Remediation: A few questions from the "problematic resident."

[ERPremed]

Removed for concern of privacy. Thank you all for the advice, it has been very helpful.

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[hundreddaysoff]

From what you're written, in focusing on the written rule rather than people and relationships and behavior, I suspect there is something very fundamental about your personality that you are not seeing. You are the hole in the Swiss cheese, and you do not see it. There is something... different... about you vs other residents that is rubbing at least one powerful attending the wrong way.

The residency system is terrible in this way. The formal feedback system is not actually for feedback; in reality it's just another bureaucratic checklist to keep lawyers happy. People will not give real feedback within this system, because it will not benefit them. They are afraid to point out that there is a wart on your nose. Or, if they are not afraid, they just do not care enough or are too ivory-tower to communicate it to you in terms that will make you see.

There is a skill to getting real feedback. It entails benefiting the one who can give you feedback... not usually in big formal ways, but in small informal and usually emotional ways. Most learn it before med school, as children, because they are properly socialized. It is a skill that I think is teachable, by myself and others who have been in this rare place. But it is not teachable in a forum post, nor is it teachable by most who were properly socialized from a young age, because they have no conscious awareness of what is right and what is wrong here.

I had issues with my own personality in this way. Like you, I did fine in all my premed jobs and all my work up until grad school and then residency. And then I had problems. Because both grad school and residency are harder than your average job, in multiple and nonobvious ways.

Understanding how to act and communicate like a... hmm... normal person was key for me. No one could help me with this at the end of the day other than myself.

I also had problems with dating, at the same time. The actual key for learning how to be a normal person, for me, was improving my dating game. Pick-up sites helped quite a bit to teach me normal social skills.

I am not saying that my problems are (or are not) your problems, only that I suspect you have a similar lack of awareness to mine and it's a really hard thing to fix within this system of screwed-up incentives that we have.

You could go the ADA route. I don't know much about that. I suspect it will lead to a lot of animosity, broken relationships, and wasted time. I hope I am wrong and that system works better than the other big systems with which I've been involved.

 

[HemeOncHopeful19]

I do share with my co-residents that I go to therapy and make them aware of our “concierge psychiatrist” our GME provides for us to try to further normalize true “mental health,” how the last year of crazy covid trauma is actually trauma they should work through, and ideally continue to help break the stigma of basic medical care.

Are you doing this stuff while actually working a shift in the ED?

 

[Arcan57]

It sounds like you're struggling and are frustrated that you're being told you're failing based on criteria that you don't understand. That's a scary place to be. It's unclear from your post if you understand the situation you're in, as it sounds like you're going to be dismissed from your program unless something drastic changes in your behavior and work-product. I know it's frustrating that it doesn't feel like your evaluations reflect a performance that's requiring remediation, but being put on a performance plan then failing that plan into remediation is going to trump neutral or positive random evals from faculty.

There are glimmers in your post of the types of feedback you've been given and it sounds like it revolves around some pretty fundamental requirements for being an emergency physician. Task-switching issues, poor communication, not seeing enough patients are all things that can get you fired or worse as an attending. Additionally, while the shift you mention felt abusive to you, it's clear that is not how your program views the events of that shift. That disconnect puts you in a dangerous place and it seems that your attempts to change the narrative (giving names of witnesses you felt would support your version of events) wasn't successful.

I would be preparing not to be continued as a PGY-3 at your program and for the possibility that the letter your current program would give may preclude transfer to another EM program. Given that you have multiple specialists saying in essence that you're fine from a mental health standpoint and don't need neuropsych eval, going the ADA route is going to burn through a lot of your money and is extraordinarily unlikely to result in a beneficial outcome for you.

Regardless of whether it would salvage your EM career, it's going to be important to address the disconnect between how you perceive your performance and how others do. It's really hard to give honest negative feedback to people because doing so damages your interpersonal relationship. Asking your friends in residency how you're doing is unlikely to yield useful responses. Nobody wants to tell their friend that everyone views them as lazy because they'll let a patient sit for an hour hoping somebody else will pick it up. Nobody wants to tell their friend that their patient presentations are scattershot and that they're dismissive or defensive when questioned about them.

Supervisors tend to stop trying to modify other's behavior after multiple unsuccessful attempts. So maybe the "nice" attendings gave you specific feedback that didn't seem like a big deal at the time. And after a couple of times of that happening, they make a decision (consciously or not) about whether the point they're trying to get across is worth escalating the amplitude of their feedback. If they decide it's not, they give bland feedback and get categorized into the "most people say I'm doing fine" category. If they decide to escalate, they're usually moved out of the nice category.

The last category of potentially untrustworthy feedback is feedback that feels mean or like an attack. This is tricky because you've likely lumped two groups together that have very different goals into this singular category. Group 1 is going to be people that are giving you negative feedback because they don't like you and want to hurt you/demonstrate their power over you. This group exists, and life sucks when one of these people is your direct supervisor. Group 2 is going to be people that want you to improve but aren't messaging that desire in a way you can hear. It's really important to identify who's in group 2 because they're the ones telling you their actual perception of your performance and listening to them is your best route to improving.

Good luck.

 

[Birdstrike]

@ERPremed

1) What specifically is it that your program is telling you need to do better, that you're not doing?

2) Are there specific things your program is telling you need to stop doing, that you are doing?

 

[southerndoc]

I would read the comments posted already several times as they all make very valid points.

 

[hundreddaysoff]

There are glimmers in your post of the types of feedback you've been given and it sounds like it revolves around some pretty fundamental requirements for being an emergency physician. Task-switching issues, poor communication, not seeing enough patients are all things that can get you fired or worse as an attending. Additionally, while the shift you mention felt abusive to you, it's clear that is not how your program views the events of that shift. That disconnect puts you in a dangerous place and it seems that your attempts to change the narrative (giving names of witnesses you felt would support your version of events) wasn't successful.

Exactly. There's the game, and then there's the metagame. OP is focusing on the game, but those of us who have struggled with these things see that the game is the easy part, and the rules of the game aren't even the same as how they're written.

OP seems unaware of the metagame, which in my recent understanding is pretty similar across any enterprise that involves humans.

Supervisors tend to stop trying to modify other's behavior after multiple unsuccessful attempts. So maybe the "nice" attendings gave you specific feedback that didn't seem like a big deal at the time. And after a couple of times of that happening, they make a decision (consciously or not) about whether the point they're trying to get across is worth escalating the amplitude of their feedback. If they decide it's not, they give bland feedback and get categorized into the "most people say I'm doing fine" category. If they decide to escalate, they're usually moved out of the nice category.

YES. Properly interpreting feedback from different individuals is one of those metagame skills that I feel like most picked up in undergrad or earlier. OP shows no awareness of this. It is a difficult skill for at least some of us!

The last category of potentially untrustworthy feedback is feedback that feels mean or like an attack. This is tricky because you've likely lumped two groups together that have very different goals into this singular category. Group 1 is going to be people that are giving you negative feedback because they don't like you and want to hurt you/demonstrate their power over you. This group exists, and life sucks when one of these people is your direct supervisor. Group 2 is going to be people that want you to improve but aren't messaging that desire in a way you can hear. It's really important to identify who's in group 2 because they're the ones telling you their actual perception of your performance and listening to them is your best route to improving.

There is also sometimes but rarely a Group 3, who are messaging in a way you can hear. For me, this was pretty much one single attending who I suspect had a similar background of poor socialization as myself. Thinking back, he was very proactive and may have singlehandedly saved my ass in residency. I hope OP has someone like him in their program.

When one gets skilled enough at the metagame, one realizes that oftentimes Group 1 are not necessary enemies, but were only turned that way by one's own actions. I consider my greatest personal accomplishment in residency to have improved so much as a person that I ended up getting invited by these people out for beers because they liked me enough. They then told me the precise ways that I sucked, in their own words, and because I was able to hear them by that point they helped me to improve even further.

One last thought: In EM residency, often how RNs perceive you is at least as important as how the other doctors perceive you. And it matters for your progress. Many more abstract newbie residents miss this. Some of the worst EM attendings I've worked with still miss this.

 

[Proudfather94]

What would happen if OP said this to the people giving him bad evaluations? "Hey I'm confused about what these issues with my performance mean and was wondering if you could explain it to me in a way I can understand? I really want to stay in this program and want to be the best doctor I can be and want to make the changes necessary to do so."

 

[hundreddaysoff]

What would happen if OP said this to the people giving him bad evaluations? "Hey I'm confused about what these issues with my performance mean and was wondering if you could explain it to me in a way I can understand? I really want to stay in this program and want to be the best doctor I can be and want to make the changes necessary to do so."

My guess is that what would happen depends on the state of OP's personal relationships with the people in question. Often, due in part to the dysfunctional bureaucratic aspect of this system, a hard part for someone in OP's shoes is even identifying which individuals are giving them bad evaluations.

 

[Proudfather94]

My guess is that what would happen depends on the state of OP's personal relationships with the people in question. Often, due in part to the dysfunctional bureaucratic aspect of this system, a hard part for someone in OP's shoes is even identifying which individuals are giving them bad evaluations.

How is one suppose to fix problems with their attendings if they can't even find the ones that have issues with them? I would also hope that most attendings would be mature enough to set aside their personal problems with people in order to give sufficient feedback about issues.

 

[FrustratedFamDoc]

Find an attending who is not afraid to cut it to you straight.

"Hey listen, I'm really trying hard to improve my deficiencies. Please be real with me. What is the unofficial issue with me in the attending circle that I don't know about?"

The majority of resident issues are interpersonal, rarely skill related, unless the resident is just obviously dangerous. It will take a big change in behavior before you can shift the wind on this one.

I came from a program that seemingly took pleasure in firing at least one resident a year. The offenses were usually perceived laziness, communication issues, etc.

Early in my PGY1 year, as an FM resident, I admitted an about to crash 6 y/o from the ER. I gave care to the best of my fledging skillset with no second year or attending to be seen for the first 30 minutes despite me calling. The outcome was good but an unofficial meeting of the pediatricians was called to discuss my future based on that one event. I had 1 attending out of the whole group actually stand up for me, thereby saving my career. She later told me details of the meeting. My ass was grass, and it wasn't my fault.

That's the politics of residency. Many attendings are insecure dinguses with fragile egos.

 

[hundreddaysoff]

How is one suppose to fix problems with their attendings if they can't even find the ones that have issues with them? I would also hope that most attendings would be mature enough to set aside their personal problems with people in order to give sufficient feedback about issues.

One can adopt the attitude that I tried to sketch in my original reply:

(1) to recognize that The System (as described by the bureaucrats/pointy-headed, socially well-adjusted, and ultimately often socioeconomically privileged academics who cannot see the water in which they swim) will sometimes fail for individual residents,

and thus

(2) to take extreme self-responsibility for this problem.

It is a hard problem, I agree. It is not about maturity so much as about human nature. It appears to be about maturity from a rules/game-based perspective, but if one adopts a metagame-based perspective one will see that this naive game-based perspective is often in fact part of one's problem.

Here is a recent discussion about this distinction on a completely different topic, which is stock trading:

Week 10: The Metagame

Play the actual game, not the imaginary game you wish was real

50in50.substack.com

TL;DR is the tagline: Play the actual game, not the imaginary game you wish was real.

 

[Arcan57]

One last thought: In EM residency, often how RNs perceive you is at least as important as how the other doctors perceive you. And it matters for your progress. Many more abstract newbie residents miss this. Some of the worst EM attendings I've worked with still miss this.

To add on to this statement (which doesn't sound like is the OPs problem), RNs are significantly more united than physicians. Barring being a significant outlier in terms of metrics, an institution's opinion of an EM doc is roughly equivalent to the lowest opinion of that doc among the full time nursing staff. Nurse that you bang heads with because they don't do their job (ever)? All that free time means that they've got plenty of time to talk to the nurse manager or director about every incident of perceived disrespect/less than ideal communication. Professionalism has to be an outfit you put on from the moment you step onto hospital grounds until you've left.

 

[hundreddaysoff]

To add on to this statement (which doesn't sound like is the OPs problem), RNs are significantly more united than physicians. Barring being a significant outlier in terms of metrics, an institution's opinion of an EM doc is roughly equivalent to the lowest opinion of that doc among the full time nursing staff. Nurse that you bang heads with because they don't do their job (ever)? All that free time means that they've got plenty of time to talk to the nurse manager or director about every incident of perceived disrespect/less than ideal communication. Professionalism has to be an outfit you put on from the moment you step onto hospital grounds until you've left.

Yes. And I would argue that "professionalism," as narrowly-defined by doctors, is not even enough to protect oneself from the silliest RNs. One needs to be... likeable by them. IOW, one needs to play the metagame.

 

[Franzd'Epinay]

There is a skill to getting real feedback. It entails benefiting the one who can give you feedback... not usually in big formal ways, but in small informal and usually emotional ways. Most learn it before med school, as children, because they are properly socialized. It is a skill that I think is teachable, by myself and others who have been in this rare place. But it is not teachable in a forum post, nor is it teachable by most who were properly socialized from a young age, because they have no conscious awareness of what is right and what is wrong here.

I know you said you can't teach this in a forum, but are you at all able to elaborate a bit more? I'm intrigued by your phrasing ("benefiting the one who can give you feedback... not usually in big formal ways, but in small informal and usually emotional ways")

 

[hundreddaysoff]

I know you said you can't teach this in a forum, but are you at all able to elaborate a bit more? I'm intrigued by your phrasing ("benefiting the one who can give you feedback... not usually in big formal ways, but in small informal and usually emotional ways")

I can try. I'll need to get a bit concrete though. Remind me: what's your place? Are you an attending, resident, med stud, or other?

 

[Arcan57]

How is one suppose to fix problems with their attendings if they can't even find the ones that have issues with them? I would also hope that most attendings would be mature enough to set aside their personal problems with people in order to give sufficient feedback about issues.

Based on OPs original post, I don't think it's a matter of finding which attendings have issues with them. It sounds much more like the things that the OP consider important and the things their attending consider important don't have much overlap. If the post is an accurate representation of the OP's view of events, they've been given a lot of feedback and very little of it penetrated whatever armor they wear to get through the shift.

Most of us have personal or at least 2nd hand knowledge of the "colossal f'-up that landed a resident on the hot seat and required some focused learning/improvement" model of resident disciplinary action/remediation. The resident is mortified at their mistake, jumps through whatever hoops are necessary to get back in good standing, and other than the lingering psychic scars on the resident everything goes back to normal. Even if you don't have that experience, it's not hard to imagine a scenario where that happens to you while in training.

Much less common, but far harder to deal with is resident that just doesn't get how to be a resident. Sometimes it's a specialty specific issue (I've known several people that became great docs after switching out of an EM residency), sometimes it's that the person made it through med school without the executive functioning or professionalism to successfully integrate into the healthcare system.

It's really hard to deliver some version of "it doesn't seem like you care about your patients, you don't seem to take pride in your work, you view honest feedback as a personal attack, you aren't focused on work when you're on shift, and I'm worried these are your innate personality traits that I don't know how to change and if we graduate you you're going to harm patients at an unacceptable rate."

 

[RustedFox]

I get the sense that the OP is significantly smarter than many others around them, and makes the critical cognitive error of presuming that their baseline cognitive agility is shared by others. This then becomes super frustrating and they're not afraid to tell the others (including the academic attending staff, but mostly the patients and residents from other sercices) to "keep up", which pisses them off.

Am I right, OP?

But, knock it off with the ADA thing. You're not disabled.

EDIT: I had a few "tough talks" with my PD and Chair as an intern, where I basically said: "Yeah, so Doctor X and Y completely paralyze the department because they cant make a decision to save their lives. I'm 6 months in to residency, and I already see this. Why don't YOU guys see this?!"

I wasn't wrong. I was just the only one to say out loud: "the emporer isn't wearing new clothes, guys."

 

[Apollyon]

I would also hope that most attendings would be mature enough to set aside their personal problems with people in order to give sufficient feedback about issues.

I've said it many times - "some animals have to live in the zoo, because they can't survive in the wild". Medical faculty, paralleling academics in general, have some of THE most juvenile, petty, untrustworthy people, who will argue severely about the most trivial issues, instead of the inverse. Also, most lack the confidence to say anything "bad" to a resident. People hide in academics.

 

[Franzd'Epinay]

OP, I would follow everyone's advice above and do everything in your power to stay in residency. However, I would simultaneously start taking actions with the assumption that you're going to be dismissed soon.

It would be a good idea to look at the requirements to get a full license here and choose 2 populous (and ideally nearby) states where you can get fully licensed at your current level of training. You want to hit the ground running if you do get dismissed, plus, it may be harder to obtain the license once the dismissal has taken place.


I would start searching for jobs in those states for non-boarded physicians (wound care, Medicare exams, disability exams, worker's comp, etc.). Given your residency issues, you will need to be very honest and harsh with yourself about whether you think you can take a job that is more complex clinically (corrections, Indian Health Service, etc.).

 

[Franzd'Epinay]

I can try. I'll need to get a bit concrete though. Remind me: what's your place? Are you an attending, resident, med stud, or other?

Attending, several years out of residency.

 

[Pleurodesis]

Following this. Also in a near identical situation

 

[RustedFox]

I can try. I'll need to get a bit concrete though. Remind me: what's your place? Are you an attending, resident, med stud, or other?

I think he's psych.

 

[bravotwozero]

EDIT: I had a few "tough talks" with my PD and Chair as an intern, where I basically said: "Yeah, so Doctor X and Y completely paralyze the department because they cant make a decision to save their lives. I'm 6 months in to residency, and I already see this. Why don't YOU guys see this?!"

I wasn't wrong. I was just the only one to say out loud: "the emporer isn't wearing new clothes, guys."

Wow man, that takes cajones. Was your comment well received?

 

[RustedFox]

Wow man, that takes cajones. Was your comment well received?

Big post on this topic when I get back home.
I'm face down in a huge lunch right now

 

[Arcan57]

Wow man, that takes cajones. Was your comment well received?

Does it take cojones or just an almost willful ignorance of how organizations work?

 

[RustedFox]

Does it take cojones or just an almost willful ignorance of how organizations work?

Pretty much willful ignorance.

 

[ERPremed]

Are you doing this stuff while actually working a shift in the ED?

No no, like at our retreats and conference when we are doing a dedicated small group time talking on things like "how are you doing during a pandemic." Most of it is one on one after a shift or when we are all just casually hanging out

 

[gro2001]

Howdy y’all,

PGY2 here from a 3-year academic shop. I was placed on an improvement plan in November which has now progressed forward to remediation despite working incredibly hard on the few random bits of feedback I was given. (FYI, we use the following progression Formal Plan > Remediation (inhibits progression to next year)> Probation > Expulsion/Failure to renew contract).

I come to you for advice/to hear your experiences with remediating the deemed “difficult competencies” such as communication, and "perception."

Per my program, there is “concern I am not meeting level 2 milestones” in various sections of interpersonal communication, patient care, and professionalism (very random things like task switching,”not seeing enough patients,” and things such as “poor communication” despite a collection of evals stating otherwise).


When looking into this, the only examples for each milestone level I could find were in the ACGME’s specialty-specific supplemental document. When compared to these examples, I am level 3/4 in most of those areas ( scored by faculty mentors with history scoring residents as well). Also, it states the levels do not correspond to pgy year and will likely vary across the six big milestones.

However, I am told I “do not meet the expectations of a senior resident” and “cannot have any further spontaneous feedback regarding these issues for the remainder of my training to remain in good standing” as my only real "feedback"

And after that background for some context, A few questions for the crowd:

1. Does anyone’s program have specific examples for each of the ACGME competencies/milestones their residency provides as expectations they would be willing to share? I only have access to the supplemental examples from ACGME. Also, do you have noted “expectations” for each PGY year? such as a hard patient/hour number?
2. Is it normal to be on an “improvement plan” that just states you are not meeting expectations, w/o referencing the exact deficient behavior or expectation minimum to meet that milestone. The “action plans” for each competency then is that “the leadership should just not hear anything about you from faculty again about this issue.

I find this especially odd when comparing my journey to my peers, others have been assigned 1 on 1 mentors that met monthly for the 6 month “improvement period.” Ironically, none of them were placed on remediation plans for failing to meet their clearly defined expectations..

More context for this last part:
I have had multiple really close friends who almost failed out of medical school due to their fear of seeking care for their untreated OCD and panic disorder. I do share with my co-residents that I go to therapy and make them aware of our “concierge psychiatrist” our GME provides for us to try to further normalize true “mental health,” how the last year of crazy covid trauma is actually trauma they should work through, and ideally continue to help break the stigma of basic medical care. I also started a mental health group in medical school as it has always been important to me.

I have had an ADHD diagnosis since age 8. I have been treated since undergrad and have had no issues with any job or in medical school with this being a “barrier.” I have never been suicidal or severely depressed. Despite this, I was randomly asked to be “medically cleared” by a psychiatrist following a terrible abusive shift with an attending (which was never investigated, despite me giving names of others in the room for collateral.) I was not allowed to return to work until this was completed, which could not be from an in-house doctor. During the two weeks, it took of waiting for my “stat appt,” I additionally saw a different therapist, confidential advisor, different psych MD, a specialized therapist for physicians, and a neuropsychologist. A total of 5 mental health providers wrote a “clearance” note stating I had no active issues, interpersonal communication barriers, did not require neurocognitive testing, and didn’t even have depression/anxiety, so they encouraged them to focus on the academics as a kind way of telling them to “stay in your lane”. Despite this, I continue to get unsolicited narrations of the “mental health journey” I am on from leadership during shifts. After spending around a week of heavy evidence-based research and re-writing my plan to include some actual measurable skills (I was told to edit it however I wanted, “because they didn’t know how to help me”..) I am still being told “we are here just to make sure you are ok and get you past your mental health barriers that are preventing you from being equal to your peers. I have also asked in my plan to drop this and talked to my PD about it independently.

3. At what point and after how many requests to stop bringing this up would you look into some sort of ADA legality approach. Just looking to my colleague's clearly outlined plans and assigned mentorship relationships, I feel a smidge neglected and am beginning to worry about discrimination.

First of all, I am sorry that you find yourself in this difficult situation. This sucks, and I can only imagine it adds a ton of stress to an already stressful residency experience. I am sincerely wishing that this situation gets fixed and you go on to have a long, happy, fruitful career as an emergency physician.

I've had some experience sitting on fitness to practice medicine committees, so perhaps you'd find my comments helpful. I am going to tell you some things that are hard to hear. Please know this I am doing this to try to help.

Some things you need to accept and fully internalize to move forward:

1) No one wants to give bad or even constructive feedback. It's difficult to do well, is emotionally exhausting, has a social cost to the person doing it, and most people value agreeableness/conflict avoidance way more than your improvement. So unless something really pushes them (they are unusually personally invested in your success for some reason, they feel obligated by their role as APD, etc) they will mostly just say "everything's ok" or that they can't think of anything, or something generic to get you off their back. So any negative feedback that you do get is not just real, but just the tip of the iceberg. For every person that told you for example that you might not be seeing enough patients compared to your peers, at least 10 others are thinking that or saying it behind your back. I say that not to dishearten you, but to encourage you not to dismiss the negative feedback (particularly if it's specific and constructive) because only one person ever told you that. The things they are telling you are real.

2) The administration almost certainly does not want to go through this process. It takes more than one malicious person (even a malicious PD) to dismiss a trainee from an ACGME accredited program. And it's such a painful and emotionally exhaustive process for everyone involved, that if the institution sees an off ramp, they will take it. This is both good and bad. It's bad in that a lot of the time something like this is fixable, if for no other reason that it's easier to let a problem resident graduate than it is to go through the dismissal process. A lot more problem residents graduate than get dismissed (but some obviously do). The bad news is the fact that things have gone so far means that the department sees the problem as very real and very bad.

So here are the things I would recommend:

1) Drop the ADA/discrimination thing. Emphasizing your mental health history so much can only hurt you. It will not give you any additional protection. This is not college where it might give you additional accommodations in exams. There are no accommodations in the ED. If anything, being too successful in arguing that this is the cause of your problems will only strengthen the argument that you might be unfit to practice medicine.

2) Fly under the radar. Put your activism on hold until you climb out of this situation. Don't do anything to attract any additional attention.

3) Do everything on the performance improvement plan. Doesn't matter if you agree with it or not. You may think you have a good reason to have seen fewer patients on that shift (eg we had a resident who would see about half as many patients as his peers because he would get extremely involved with their stories, spend WAY more time talking to them about the social determinants of their health, and start doing lots of things on shift that frankly the inpatient team or their PMD should do; from his point of view he was very certain he was providing better care, and in some sense maybe he even was, but the reality is that we were drowning and everyone hated working with him) or for arguing with your attendings or the nurses or whatever. For your sake, for the next few months, just assume they are right and you are wrong. This is a hard pill to swallow. But just try it out for a few months.

4) Start each shift by asking the attending to focus on a key issue. Straight up tell the attending "I've had some feedback I have to improve on communication skills (or workload or whatever). I am going to try to focus on that today. Can you keep an eye on how I am doing with that today and let me know if you think of ways I can improve?" and at the end of the day encourage them to give you specifically negative feedback or tell you things you did not do perfectly. This should give them permission to hold you accountable.

Hope this help!