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The art of giving feedback

September 2008

Published in the September 2008 issue of Today’s Hospitalist

VINCENT CHIANG, MD, vividly remembers some excellent feedback he received as a resident from an attending while he was placing a subclavian line.

“He was standing behind my shoulder, saying, ‘Good, good,’ ” Dr. Chiang said. “Then he started whispering, ‘And if you keep going that way, you’re going to probably drop a lung.’ ”

When it comes to giving colleagues feedback, Dr. Chiang acknowledged that providing useful information is difficult. But he added that the attending in the above example succeeded because he understood that feedback should work as a mirror.

“The attending was showing me what my actions would do, and it was up to me to decide whether or not to go forward,” he told a group of pediatric hospitalists in Denver this summer during a presentation on leadership and feedback.

The problem is that for many hospitalists, that type of feedback can be hard to find. While physicians may think they’re giving feedback to their colleagues all the time, real feedback is a skill that needs to be learned, particularly by any hospitalist who is in a leadership position “or who aspires to be in one.

Feedback: finding fault?
What exactly is feedback? According to Dr. Chiang, many physicians don’t have a clear idea.

“I’ll see the overnight attending, and he’ll tell me that he gave great feedback to the junior residents,” said Dr. Chiang, who is both an emergency physician and chief of inpatient services at Children’s Hospital Boston. “I’ll ask, ‘What did you do?’ and he says, ‘I said, Great job!’ But feedback is not reinforcement, and that’s an important distinction to recognize.”

Another misperception equates feedback with finding fault, as if all feedback is negative. Instead, Dr. Chiang explained, the term feedback is derived from rocket science, referring to a signal sent out by a rocket to find out whether or not it was going to hit its target.

“If it was clear the rocket wouldn’t make it,” he said, “a course alteration was made to move the rocket to the target. Feedback is about getting the object to the target.”

Dr. Chiang acknowledged that people stumble much more often when giving negative feedback than in giving positive feedback. But that raises another key hurdle to learning how to give effective feedback: the fact that many of us, in the words of a Harvard Business School professor whom Dr. Chiang quoted, suffer from “excess caution.” Out of a misguided effort to avoid hurt feelings, we often don’t give people information that could ultimately help them.

That helps perpetuate flawed expectations or even poor performance to the point that those people end up being passed over for a promotion or even terminated. Far from safeguarding someone’s feelings, Dr. Chiang pointed out, failing to give constructive feedback is actually cruel because you’re refusing to offer the honesty that could help a colleague.

The feedback process
The key to giving constructive feedback is to keep in mind the concept of feedback as a mirror. “Feedback is all about showing somebody else their behavior and how it appears, how it looks, how it is perceived,” Dr. Chiang said.

He outlined the process of giving feedback that works for him.

  • Think it through first. Before throwing yourself into feedback mode, go through a critical prefeedback process where you ask yourself several important questions.First, is the person truly able to receive the feedback right now? “This translates generally into not giving someone feedback postcall when they’re sleep deprived,” he said.

    At the same time, recognize that feedback is not at all the same as correcting an error that someone has made. If someone has made a mistake, they need to hear about it right away.

    “I hear that a lot,” said Dr. Chiang. ” ‘Somebody wrote, Give this patient 1 g of potassium IV push, but it doesn’t matter because they’re post-call.’ Instead, correction should happen as proximal to the event as possible.”

    Another question to ask yourself before launching into feedback: Is this the right place? A corner in the cafeteria or an office is a much better setting than the hall.

  • Prepare for the reaction. How will the person handle the feedback? “Are there going to be tears or anger or a commotion? And am I willing to stick around if things go badly?”If Dr. Chiang feels there’s a chance that someone might have a hard time hearing what he has to say, for example, he won’t initiate a feedback session 15 minutes before he has to go to an important meeting.

    You also need to take your own emotional temperature about the issue: Can you be calm and objective? “You just left the parents and the mom is yelling because of how the resident treated the child,” he said. “That’s not a moment where you should be giving the resident feedback.”

    Another question to ask yourself ahead of time: Is this feedback about an issue that the person can actually change? Many people in medicine, for instance, exhibit behaviors that can be overly obsessive, Dr. Chiang said. No amount of feedback now is going to swiftly change behavior patterns that have been engrained over a lifetime.

    And then there’s this prefeedback component that Dr. Chiang said he spends the most time thinking about: Do you have all the specific facts and details? If you’re going to hold up a mirror to someone, he said, make sure that reflection is as accurate as possible.

    It is those details, he added, that will allow you to avoid a “he said/she said” situation where feedback becomes nothing more than passing along someone else’s comments or gossip.

  • Introduce the topic. Once you have the right time, place, details and demeanor, introduce the issue: the interaction that went wrong with a patient, the lack of attendance at necessary meetings, the chronic lateness.”Just introducing the topic is often all you have to do,” Dr. Chiang pointed out. “Most people will recognize their flaws.”

    However, there are those to whom you give feedback, and the reaction is, “Huh?”

    “Those are the hardest,” he said. “That’s where you need to have the facts and specific information. Give examples when you run into the blank stare.”

    When citing specific examples, be sure to focus on the behavior itself, not what you suppose the recipients’ motives for the behavior may be. “You want to state the facts in no uncertain terms, then tell them, ‘I’m coming to these conclusions. Am I wrong?’ “

  • Shut up and listen. The next step, Dr. Chiang continued, is to just listen. “Expect discomfort and defensiveness and statements like, ‘The nurses are all out to get me.’ ” Keep in mind, he said, that the person may need to talk it out and save face. This is not the time to argue or debate.”It’s important to acknowledge that the recipient has been hurt, and I often repeat what they say,” he said. “Understanding is not the same as agreeing.” If you don’t acknowledge their response, he pointed out, “they won’t be able to hear anything you say because you’ve just joined the conspiracy.”

    While he’s listening, Dr. Chiang said that he often writes down what the person says. Then, as far as the back-and-forth discussion is concerned, “I tend to give the direct quotes back to that person.”

  • Move forward. Once you’ve given the feedback, you need to offer an action plan.”Do you need to meet again?” he asked. If so, work together to choose an appropriate time.

    At the same time, he said, “know when to bail and when it wouldn’t be helpful to move forward.” Some feedback sessions just blow up in your face when the person you’re giving feedback to, for instance, starts to cry.

    In that situation, Dr. Chiang said, suggest that the two of you take a break and revisit the issue later. And regardless of whether or not you can move forward, keep in mind that “feedback corrects nothing,” he said. “It is up to the individual to decide whether or not anything needs to be done.”

    Phyllis Maguire is Executive Editor of Today’s Hospitalist.