♦Part of the Assistant Professor Playbook Series
I am terrible at giving feedback. Ask me to come back in the middle of the night to check on a patient? Sure. Start a redo-redo-low anterior resection at 4 pm? No problem. Rewrite an entire manuscript the day before revisions are due? You got it. Give feedback to an intern who has been performing poorly but probably does not realize it? Oh the dread.
Giving negative feedback goes against our human desire to be liked, to be non-confrontational, to not want to make other people upset. Our jobs are difficult enough – why ruin someone’s day when you could just let it be, inadvertently kick the can down the road and assume someone else will eventually tell them what you could not?
I was thrilled when Dr. Scott Steele, my department chair in fellowship, started a book club and chose to discuss “Radical Candor”, the New York Times bestseller by Kim Scott.1 She created a visual guide for giving feedback, a 2×2 diagram with “Care Personally” on one axis and “Challenge Directly” on the other axis (Figure 1).2 While it seems obvious that we should care about each other, academic surgery can be so hierarchical that it is often difficult for students and residents to feel respected and valued. Put aptly by Kim Scott, “there are few things more damaging to human relationships than a sense of superiority.”
Challenging directly is where most of us struggle. Even when I muster up the courage to give constructive feedback, I often mumble it surrounded by so many other sentences that the listener does not even realize what I am saying. To this, Kim Scott says “It’s not mean. It’s clear!” When we care personally but fail to challenge directly, we fall into the “Ruinous Empathy” quadrant of the 2×2 diagram. We think we are doing someone a favor and sparing their ego, but instead we are failing to guide them. The trainee continues to perform sub-optimally, with or without realizing it, potentially leading to poor patient care and burnout.
Conversely, when we challenge directly but do not demonstrate that we care personally, we land in the quadrant of “Obnoxious Aggression.” Many of us can probably think of a few choice examples of this from our training. This behavior can be effective, particularly in the short-term, but often to the detriment of the trainee’s self-esteem and the cohesiveness of the team. A lack of caring and challenging places you in the quadrant of “Manipulative Insincerity”, a world of passive aggressiveness and neglect. It is easier to tell someone they are doing a great job and move on with your day, than it is to sit with them and talk through strategies on how to improve their performance.
Only by caring personally and challenging directly can we bring ourselves to the ideal quadrant, “Radical Candor”. In this quadrant, there is a culture of “getting, giving, and encouraging guidance”, founded on a basis of openness, trust, and respect. It almost sounds too good to be true. The reality is that we all wander among the quadrants of the 2×2 diagram. By using the diagram like a compass, pulling ourselves along the axes of caring personally and challenging directly, we can maximize our radically candid feedback opportunities.
Recognition of the need for formal training on giving feedback has been growing in the medical field ever since Dr. Jack Ende’s 1983 article in JAMA.3 His guidelines for offering feedback include that it should “be well-timed and expected,” “be based on first-hand data”, and “deal with specific performances, not generalizations.” He emphasized the importance of focusing on observable and remediable behaviors, not assumptions about the trainee’s overall character.
Despite the growing body of literature on this topic, most surgeons receive limited training on giving feedback and instead learn through trial and error. Sometimes we are fortunate to also learn by example. During fellowship, Dr. Steele would call at the end of every OR day to debrief. Though the first few phone calls were nerve-wracking, my co-fellows and I quickly realized that the calls simply consisted of observations of our techniques and specific strategies on how to improve. He used those 5 minute phone calls to emphasize teaching points he made during the case that may have fallen on distracted ears. This is the whole purpose of giving feedback – not simply to check a box, but to improve clinical skills.
As academic surgeons, we wear many hats. With our educator hat comes the responsibility to guide the next generation of physicians, surgeons, and scholars. Like many other aspects of our jobs, giving constructive feedback is not easy, but the rewards can be profound.
Figure 1. A guide to “radical candor” by Kim Scott2
- Scott K. Radical Candor: Be a Kick-Ass Boss Without Losing Your Humanity. New York: St. Martin’s Publishing Group; 2019.
- Scott K. Brutal Honesty and Radical Candor. The Blog: Radical Reading. https://www.radicalcandor.com/radical-candor-not-brutal-honesty/. Accessed Sept 8, 2022.
- Ende J. Feedback in clinical medical education. JAMA. 1983;250(6):777-781.
To see Dr. Lee’s short video on this topic visit the *Assistant Professor Playbook , a series of short videos designed to provide effective strategies towards a successful career in academic surgery. Other videos include Preparing for Promotion, Finding Funding Sources, Setting up a Translational Research Program, Succeeding in Surgical Societies, with more to come!
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