skin. You will learn that the stylistic stuff isn't personal criticism, it's just something you need to adapt to do for that specific boss and shrug off the personal feelings of frustration you have in the moment.

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12 hours ago, Butterfly_ said:

I am a FM R1 resident doing a hospitalist rotation. 

It’s been quite a frustrating rotation as I constantly get conflicting feedback from different preceptors. I work with a different preceptor almost every other day. 

For instance, one thought my assessment plan was too detailed and wanted me to become more concise

Another preceptor told me to be more detailed. 

Even prescribing medications, one preceptor does it one way, another one does it another.

For instance, I was taught to give a range for opioids, aka “hydromorphone .25-0.5mg po q4h prn” by one preceptor. She said this allows patient to   easier titrate their pain med needs. 

Today, I had a preceptor say, “NEVER PROVIDE A RANGE, just stick to one number and adjust as needed” . He said it makes it easier to figure out how much prn is taken and you adjust as needed.

Both ways make sense to me and I get criticized choosing one over the other.
 

It seems like whatever I choose there’s going to be someone  unhappy about it.

So at the end of the day, I just feel like I’m always doing it wrong and hearing the constant criticism is hurting my confidence.

I feel like crap. Sigh :(.

Any advice on how to navigate this?

 

Short answer, just accept that is how it is in both the hospital and outpatient setting - keep track of different approaches, and acknowledge which ones you like to adopt yourself. When you are done, you'll be able to do what you want and find a balance.

Acknowledge that nothing you are experiencing is unique to you, and that it is in no way a reflection of your clinical skills or otherwise. It is them, not you :)

Also, a bit crummy that you have different preceptors daily - we usually try to advocate for at least 1 week internal rotations with preceptors for learners within a block rotation. Can you ask to be with the same preceptor? surely they are working more than 1 day in a row.. 

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1 hour ago, indefatigable said:

This happened to me as a clerk.  I'd also suggest to consider being pro-active/prophylactic at the beginning of the shift/day - i.e. briefly ask them their preferences wrt x (?more summary or detailed assessments) or y(as needed mentioning having received conflicting feedback), etc.. I realize that it could seem like overkill, but I think it can be easier than dealing with criticism later on when their expectations are not being met.  It also shows that you are keen and eager to "improve".

 In general, I'd suggest trying to read their style as much as possible and quickly adapting to whatever preceptor you are with (with respect to investigations,  management..) as often in medicine there's more than one "right" approach.  It's often more about "attitude" even if x is doesn't according to their preferences how do you react to criticism.. etc..    

I have started doing this too - I always start a rotation or shift with a quick “how do you like to do things, how do you want to review, how concise do you like things”  to try and get a sense of there style and I have found it really helps. 

And for things like opioids, or anti depressants/anti-psychotics, etc, where I know people have such strong personal preferences, during review I will often  preempt comments with something like “I’ve seen a lot of variation in prescribing practice for __, I am interested to know how you approach it” and then we discuss it, and if needed I change the orders.

OP, I think we’ve all been there. Even with the above strategies, some days I think I am doing great and then the next day I just feel like I have no idea what I am doing, and half of that is conflicting feedback.

 

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Sounds like residency lol. In all honesty, you'll meet so many people who does things differently that in the end you can be confident to take what you need and leave behind what you don't. Like others have said, be courteous, don't get kicked out, grow a thick skin. Once you have CCFP, you're free.

Let me tell you a fun story, there's a staff in my residency who's like some world leading renowned expert in his field blah blah blah. One day I had a difficult specimen so I asked for his help. There's one specific area where I wasn't sure how to cut it, so he took the knife and CUT IT HIMSELF.

Now few days later I am doing this case with another more junior staff, who's like a lapdog to this world expert. She immediately blasts me for 5 minutes for doing such a poor job of cutting that area, blah blah blah. So I straight up said Mr World Expert did the cutting HIMSELF, so we should go to his office and discuss the problems with the cutting. Right away she STFU. Never mentioned it, gave me a good evaluation for that day.

 

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3 hours ago, OldManNearTheSea said:

I'm still only at the applying to med school stage, but as a non trad that is a manager in a different industry I have some generic advice that may be useful. Humility and allowing superiors to save face goes a long way. Even if they are wrong they are still human. No one likes being corrected, so the game is to get them to correct themselves without realizing you led them there.

1. Always be kind and respectful to everyone, but pleasing people that have no long term influence on your career is completely optional. Don't need a reference or performance review from this person? Smile, nod, and then you are free to move on without incorporating their advice as soon as they leave the room.

2a. When there is enough time for discussion you can approach managers/supervisors with a question phased as "The advice you gave on how to do X makes sense, but I was also told Y in a situation that I thought was similar. Can you help me understand how I can think about Y differently?"

2b. If the conflicting advice came from the supervisor's direct superior you can straight up say "Dr. Boss told me I should be doing Y. Obviously, you both know more than me, but I need some guidance on how to determine which approach applies here." 

3. When presenting to superiors, open by asking if they want all the background details, the highlights and recommendation, or just the recommendation. Have a rough time estimate for each approach incase they ask. Letting them pick the format makes them feel comfortable and in control. 

4. Unless it's an emergency, never outright disagree with your supervisor infront of "out group" people. For you I suppose this would be patients, family, department chairs, and perhaps nurses or support staff. If it's a non emergency then you ask questions privately and from a place of pseudo-ignorance "I was studying for boards last night and the book said X about Y. Do you think that makes sense for us here or am I thinking about this the wrong way?" With this phasing, you aren't some know-it-all correcting the boss, you are a dutiful student asking the wise teacher how to apply books to real life.

5. Observe the actions of people that are what you want to be. The senior colleagues with the personal and professional lives most like the one you want are good role models. They might even give confusing or bad verbal advice, but their actions are almost always worth emulating.

Some of this may feel a little fake or disingenuous. However, sometimes you really will get a good reason why the textbook or Dr. Boss doesn't apply to your specific situation. Other times it will become clear that your supervisor isn't staying current with the industry standard. As the junior colleague, it's not your job to do anything about that unless it is a serious risk to patient safety or it is in some other way so egregious that you have an ethical obligation to report it as misconduct. 

Also just want to highlight that I think this is great generic advice - it’s a good reminder of the many ways in which medicine is just like any other job. 

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12 hours ago, Butterfly_ said:

For instance, I was taught to give a range for opioids, aka “hydromorphone .25-0.5mg po q4h prn” by one preceptor. She said this allows patient to   easier titrate their pain med needs. 

I had to chuckle at this one though, as most places i've worked, nursing will automatically up it to the max dose if the patient asks them for a p.r.n more than once :P So it rarely ever works out that there is a true "patient-led" titration of medications. Or scenarios when patients are non-communicative dementia/palliative and are just always pushed max doses for being "too much work". 

Too many idiosyncrasies and process variations dependent on the providers carrying out your requested plans.

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Who cares. Honestly it makes no tangible difference to patient care. If it made a difference, then maybe I would care, but since it really doesn't don't sweat it.

If you write a range, you still will look at the MAR to calculate how much they actually got, so it doesn't make anything easier really. The attending's just flexing on something that is completely inconsequential.

If it were me, because I tend to just say things at this point in residency, I would probably just say "well Dr. X insisted I write a range for Y reasons, and that's why I wrote a range." (actually, maybe don't do this, lol - gotta pick your battles).

But honestly who cares, there are times in residency its better to just keep your head down and get the work done. Just shake it off, this shit is temporary and it to will pass.

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One of the most important things to realize in clerkship/residency is that for a lot of things, there are multiple "right" ways to do things, and in the end you serve at the pleasure of your staff, and whatever way they want is the "right" way. So just say things like "Previously I've seen some people write meds in ranges but others like to give specific doses, which is your preference?" Or "uptodate" recommends X treatment for Y, but I've seen other staff do Z, do you know which is better?". Over time you'll see how things can be done different ways and come up with your own preference, and for longer residencies you will learn what each staff likes and act accordingly.

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Yeah, it sounds like clerkship and residency indeed.

People have different ways of doing things. They are just showing you their ways of doing things.

Your attending isn't always right. Your attending isn't necessarily up to date. Your attendings have different personalities and different risk tolerance, hence influencing their practice. Different attendings do things differently when it comes to things in the gray zone (a black and white type of scenario would be a case where any attending should be doing the exact same thing. Patient comes with a displaced distal radius fracture: you should reduce it and put a cast of some sort on it)

Be open-minded. Look at their different ways of doing things. You'll accept some feedback, you'll leave the non applicable ones behind.

It shouldn't affect your confidence in any case. As long as you are becoming a better clinician, it's all that matters. Most attendings, when giving feedback, they do it with the intention of helping you becoming better. Some aren't good with teaching or giving feedback.

In an environment where you constantly work with different people, it's inevitable that some attendings will find you good, and some will find you not so good simply because they do things differently. Residents typically find it to be the case in an ED where they work with different people all the time.

As you keep progressing, you'll develop your own style. It is likely that by the end of your residency, you will be fed up with these kind of evals all the time.

Keep it up!

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feedback is so annoying - my turn to vent.

my academic advisor is so negative and critical. originally i was overconfident and come across overconfident. today it was i'm too intense and enthusiastic. its just like never enough. he told me i'm middle of the pack amongst my cohort. i'm just annoyed. and then when i ask for anything positive it's like "you care too much about the evaluation and i just want you to get better" - like?? of course i care about the eval?? it's going on my record? i may apply to fellowship? all of med is an evaluation!? like fuck!? 

anyway i've never come out of any of my meetings with him feeling good about myself and its always just torture. and honestly i think i'm pretty ok as a resident, i'm on top of my patients, very diligent about everything. lacking in knowledge sometimes for sure (that's where i know i'm def average compared to my colleagues) but fuck man. feel like sometimes i can't catch a break. 

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3 hours ago, bellejolie said:

feedback is so annoying - my turn to vent.

my academic advisor is so negative and critical. originally i was overconfident and come across overconfident. today it was i'm too intense and enthusiastic. its just like never enough. he told me i'm middle of the pack amongst my cohort. i'm just annoyed. and then when i ask for anything positive it's like "you care too much about the evaluation and i just want you to get better" - like?? of course i care about the eval?? it's going on my record? i may apply to fellowship? all of med is an evaluation!? like fuck!? 

anyway i've never come out of any of my meetings with him feeling good about myself and its always just torture. and honestly i think i'm pretty ok as a resident, i'm on top of my patients, very diligent about everything. lacking in knowledge sometimes for sure (that's where i know i'm def average compared to my colleagues) but fuck man. feel like sometimes i can't catch a break. 

I'd be happy to be in the middle of the pack but I hear you! Feedback can vary so much from one staff to the next that unless it's truly useful and constructive, I try not to waste my mental energy on it and just nod and agree

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1 hour ago, chateau22 said:

I'd be happy to be in the middle of the pack but I hear you! Feedback can vary so much from one staff to the next that unless it's truly useful and constructive, I try not to waste my mental energy on it and just nod and agree

It’s not about the content it’s the way he says it - he wants me to be discouraged, he doesn’t want me to be confident or enthusiastic. It’s just breaking me and I feel very defeated. It’s making me hate my program and site. 

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2 hours ago, bellejolie said:

It’s not about the content it’s the way he says it - he wants me to be discouraged, he doesn’t want me to be confident or enthusiastic. It’s just breaking me and I feel very defeated. It’s making me hate my program and site. 

If knowledge is your main problem, you can just read! It is very easy to acquire knowledge and do better compared to your colleagues by being knowledgable.

I recommend listening to podcasts like the GenerEhlist and doing question banks ( like amboss) to build your knowledge gaps! Being keen is great, but you need to develop your competency ( knowledge/assessment/management plans) as a resident, etc.  You are not a medical student any more to be graded on you being keen or enthusiastic lol.

I never chose FM as my first choice specialty, and I actually hate FM so much so I am definitely not very keen or enthusiastic about FM, yet I manage to get quite quite good evals in most of my rotations b/c I do +++ question banks and as a result I immediately have assessments/management plans for my patients and I am quite efficient so preceptors like having me around because they can go home sooner lol.   You may need to work on being a competent resident instead of being keen/enthusiastic. 

I do agree with you thought that feedback is quite subjective, but use it to continue to develop yourself.  Also don't let your preceptor discourage you, you need to always believe that you can improve and you can always do better and learn/progress.

 

Best of luck!

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6 hours ago, carmsregrets said:

If knowledge is your main problem, you can just read! It is very easy to acquire knowledge and do better compared to your colleagues by being knowledgable.

I recommend listening to podcasts like the GenerEhlist and doing question banks ( like amboss) to build your knowledge gaps! Being keen is great, but you need to develop your competency ( knowledge/assessment/management plans) as a resident, etc.  You are not a medical student any more to be graded on you being keen or enthusiastic lol.

I never chose FM as my first choice specialty, and I actually hate FM so much so I am definitely not very keen or enthusiastic about FM, yet I manage to get quite quite good evals in most of my rotations b/c I do +++ question banks and as a result I immediately have assessments/management plans for my patients and I am quite efficient so preceptors like having me around because they can go home sooner lol.   You may need to work on being a competent resident instead of being keen/enthusiastic. 

I do agree with you thought that feedback is quite subjective, but use it to continue to develop yourself.  Also don't let your preceptor discourage you, you need to always believe that you can improve and you can always do better and learn/progress.

 

Best of luck!

Yeah I agree with you but unfortunately all my preceptors this month (we work with different staff each half day clinic) has said my knowledge was great. I always have assessments and plans ready to go as well and come up with impressions before reviewing which are generally right. I listen to curbsiders and prep my clinics every night. That’s why I was surprised, my feedback overall has really been excellent from my supervisors truly and it just felt like from him he’s just not used to the personality type. 
 

the feedback wasn’t that I need to develop more knowledge and be less keen and eager, it was in general I’m too eager or enthusiastic. I’m a bubbly person by nature it’s just my personality. I also take on a lot of leadership roles and my personality shines. I think for sure there’s a time and place to be more outgoing and over my many years I’ve learned that but I genuinely feel he can’t handle someone confident and it’s threatening. I just have to not let it bring me down. 

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6 hours ago, bellejolie said:

Yeah I agree with you but unfortunately all my preceptors this month (we work with different staff each half day clinic) has said my knowledge was great. I always have assessments and plans ready to go as well and come up with impressions before reviewing which are generally right. I listen to curbsiders and prep my clinics every night. That’s why I was surprised, my feedback overall has really been excellent from my supervisors truly and it just felt like from him he’s just not used to the personality type. 
 

the feedback wasn’t that I need to develop more knowledge and be less keen and eager, it was in general I’m too eager or enthusiastic. I’m a bubbly person by nature it’s just my personality. I also take on a lot of leadership roles and my personality shines. I think for sure there’s a time and place to be more outgoing and over my many years I’ve learned that but I genuinely feel he can’t handle someone confident and it’s threatening. I just have to not let it bring me down. 

If that's the case - then maybe your personalities don't jive! Don't worry about it! 

It seems that they are just a critical person for no reason, so don't let it bring you down! It's important to filter all feedback you get. If the feedback can help you grow/improve/ progress then use the feedback to help propel you forward!  If the feedback is mainly about your personality type ( ie. your a bubbly/enthusiastic person), then I am not sure if that's feedback or that's them being critical.

Feedback in medicine should be actionable and should provide you with a plan to improve, it does not seem that your preceptor is doing that ( they are mainly criticizing your personality). 

in general, I think you need to focus on becoming a better physician, instead of your evaluations in medicine  ( although I understand your fears that it may affect your future plans/fellowships).  

Best of luck!

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21 hours ago, bellejolie said:

It’s not about the content it’s the way he says it - he wants me to be discouraged, he doesn’t want me to be confident or enthusiastic. It’s just breaking me and I feel very defeated. It’s making me hate my program and site. 

Don't let it break your confidence and enthusiasm! If other preceptors are telling you good things, it's probably a mismatch of personality and you're done in a few years 

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