Matt Morgan: Time to stop serving the “shit sandwich”

If you have attended an Advanced Life Support course, you will be familiar with the so-called “shit sandwich.” Despite electrocuting yourself with the defibrillator, tripping over the ECG cables and giving your assistant a needle-stick injury, the feedback will inevitably start with “Right everyone, what did they do well?” A lone voice will respond with “I like the way they introduced themselves to the patient” which would be fine had the patient not been having a cardiac arrest. Once the bottom slice of motivation has been laid, next will come the filling of errors you made, each delivered with a sympathetic facial expression. Finally, you are left with that top buttered slice of “Well done! You can do this! What do you think you could do better next time?” “Read the manual,” you think to yourself. And so the “shit sandwich” is served, whereby criticism is couched in positive feedback. 

I had been happily eating this staple diet throughout my medical education until I met an extraordinary person. Gary Thomas amazed me from the moment I met him. A talented clinical teacher, he could take you on a journey from fundamental physics to caring for a sick child in the blink of an eye. While revising for an anaesthetic exam, he offered viva practice, which I was strangely looking forward to. I had passed my written exams, felt confident about my knowledge base, and hoped that I could impress him. Days before Christmas, I stepped into Gary’s office for our first session. The next hour was a blur. Perhaps I have mentally blocked out the pain. The memory I have retained is responding to a question on the risks of thermometers with “Well, they might explode!” Not only had I performed terribly, but there was no comfort of a shit sandwich to chew on. “That’s not good enough to pass. You have to do more work and in a different way if you want to pass.” “Happy Christmas to me,” I thought.

But Gary was right. I worked hard, changed the way I was revising, and passed. Increasingly, I realise that Gary’s response was so much richer than a shit sandwich. It would have been easy for him to start his feedback with “Well you were good at remembering your name.” What he gave me instead was an honesty wrap. The filling was my inadequate ability at that time to pass an exam. But this was wrapped in something powerful—a choice. He gave me a choice to improve my ability—work harder and in a different way then you can pass. Sometimes it is not your ability, but the choices you make in medicine that are important. A great teacher knows that. A good student should be told.

Matt Morgan, Honorary Senior Research Fellow at Cardiff University, Consultant in Intensive Care Medicine and Head of Research and Development at University Hospital of Wales, and an editor of BMJ OnExamination. He is on twitter: @dr_mattmorgan

Competing interests: none declared.