Academic Affairs Committee: Resilience Lesson: Giving Negative Feedback

Mary Claire O’Brien, MD FAAEM

One of the things that used to be stressful for me as a young attending was giving negative feedback to a resident. I suppose my own training still felt very fresh and I was sorry for them: the anxiety, the exhaustion, the constant criticism. But it’s the duty of faculty to offer verbal performance evaluations to trainees, both positive and negative. As part of my own personal resilience plan, I have learned to “frame” this feedback as an opportunity.

“Framing” begins with the premise that you can’t control how you feel, but you can control how you think — which influences how you feel. Framing doesn’t change a given situation but can influence what we get from it. Author Trevor Ragan says:

There are three big ways we can frame a situation:

• As an opportunity

• As a threat

• As useless. 1

Balancing “opportunity” and “threat” is key to avoiding burnout. Framing negative feedback as opportunity means it is no longer stressful for me and it’s not as painful for the recipient. Medical education is very different from my time as a trainee, when our weekly conferences included a healthy dose of Vitamin WhoopAss. These days we focus on the learner and how he or she will feel when corrected. We try not to make learners feel bad because they made a mistake or forgot to do something important. Early career physicians are especially vulnerable to burnout. A trainee is less likely to be defensive if the supervisor focuses on the error itself and not on the person who made it. After all, the purpose of feedback is learning, not public humiliation.

“Do you have any feedback?” the resident will say.Sometimes trainees do not want an answer. They have just worked eight grueling hours; they are fatigued, they are hungry, they want to go home. They also have another two to three hours of charting to do on the computer. “Do you have any feedback” is sometimes code for “I’m required to ask for feedback, but have mercy on me, we just got our asses kicked, and for God’s sake, I need to pee. Just say, ‘You did fine.’ I’ll nod, you’ll nod, and we can both get out of here.”

“Well,” I say. “Did you ever take piano lessons?”

This gets their attention — there’s that (old) Dr. O’Brien again. What the heck is she talking about? Just gimme the darn feedback.

“Piano lessons,” I repeat. “Did your parents make you take piano lessons? If not piano, some other instrument.”

Almost everyone says yes. If they say no, I ask whether they ever played sports and had a coach.

Now I’ve got them. They are jiggling their feet at this point, looking around the department to see if anyone is listening. They still need to pee. And they want to get out of there before another patient codes!

“Here’s the thing,” I say. “When you were a kid, your parents paid for your music lessons. What would it have been like if every week your piano teacher watched you for an hour and then said, ‘That was great, you did fine!’ Would you have ever made any progress? What if your coach never corrected you, would you have ever learned how to play?”

TELL THEM THAT THEY ARE IMPORTANT ENOUGH THAT THEY DESERVE FEEDBACK, BECAUSE YOU HAVE CONFIDENCE IN THEIR ABILITY TO USE IT TO IMPROVE THEIR PERFORMANCE.

They look at the floor. By now they can guess where this is going.

“You paid to be criticized,” I say. “Well, your parents did. If you were not criticized, they were not getting their money’s worth.”

Occasionally a smart aleck resident will interrupt, glancing at the departmental mayhem, “I sure as hell didn’t pay for THIS!”

“Listen,” I say. “You are a hospital resident. You are paying with time. With your hard work and time, you PAY me to criticize you. And I wouldn’t be doing my job if I didn’t criticize you. I get paid to criticize you.”

They sigh, resigned. Shoot me, Dr. O’Brien, if you must. Just get it over with so I can leave this zoo. Please.

Then gently I say something like, “Don’t stand with your hands on your hips when you talk with families. I know you are tired and just resting your arms, but how does it look when I do this to you?”

A TRAINEE IS LESS LIKELY TO BE DEFENSIVE IF THE SUPERVISOR FOCUSES ON THE ERROR ITSELF AND NOT ON THE PERSON WHO MADE IT. AFTER ALL, THE PURPOSE OF FEEDBACK IS LEARNING, NOT PUBLIC HUMILIATION.”

(SEE! Active Learning! Boomer Attending Demonstrates Millennial Learner’s Mistake in a Gentle and Non-Critical Appropriate Feedback Fashion!)

“I look bored, or angry, huh? But I am not bored. I am not angry. Adopt a rest position like this…arms down, hands clasped gently in front of your waist, yes, see how much nicer that is? Good job today, by the way, good job. Excellent job! Pleasure working with you, as always.”

As a professional, you are going to have to give negative feedback to subordinates, to colleagues, and occasionally even to your boss. Here’s what I’ve learned: It takes some of the sting out of negative performance feedback if you frame it as something to which the recipient is entitled.

How can a person improve if their deficiencies are not identified? Whose responsibility is it to offer them the opportunity to do better? Yours! It is much easier to gloss over someone’s performance problems than it is to look them in the eye and give candid criticism. But you owe it to them because you care about them and believe they can do better. Tell them that they are important enough that they deserve feedback, because you have confidence in their ability to use it to improve their performance.

Frame the situation as opportunity, not threat.

References

1. trainugly.com/resilience/