“Any feedback for me?” Shelly, my resident, is wrapping up a successful intern year in the emergency department during which, as far as I know, she still hasn’t killed anybody. At the end of the night shift, we were both exhausted and ready to head home to our families, hobbies, and beds.

Yet she still found the gumption to ask for feedback, a customarily painful experience. Most supervisors just can’t resist adding in some acidic criticism after the token praise.

“You did well with blah blah, but you really need to work on this and that and this other thing, which absolutely cannot happen again, and that time you were totally wrong, I’d like you to inform me ahead of time when you get confused before it becomes a real disaster, and …”

Often coated in flowery professional verbiage, feedback tends to focus on the negative and highlight failure and often degenerates into emotional flogging. “Constructive feedback,” lauded as the ultimate educational tool, is still essentially negative, albeit coupled with usable strategies for improvement. When it comes to the trainee’s confidence and self-esteem, it is difficult to avoid having constructive feedback become destructive.

I had to admire her diligence, asking for feedback after an overnight of hard work. Impressed, I decided to do better than feedback.

She was going to experience “feedforward” for the first time. Feedforward radically turns negative to positive. Instead of beating up, it bolsters and builds. Here we go …

Feedforward Step 1: “What was your best case today?” I asked.

“What?!” she gasped, looking at me with suspicion.

“Not a trick question. I just want to hear about the case that worked out well, where you were awesome. Trust me, it’s worth the time.”

Still suspicious, but playing along, she began with caution, but soon was speaking with genuine excitement.

“It was that ultrasound-guided IV case, actually,” she said. “I didn’t get the IV; you had to take over there, but I figured out his CHF, optimizing his oxygenation and ventilation. I also addressed his concurrent COPD and remembered to check for hypercarbia. I even thought of the best antibiotic regimen for possible, but less likely, pneumonia. I remembered the renal adjustment of dosing. I felt in control. I felt empowered. He was my patient, I was his doctor, and I was making him better. I was using my knowledge and skills to keep a human being from dying. It was awesome!”

I felt no less excited. She was really shining, and describing this case was converting her competence into something immensely valuable.

My resident was going to experience ‘feedforward’ for the first time. Feedforward radically turns negative to positive. Instead of beating up, it bolsters and builds.

Feedforward Step 2: “What was it about this case that made it possible for you to perform so well?” I asked.

She answered without reservation: “You let me do it,” she said.

“Sometimes, attendings just take over too early. And you didn’t criticize my initial ideas, so I could get my mind around the whole thing without getting self-conscious. And the nurses were so helpful, like they often are when the attending gives the orders. I think it was because I ordered politely but firmly while looking them in the eyes and explaining my reasoning without apologizing or looking indecisive. Also, I wasn’t overwhelmed with too many cases, so I could really focus on rocking this one. I am going to work on making faster decisions so I can get more done and handle more concurrent cases. Decisions are a rate-limiting step for me. I think I can see a lot of things now that I need to improve, but I can do it. I like this feeling.”

I stood back in awe. She showed insight. She gave herself feedback that she didn’t resist because it wasn’t coming from me. She did manage the case rather well and was building real confidence. Confidence takes you from being a knowledgeable wallflower paralyzed under stress to leading a team down the field for a decisive victory over decompensated disease.

Confidence also fosters peak performance that leads to more confidence, but getting trainees to begin this cycle can be like pulling teeth, as most hesitate to be decisive even when fully capable of it. Instead of beating down on her with feedback, I was helping her rise with feedforward. Delighted, I responded: “You are right,” I said. “You did great. And what I appreciated the most was the first thing you mentioned – the ultrasound guided IV you didn’t get. I took it from you, probably because the patient looked like he was ready to kill the next person who failed. Remember what you said right after I got the IV?”

After a moment of reflection, she recalled: “Next time, can you please guide me through it?” Then, suddenly realizing the boldness of the statement, she looked concerned. “Was that OK?” she asked.

“More than OK,” I reassured her. “It was necessary. A good student takes control of her education and guides the teacher on how to be more effective. My mistake was taking away your opportunity to learn to do this well yourself. I let you succeed with the case but failed to let you succeed with the procedure. I will now try to do better.”

She beamed as we said farewell for the night. We will work together again, and she will continue to improve as a resident. I, in turn, will try harder to improve as an attending.

Dr. Veysman is assistant professor and attending physician, Department of Emergency Medicine, the University of Medicine & Dentistry, New Jersey Robert Wood Johnson Medical School.