Tossing hand grenades: how to deliver feedback in medicine today

Physician Executive, Sept-Oct, 2006 by Kent Bottles

The well-run doctor's office or hospital requires many people with different competencies doing myriad things skillfully and efficiently. No matter how competently each person performs his essential job (diagnosing patients, answering the telephone, getting claims to the third-party payer, hiring the right people) patients will not get the best care unless the players work well together.

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It sounds so simple and yet anyone who has worked in a busy doctor's office knows that conflict is inevitable. Giving and receiving feedback to deal with disagreements is the key ingredient to an office with high worker morale and well-cared for patients.

Why do all of us have trouble giving and receiving feedback?

If we try to avoid the problem, we'll feel taken advantage of, our feelings will fester, we'll wonder why we don't stick up for ourselves, and we'll rob the other person of the opportunity to improve things.

But if we confront the problem, things might get even worse. We may be rejected or attacked; we might hurt the other person in ways we didn't intend and the relationship might suffer. (1)

Failure is the best teacher

Another reason we are uncomfortable giving and receiving feedback is related to our fear of failure. Most of us know we are imperfect, but we are not so sure others have discovered all of our weaknesses. By avoiding feedback, we hope to avoid discussing our failures and shortcomings publicly.

Any group of people will function better if they view failures as a marvelous teaching and learning opportunity; most of us do not talk about our failures because we are embarrassed.

"When you're successful you don't appreciate all the magic that went into that success as much as when you've gone through failure. When you try something and it doesn't work, you have a tendency to spend time reflecting," mused Jason Rasky of Failure Magazine.

Dietrich Dorner studied real-life cases such as the derailed locomotive pictured on his book's cover. Common features of bad decisions that led to failure include failing to state goals clearly, gathering information without thinking about the task at hand, failing to realize goals can be contradictory, looking for one central cause and not establishing priorities. (2)

Destructive feedback

All of us have received feedback that hurt and made us angry rather than willing to learn new approaches to a difficult situation. Twenty-one years later, I can still hear my surgery private practice office preceptor screaming at me: "Bottles, you stink; I cannot believe I let you see that patient by yourself. You're going to drive all my patients away. You will never be a real doctor."

Such an approach did not make me eager to openly discuss my questions with my mentor. I wanted to get away from him as quickly as possible. Most of his office staff walked on eggshells because of his feedback style, and problems were not openly discussed.

Psychologists tell us that my mentor's feedback was too vague, threatening and pessimistic to help me learn how to better relate to patients. This type of feedback offers no hope and no specific suggestions on how to improve performance.

Constructive feedback

In contrast to destructive feedback, constructive feedback is described as being specific, supportive, problem-oriented and timely.

If my preceptor had followed standard advice on constructive criticism, (3) he might have said:

"Bottles, today you did not introduce yourself to the patient; you were too quick to interrupt her as she tried to tell her story. You seemed very nervous with this patient and that puzzles me. Tell me if I am right that you were nervous. You have really improved in your interviewing so I was a little surprised that you did not listen well this time."

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While this approach is an improvement over the destructive feedback model, it still suffers from some inherent limitations. Robert Kegan and Lisa Laskow Lahey (4) observe that "many a relationship has been damaged and a work setting poisoned by perfectly delivered constructive feedback!

In my medical school we teach students to prepare and deliver a "feedback sandwich" with the criticism as the meat in the middle surrounded by two pieces of positive, encouraging slices of bread. The limitation here is that the person receiving the feedback often concentrates on the bread and ignores the meat of the matter.

I have personally received such skillfully crafted and delivered feedback and it took me weeks to realize that the main message was the beef.

Beyond constructive feedback

Gary Klein's research into master coaches across different fields and settings found three consistent dimensions of effective feedback givers: assessing and diagnosing, tailoring instructions, and setting the climate. (5)

Master coaches do not jump right in and give suggestions to improve performance or deal with a disagreement. They first try to assess the situation and understand how it looks from the other person's point of view.

Kegan and Lahey make a similar point. Their criticism of constructive feedback is that it assumes that the feedback-giver knows the truth and only has to get the receiver to change. (4)