Giving and Receiving Feedback

Feedback is a big part of residency training. Written evaluations have an impact on future training, employment, and promotion opportunities. In most programs, faculty and residents aren’t taught how to give feedback, and, as a result, it’s usually done poorly.

I gave this talk when I was at Dartmouth, to help bridge a communication gap between our residents and attendings. What I am about to share is drawn from the literature on feedback in medicine and other disciplines, as well as from my own background as a Psychology major at McGill. The discussion below refers specifically to Radiology residency training, but the principles can be applied more broadly.

Feedback is a specific kind of communication: to share with another person the impact of their behavior. The purpose is to help the other person become more effective, as they change their future actions based on the effects of their prior actions.

We need feedback in any productive collaboration. When done correctly, it makes all relationships function better.

Feedback is not Yelp!
There is a common misconception that I feel drives most of the ineffective and inappropriate feedback we get and give: We rate attendings and residents like we would review a restaurant on Yelp. While we may feel that we are doing the natural and helpful thing by giving a very straight-forward judgment of someone’s performance, for example “This person is unfit to be a radiologist because X, Y, and Z,” it’s actually unprofessional and unproductive. In our workplace evaluations, we’re NOT supposed to be warning other customers to avoid this establishment! We’re supposed to help all establishments thrive. We’re supposed to use this opportunity as a conversation starter about how things can be improved.

Ineffective feedback will go ignored.
In preparing my talk, I chatted with attendings and residents one-on-one, and heard from both sides that giving feedback is futile. They say the same things year after year, and yet no meaningful changes result. No matter how incompetent a resident is, that resident will still graduate. No matter how horrible an attending is at teaching, that attending will remain in their position. In fact, many feel that bringing up concerns only leads to retaliation. So, if anything, evaluations get more “toned down” and meaningless with each cycle.

There are a lot of reasons why feedback can be dismissed as invalid. Some of it has to do with our own cognitive biases. We generally hold a positive view of ourselves, and believe that we are competent, hard-working, worthwhile individuals. This bias allows us to live with our own shortcomings and to keep trying when we make mistakes.

In social psychology, there is a well-known phenomenon called “fundamental attribution error.” We judge ourselves differently than we judge others. We attribute our own negative actions to external factors (e.g., I missed a key finding because I was reading a high volume of cases at high speed, with frequent interruptions, and I was really stressed out!) We attribute other people’s negative actions to their own character (e.g., You missed a key finding because you are lazy and haven’t done enough studying.)


How to Give Feedback

When giving any kind of criticism, you’re delivering bad news. I use this term intentionally because “delivering bad news” is a doctorly skill that doctors take pride in. You have worked hard to gain this skill and should use it here! Tell a resident they suck at radiology with the same care that you would tell a patient they have cancer.

Everything applies in this analogy: establishing a good rapport, choosing an appropriate time and setting, sitting down, watching your posture and tone of voice, and gauging the other person’s reaction at every step of the conversation. You must come to an agreement on the diagnosis, and only then can you move on to form a treatment plan. You cannot just blurt out, “You have cancer!” in the waiting room. You cannot just jot down the diagnosis in the chart and never have an open discussion with the patient. You cannot give critical results without alerting someone.

For feedback to be effective, it must be well-intended, tactful, credible, and actionable. These principles are inter-related.

  • Your intention must be to help the other person to improve, not just to prevent them from being promoted. Malicious feedback is not credible and will not be heard or acted upon.
  • The appropriate time to give feedback is after a sufficient amount of time has passed to make an accurate assessment, and with an appropriate amount of time left to observe a change. Mid-rotation is great.
  • Nothing should end up in the written evaluation that hasn’t already been addressed verbally.
  • If you give a “critical low” numerical rating, such as a “1 out of 10” in medical knowledge, you should feel obligated to write a comment explaining your rating.
  • Be kind! Avoid judgmental labels. Nobody has gotten this far in life by being “dumb,” “lazy,” or “unprofessional.”
  • Use specific examples, not sweeping generalizations. Nobody can even begin to process a comment like “This person doesn’t care about patients,” so it will never result in meaningful change.
  • Use facts and observations as a start, but also include how the behaviors you’re describing make you feel so that the person can understand the impact of their behavior.
  • Speak for yourself! Don’t refer to other people’s views or “general perceptions.”  
  • Only bring up things that the other person has control over. If the behavior cannot be changed, bringing it up will only create resentment.
  • Keep your assessments within the scope of your role.
  • Don’t underestimate the power of encouragement. Residency is hard! Being an academic attending is hard! And most of us are already hard enough on ourselves!

In my full lecture I give detailed instructions, and I illustrate each point with examples of well- and poorly-written comments, both critical and complimentary, given by both residents and attendings.

I also break down and analyze the most common ineffective comments. For example, saying that a resident “needs to read more” implies you know the resident missed your pimp question because they didn’t read enough, and that spending more hours in front of a book would have fixed that problem. Perhaps they simply misunderstood your question. Perhaps they studied sources that contradict what you’re teaching. Perhaps they are so exhausted from staying up late every night reading that they can’t retain anything they’ve read. By passing a premature judgment, you are shutting down what could have been an opportunity to understand and mentor that person.

 

How to Receive Feedback

This part is just as important as the giving of feedback. Proper reception of feedback helps the person giving the feedback to feel heard, and validates the entire process. Your goal is to enact meaningful change in your own behavior and thereby to improve yourself. Even if your criticizer didn’t do their part correctly, try to do your part correctly. If nothing else, they are continuing to judge you as you react to their criticism, so don’t give them any more reasons to criticize!

  • Relax. Assume the other person is trying to help you, and it’s in your best interest to be open to suggestions.
  • Invite feedback in specific areas. It shows that you are receptive and self-aware. It also helps to keep the comments more focused, constructive, and useful.
  • Listen actively. Don’t defend. Clarify any vague criticisms. Summarize what you got out of your conversation at the end.
  • Take time to respond. If it’s a complex problem, telling the other person that you will reflect and get back to them will show that you understand the importance of what they said and really want to change.
  • Close the loop. Verify the plan, set a time for follow-up, and monitor the results together. This helps the other person be invested in your improvement and recognize your efforts.

 

This lecture should provide a platform for honest discussion and understanding between faculty and residents. Where people are willing to adopt the suggested methods, there should ideally be improvement in the quality of written evaluations as well as performance. However, because we are all human, expect this to be a slow process! It takes a lot of effort to give evaluations as a guide for improvement and not a means of catharsis. And some people will always be resistant to change. But at the very least, raising awareness of cognitive biases and communication flaws should help curb ineffective feedback from those who care, and at least put ineffective feedback in context coming from the rest.

 

Here is a PDF handout of this article:
Giving and Receiving Feedback

How My Book Got Its Name

I wondered for a whole year what I was going to title my book, and suddenly, “The Ugly Docling” came to mind. I think it’s fitting on many levels.

For one, the Ugly Duckling is the story of a nerd kid who grows up to be a doctor (or engineer, or astronaut, or member of any profession that draws from the smart kid pool.)

I’ve been a misfit since elementary school. First it was because I was an immigrant, had an odd name, wore different clothes, and didn’t speak the language. But even after I grew accustomed to American culture, I still struggled with being a nerd. I tried so often to dumb myself down so I could be accepted by other kids. I wanted people to know that I was a musician, a poet, and a tennis player, but I would be mortified if anyone found out that I was in MathCounts or Academic Olympics. And though I spent way too much time trying, I never had nice hair. For me, this one was tough; high school is all about the hair.

Fast forward to medical school: Everybody is a smartypants. Everybody is charismatic. Everybody has nice hair. Well, almost. When we tell people that we are going to be doctors, they react with kind words of admiration, appreciation, and respect. (And then they show us skin lesions for diagnosis.) Yet, when I found my old MathCounts roster and pointed out that a couple of my classmates were on it, they were mortified. It really is bittersweet to look back on those years. But hey, let’s face it: doctors don’t just pop out of thin air; they were Mathletes when they were little! Nobody makes fun of a doctor. So why are American kids taught to make fun of nerds? I consider this book to be a big hug for my young self—and for nerd kids everywhere. Nerd kids: It gets better!

But my personal Ugly Duckling story continued even after I met up with the other swans in medical school.

Perhaps because of our common unspoken background as nerds, the culture in medical school is reversed. We admire and compliment each other for knowing the right answer at the right time. We fear being laughed at when we act ignorant or incompetent. Some may brag about how they never study, but they are either lying or willfully endangering lives and mocking the practice of medicine, and the rest of us know in our hearts that we would never refer our own patients to those individuals.

It was in this culture that I realized I may still be a misfit. Yes, of course I have studied my tail off, and of course I want other students to think of me as being a stellar student. But to the degree that I still have gaps in my knowledge, I question my doctoring skills. When I get an answer wrong, I question if all my classmates are smarter than me, if I can be a good doctor, if other doctors will want to refer their patients to me. For the first couple of years, I focused so much on test scores as measures of my doctoring skills. But then, when the exams were over and I was thrown into the real world of hospitals and clinics, I was humbled to learn so many things that were never taught in the medical classroom. These are the things that I felt moved to write about.