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If you read The Rheumatologist regularly, you may remember a column I wrote a few months ago about giving and receiving feedback (July 2017). I wrote it when I was finishing fellowship and looking back at six years of my graduate medical education. Now, as an attending physician who spends a considerable amount of time precepting fellows, I’ve started to see things a little differently.
As Spider-Man’s Uncle Ben once said, “With great power comes great responsibility.” As the newest kid on the block, I may not have that great power, but I do have a responsibility to help uphold a culture that values high-quality feedback.
2. Keep fellows in the driver’s seat: You must show that feedback is a two-way street. I make it a habit to always inquire about my performance before giving feedback. That way, I can get a more realistic view of the fellow’s thoughts and expectations. But this is more than just asking, “Do you have any feedback?” or “How am I doing?” It’s always important to acknowledge the power differential between fellows and attending physicians. Letting them know they are free to give feedback and that such feedback is encouraged enables me to give my own feedback as freely as possible.
3. Attendings must ask for specific feedback: If a learner doesn’t give much unsolicited feedback, I ask specific questions. Common questions include, “Was the bedside teaching useful to you?” and “Did I give you enough autonomy?” I admit, I do feel a touch of insecurity when I ask in such a way, but that’s vital to keep attendings and fellows on a fair footing. Curiously, I find it even more important to do so for first-year fellows and residents because they have no memories of me working among their ranks. I imagine more senior attendings must take even more steps to ask for more feedback.
4. Base feedback on objective observations: Once I receive feedback, I prepare to give feedback, usually immediately after a patient encounter. I always base my comments on observations, such as, “I noticed that smoking status was not addressed,” or “I noticed the word inflammation was used a lot during explanations.” (The more specific the observation, the higher quality the feedback.)
These observations inform the comments I deliver next. For example, following the smoking observation, I might comment, “It’s important to start the discussion on smoking because coronary artery disease is one of the most common causes of death in rheumatic diseases, and smokers are at increased risk.” Following the inflammation observation, I might comment, “Patients often have different ideas about what inflammation means. It may be better to say ‘swelling’ or ‘pain’ instead.” I also employ “I” and other personal pronouns to signify my ownership of the observations to ensure objectivity. This may seem excessively strict, but making the feedback more personal helps check our potential subconscious biases and prejudices.
Finally, I leave learners to evaluate the validity of the comments and never force them to agree—something I resented deeply as a trainee.
5. Don’t serve a crap sandwich: The crap sandwich, to those who don’t know, is a common way of relaying comments by starting with vague compliments, such as, “You did a good job,” followed by judgmental criticism, such as, “You look at the computer too much,” and ending with an equally worthless, “But you’re improving.” The crap sandwich is like comfort food, because it’s easy to make and feels natural. Most of us have been fed such fare throughout the course of our medical education. But if you examine it closely, it’s just as artificial as the observation-and-comment approach. And worse, it destroys the teacher–learner bond and promotes a culture of insincerity.
Nobody is so clueless they can’t see through the general vagaries of positive feedback that couch a lot of nastiness. For certain fellows, it may provoke a lot of unneeded stress and anxiety as they wait for the crap part of the sandwich. Nevertheless, the allure is so great I often find myself tempted to say, “Good job.” Whenever I do, I swallow those words and express my observations about why I felt the learner did a good job.
6. Express appreciation (but don’t call it feedback): That’s not to say anyone should become a feedback robot. Whenever I’ve seen exceptional behavior, I make sure the learner knows how much I appreciate it. Often, I inform the program director and division chair about such commendable personality characteristics. But this isn’t feedback, and I make sure I say so. Expressing appreciation is a way to build a culture of positivity and sincerity to ensure the feedback is effective. Moreover, everyone likes to work and learn in an environment in which their contributions are acknowledged and respected.
7. Recognize the destructive power of negativity: Unfortunately, teaching isn’t all appreciation and feel-good moments. In deeply distressing moments, attendings must lay down the law. In such situations, I take a very cautious approach. Often, nonjudgmental feedback can prove just as effective as heavy-handed condemnation. Of course, it requires more effort and dedication to develop a relationship with a challenging learner to ensure I can deliver feedback effectively, but this approach typically works better than furthering conflict.
Throughout my residency and fellowships, I’m sure I received a thousand nice words from attendings, but I remember the few inconsiderate, judgmental criticisms most of all. I never accepted those judgments, and even though I was forced to show changes in my behavior, this harsh approach ultimately proved unsuccessful. I continued my habits, occasionally secretively, and sought to avoid interacting with such attendings. Now, as an attending, I keep that lesson in mind when I must address such situations.
These past few months have provided me a fresh perspective on feedback. But regardless of the position, feedback is feedback. Yes, attendings may have an added responsibility of ensuring fairness and equality, but ultimately, attendings benefit from upholding a culture of high-quality feedback. After all, attendings are learners, too, and fellows, residents and students have a lot to teach us. When delivered correctly, feedback dignifies and destigmatizes this role reversal.
Admittedly, this approach can prompt a sense of apprehension among certain faculty members who see weakness in losing control and hard power over their learners. But gaining learners’ esteem and respect strengthens the educational environment and the attendings’ status as venerable teachers.
Bharat Kumar, MD, MME, FACP, RhMSUS, is a clinical assistant professor of internal medicine at the University of Iowa in Iowa City. He completed a dual fellowship in rheumatology and allergy/immunology, and a master’s in medical education in 2017. He has special interests in journalism, healthcare policy and ethics. Follow him on Twitter @BharatKumarMD.
