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.