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For some of our physicians, they see that feedback and they want to change. They realize ways in which they can improve. Or for some it’s a great pat on the back to learn that your colleagues really think of you highly and that they appreciate the way that you interact with them.

Aalok Agarwala, MD

former Chief Medical Officer, Mass Eye and Ear

The work of medicine today requires collaboration and, increasingly, a mastery of team dynamics, regardless of specialty. Achieving the best clinical outcomes and avoiding medical error demand a focus on communicating well with colleagues from other disciplines up and down the hierarchy. The same can be said for preventing wrongful acts in the workplace, such as discrimination or harassment. A critical challenge is that, unlike the vast clinical instruction that medical professionals receive, formal training is lacking or non-existent for interpersonal skills.

In Aalok Agarwala’s role as Chief Medical Officer at Massachusetts Eye & Ear in Boston, he led a program to provide personalized feedback to physicians about the effect of their behavior and interactions on others.

“We have trained and trained and trained and spent years and years in residencies and fellowships to become who we are as clinicians. We haven’t all had the training to know how to work in these professional environments with different folks necessarily in the same way.”

The hospital’s medical professional liability insurer, CRICO, funded a pilot project to implement a feedback tool, the Rapid PULSE 360 Survey, at several of the Harvard medical institutions.

“We often have feedback from our clinical work because we know how our patients do. We have feedback in our academic pursuits because we know whether our papers get accepted for publication or presentation. But there’s very little formal feedback in regards to what our team members think of us, those that are around us think of us. And this process allows some of the hierarchy to flatten, if you will, where folks like scrub techs can give feedback when they would otherwise not feel comfortable doing so in a more direct way.”

At the center of the program is a 24-question tool designed to collect feedback that will aid health care providers in improving their practice and communication skills. Providers and their direct supervisors choose the evaluators. Each evaluator receives an online survey about the subject’s communication and behavior patterns. It is called a 360 evaluation because the provider gets the perspective of their peers, subordinates, and supervisors on how they work and interact with colleagues around the hospital. Dr. Agarwala said responses are aggregated and anonymous.

“Typically, for example, for a surgeon, they might choose some of the colleagues that they work with, some of their surgical colleagues. They would choose anesthesiologists with whom they work in the operating room, some of the OR nurses, for example, or scrub techs. And if they work in a clinic setting, then folks that they work with in the clinic. So that might be administrative staff or their medical assistants, really anyone with whom they interact in a professional capacity in the hospital or clinic environment.”

On the resulting evaluation, participants are given red, yellow, or green behavior classifications based on indicators from the survey tool. Most are green. For people in the red or yellow category, indicating worrisome or problem behaviors, department leaders aren’t left to deliver difficult findings to participants on their own. Results and analysis are delivered to individual clinicians by trained Pulse professionals, and the program provides coaching to address areas for improvement.

“For some of our physicians, they see that feedback and they want to change. They realize the ways in which they can improve. Or for some it’s a great pat on the back to learn that your colleagues really think of you highly and that they appreciate the way that you interact with them. It’s wonderful to have that sort of positive feedback that we don’t often get, as well.”

Promoting culture change and the teaching and monitoring of interpersonal skills is an objective of the project. CRICO took an interest as it focuses on helping subscriber institutions prevent claims and suits in the employment practices liability space. Beyond that, difficulty with provider-to-provider interactions is also an issue in a wider spectrum of professional liability claims because patient safety so often requires excellent teamwork. According to recent analysis of all cases asserted between 2018 and 2023 in CRICO’s national Candello database, provider-to-provider communication is among the top 10 contributing factors in medical malpractice cases.

“I think that the signals that you get from a program like this about folks that are having some trouble with interpersonal interactions, absolutely is a marker for what could come. The sooner we can intervene, the sooner we can correct those behaviors that are leading to the perception that a particular physician is not really a team player or I think the sooner we can get ahead of it, the better off we are as an organization, any organization.”

Dr. Agarwala says leaders across his institution from department chairs to HR to the administrative leadership “bought into” the project. It was made clear that the purpose was for improvement. All hospital-employed physicians at Mass Eye and Ear were required to participate.

Every participant is offered a debriefing, but the survey feedback is just the first of two elements in the Rapid PULSE 360 program. It has a second step, and it’s offered to those with yellow or red scores: coaching. Here, says Dr. Agarwala, some clinicians need persuasion to take advantage of this element. He says he shared some of the skepticism himself about the value of seeing a coach, even one who specializes in working with physicians. But Dr. Agarwala says it helped to have an objective and trained professional ask hard questions, such as what does professional satisfaction look like, and how to balance work goals and family priorities.

“You know, it’s interesting that we as physicians are often resistant to coaching. Considering how many years of training we’ve gone through; you would think that we would be used to this idea that you get feedback to get better. But when you think about the people in the world that are the best at what they do—athletes and musicians—they have coaches throughout their entire careers. You wouldn’t think twice watching a pro athlete talk with their coach before, after, or even during a tennis match or a game. It’s a part of what they do. It’s a part of who they are. It’s a part of how they perform at their best.

"Serena Williams has probably three coaches, right? She probably has somebody to help her with her serve alone and someone else to help her with her backhand return. Never mind the physical trainers that she has and the nutritionists. I mean, think about the teams that the best in the best have to help them perform at their best. And I use that analogy because again, we have this drive to want to be the best that we can be. Why wouldn’t we take advantage of guidance, mentorship, coaching. They are all different, but they’re all related to create a team of people to help support us in all that we do. And this coaching, this opportunity to have a coach is just that.”

Dr. Agarwala hopes that the Rapid PULSE 360 program can be formally adopted as a tool to provide feedback at his institution and others. One Boston-area institution has already incorporated the feedback tool into its recredentialing process. As of April 2024, this multi-institution pilot program has resulted in the evaluations of more than 675 individuals (physicians, nurse practitioners, physician assistants, and clinical leaders) from more than 20 service lines.

I’m Tom Augello, for Safety Net.



  • Aalok Agarwala, MD, Mass Eye and Ear
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