My student’s voice trembled as she answered my question. “How do you think you’ve done so far?” I’d asked her. We’d been together on the general medicine inpatient ward for two weeks—the midpoint of the rotation—and as was my usual custom I was giving her feedback on her performance by first asking her to rate her performance herself.
“Okay, I guess,” she replied.
I waited to see if she had more to say. In fact, she hadn’t done okay. She certainly wasn’t the worst student I’d ever had, but she was easily in the bottom 10%. Her oral presentations were haphazard, often missing key details, their components often presented out of order (a traditional method exists for all storytelling in medicine, one that’s designed for maximal efficiency and clarity and which, when abandoned, makes complex stories difficult to follow), her knowledge base was far below average for her level of training, and perhaps worst of all she seemed disinterested in her patients. I was concerned not just about having to give her a poor grade but about having to fail her. Her apparent lack of insight into the substandard level of her performance wasn’t only a potential obstacle to her improvement, it was a potential obstacle to her developing into an effective physician.
Know your own biases. Are you more interested in being liked than you are in giving honest feedback? “Good advice grates on the ear,” the saying goes. Do you have the courage and compassion to serve their interests before yours?
Ask the person to whom you’re giving feedback to rate their performance themselves. People will often identify areas they need to improve for you, which not only makes the feedback interaction seem less adversarial but increases the likelihood they’ll be able to respond positively to it by helping them sidestep their own ego (it’s harder to become defensive about something you’ve pointed out to yourself). Also, how they answer your request to rate their own performance often gives you insight into their degree of insight, which is a good indicator of their ability to improve.
Employ the sandwich method. This involves first saying something positive, then noting something that needs to be improved, then saying something (else) positive again. People are more likely to work on correcting a deficiency if they feel good about their performance overall—that is, if their deficiency seems like a single blemish against an otherwise reasonably clean background. Your goal is to encourage them so they feel they can improve, that it’s worth it for them to make the effort to improve. If they have more than one serious deficiency, perhaps pick the most serious, give them feedback about it, and then pick another time to give them feedback about their next most serious deficiency.
Make your feedback concrete. Feedback must be actionable. Saying, “You don’t seem interested in your patients” isn’t nearly as helpful as saying, “You turned around and left the room when Mrs. Stone started crying.” Don’t pretend to be able to read anyone’s mind. We rarely get to know why anyone behaves a certain way. We should only comment on a person’s behavior, which is really what we want them to change anyway.
Allow enough time for a response to your feedback. The whole point of giving feedback is to provide a perspective which the person receiving it doesn’t have. Though their deficiency may seem obvious to you and you may have a hard time imagining they aren’t already aware of it, often they’re not. Everyone deserves a chance to improve—and how can they do so if they don’t first know what improvement they need to make?
Don’t react to the initial sting of negative feedback. It will fade. And until it does, it’s hard to make good use of what you’ve heard. Sometimes the best initial response upon hearing negative feedback is silence.
Consider the feedback you’ve been given as if you’d discovered it yourself. This is hard to do but helps prevent your ego from drowning out good advice. You may decide, after careful deliberation, that the feedback you received was inaccurate or no good. Fair enough. Just make sure you’ve done your best to silence the clamoring of your ego long enough to seriously consider what you’ve heard. Sometimes the feedback you receive isn’t helpful itself but leads you in a direction that becomes so.
Be open to feedback, but not too open. Don’t take negative feedback personally. Don’t blow specific negative feedback out of proportion and allow yourself to believe everything you do is bad. Always consider the credentials of the person giving you feedback and give extra weight to the feedback from people whose backgrounds make them especially knowledgeable (and less weight to the feedback of those who aren’t). On the other hand, embrace the notion that you can learn something from everyone.
My student’s apathy, it turned out, wasn’t apathy at all. It was distraction. After I finished giving her detailed feedback, she surprised me by confessing that her mom was seriously ill. I suggested she consider taking a leave of absence, which two days later she agreed to do with some relief. That way she could both be with and help care for her mom, she said. I told her that medical school would still be waiting for her when she was ready to come back. Her mom eventually made a full recovery, and she returned to school to repeat her medicine rotation. I learned later from a colleague who supervised her the second time around that she did great, earning a grade of honors.
Excellent, Alex! #1 really resonates with me. Good timing—I’m conducting employee reviews this week.
Good stuff here. Thanks again for your insights.
I have several clients who wrestle with this skill. I plan to share your insights with them.
Totally loved this advice, Doc. I’m passing it on and I will try very hard to incorporate the “receiving feedback” advice.
I’m wondering if your principles work as well when the relationships are more personal than professional? I often think that the hardest dialogs (to get right) are the ones where spouses try to give each other feedback. Any additional tips on this special situation? It’s certainly an area where I can and always want to improve and excel.
Mike: Spousal feedback. Much tougher. I think two important principles apply: 1) only give feedback when you’re in a loving, compassionate mood, not during or even immediately after a fight, and 2) don’t give feedback about behavior you want your spouse to change for your benefit; give feedback that you think your spouse needs to change for his or her own benefit (the well-worn principle that you can’t change your spouse seems to hold true mostly when you want them to change in way that’s convenient for you—not when you want them to change in a way that benefits them). Hope that helps. You might also check out Marriage As A Business Proposal.
Since I’m not in the medical field, one comment you made intrigued me, that there is a defined method for storytelling in medicine. Can you please point me to where I can find more information this method?
Brian: I was referring to the way we teach all second medical students to take a medical history. You might try searching online with terms like “physical diagnosis and history taking” or “medical history taking.” It’s part of the curriculum of every medical school.
Easily one of the most lucid pieces I’ve come across on this topic. I’ve just shared it with colleagues. Thanks a bunch!
Sharda: I’m really glad you found it helpful.
As a student myself, receiving feedback—or rather, tolerating criticism—is one of my biggest challenges. I struggled through my medicine and geriatrics rotations battling depression and internal chaos. I was acutely and painfully aware that I was not performing nearly as well as I was capable. On more than one occasion, when I teared up as I faced harsh criticism despite my best efforts, my preceptors would respond with even greater criticism. There are few things more uncomfortable than trying (and failing) to stifle tears in front of a preceptor…and being chastised for it wasn’t helping. I knew I could do better on the rotation—I desperately wanted to—so the negative feedback was absolutely crushing.
I think it says a lot about your character that you were open to your student’s struggles which were interfering with her ability to perform well in an already stressful environment. My psych preceptor was the first to suspect or accept that there was more to my story than the perfectionistic and overly-sensitive student she saw on the unit. Thanks to her, I’m now on a leave of absence while I get things back together. And you’re right—school will still be there for me when I come back. I’m hoping that a healthier mental state will make it easier for me to handle critical feedback in a more mature fashion.
I wish that laziness, carelessness, or incompetence were not the first assumptions people made when faced with a struggling student because I believe that true slackers just don’t get into med school. However, I realize that it’s a lot easier (and less awkward) to assume careless incompetence than to explore other possible causes and contributing factors. Kudos to you for being sensitive to her predicament and helping her realize that it’s perfectly okay to take a little time off to sort things out.
Christine: Medical school is hard enough for people not distracted by significant life events or struggling with depression or anxiety or any other psychological problem. Once such problems are sorted out and successfully resolved or managed, it’s amazing what potential we see suddenly fully manifested. Good for you for taking the time to get yourself sorted out. Years from now, when you look back, I’m sure you’ll view this as a small blip in an otherwise excellent and satisfying career. And most importantly, you’ll never make the same mistake with one of your own students that was obviously made with you again and again. The greatest benefit in struggling through awful experiences is that they position us better than others who’ve not gone through them to encourage those who are. Best of luck to you and never be defeated!
This is so helpful. Giving and receiving feedback requires that unique balance of delicacy and specificness—I know sometimes I miss the mark.
I saw the comment/response from Mike on how to handle criticism with a spouse—that seems like a post in itself! I would enjoy getting more input from you on that subject.
I’ve found that some people simply deny feedback they don’t want to hear, regardless of how it is delivered.
For these people, I find the best approach involves engaging them in a supportive way aimed at what you see as the deficit. Sometimes this is easier to dream up than others—for instance, for a group of admin supports who sniped internally, a professional development day of bonding over a self-awareness tool fit the bill very well and improved morale and performance. Various methods of feedback delivery prior to that were not helpful.
Other problems, like chronic absenteeism, are more challenging from both the feedback and the remedial support point of view—unless feedback can be heard as anything other than a threat.
There are people who criticize—sorry “give feedback”—and there are people who have to pull their cart with their mouths shut. I wonder why the people who “thanks to” their profession or position feel entitled to “give feedback & criticize” don’t ask questions first? I myself don’t think that the question “How would you evaluate your performance?” would be suitable. Of course, there are a few people who do badly on purpose, but I understand that rebels and their attitude were not the topic for this week’s story. So that means that we can suppose that the person who is in that unfavorable position that his or her performance is being evaluated by somebody else (who does not know them at all or sometimes even does not want to know them at all) did her best. So the answer “I did OK,” is very true. Why doesn’t the evaluator ask normal questions? More specific questions, such as: “Why did you do this… in such a way? Why did you take this course of action?” Guiding questions can be more gentle, more sensitive… I suppose this is more about the social ladder. So those of us who are lucky enough to find ourselves on a higher position can feel entitled to “give feedback?” Maybe I just missed the point of this week’s story. I guess I would understand better if I heard how somebody else coped when given (both fair and unfair) negative feedback under unfavorable personal situation.
Zara: I meant for this post to address circumstances in which it was appropriate for formal feedback to be delivered and that the person giving it would be doing so strictly in order to help the person receiving it to improve.
I am sorry. The way I see it is this: Your feedback DID NOT help her to improve. SHE IMPROVED LATER BECAUSE HER PERSONAL SITUATION IMPROVED. You just accidentally found out why her performance was so bad. Usually people in superior position don’t even bother to find out. That is why I say that this story would have to be told from her point of view to tell us more about “compassion” and “how-to-bring-more-happiness-into-this-world.” I read you post about compassion to find out how you understand compassion. You mentioned that the homeless person was a drug/alcohol addict, and that many of them are mentally ill. You did not mention that many of those people went through serious abuse from the others, or that they lack the skills to protect their interests. If this girl lacked skills to protect herself by explaining the situation with her ill mother, you would not even know the reason for her poor performance. You “gave her a detailed feedback” first. After that she surprised you “with her confession.” Yes, she could have told you before. But that is about “the skills to protect one’s interest.” She had limited skills to protect her interest. Homeless people sometimes have none because they have such a bad experience with others that they find it difficult to explain themselves or ask for help. Actually no one wants to hear their stories; that’s why they seem/or/go crazy. Remember times when you are in pain; at such times people usually are not very articulate.
Zara: You’re absolutely correct that my student didn’t improve as a result of my feedback but as a result of her personal situation improving. Nevetheless, my intent in giving feedback was still to help her improve. Though I didn’t include this detail in the post, in point of fact she told me about her mother in response to my asking if there was anything going on in her life that was coloring her performance. I can’t claim it was my first thought, but I did ask. I do agree with your point that being interested in the underlying story of a person who’s struggling is often exactly what such a person needs to feel safe enough to tell their story.
This week I shared this with a several groups I work with and it was an excellent teaching piece. I agree with others that that is a lucid and clear piece.
It led to good discussion about the importance of listening and asking good questions.
Kevin: Glad you found it useful.
Then some people choose to ignore what they hear or say!
Thank you very much for 1) answering my “angry” piece and 2) for adding that little detail that you did ask that medical student for reasons behind her poor performance. I guess I should apologize if my response sounded too aggressive. My reaction was provoked by my past experiences with people who were not able to give feedback successfully because…because I guess they had no insight into the complexity of somebody’s performance, and they merely imposed their opinion without taking feedback from the person whom they criticized. Thanks to your post I can now see a better picture of someone who tries to give genuine feedback 🙂 with the aim at a common goal.
Zara: No apology necessary. Giving feedback well really is hard. Having given it to students and residents for 15 years I can attest to how awkward it can be to have to point out someone’s deficiencies. Most of my colleagues want to say nice things but sometimes when deficiencies glare more brightly than strengths often blurt out their feedback insensitively. No doubt many people really don’t care if their criticisms hurt others but sometimes that hurt is created unintentionally by a simple deficiency of skill.
This has been so hard for me to learn to take constructive feedback and trust that the person is not being spiteful or saying it just to hold me back. It’s really taken me doing some inner work to not take anything personal and know that I always have the potential and confidence for improvement.
If I receive feedback that’s not so good, it still takes me a moment to process the sting of it, but now I’m always able to do so without reacting and 9 times out of 10 I agree with it, but it may have been something I didn’t want to admit.
If I have to give feedback I always try to make sure I’m coming from love and sincerity. I chose my words carefully but don’t walk on egg shells, and I know the delivery is really important. If I see someone’s progress I make it a point to congratulate them, like Zara’s realization of why she reacted with aggression to this post at first, a lot of people wouldn’t even take the time to think about that. I think standing outside yourself and observing yourself is sometimes very hard, but worth it.
Thanks for another thought provoking post, Alex; with your sincerity and compassion you have developed trust amongst your readers.