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Shaming Feedback vs Growth feedback - take homes from Duolingo.

Can we talk about all things feedback? Feedback can be beneficial for doctors to gain awareness of strengths and opportunities for improvement.  As physicians who went through innumerable tests and critiques before and during medical school, we can fall into some unhealthy patterns around evaluations throughout training and in ongoing board certification and quality measures.  The impact of any feedback actually depends not only on the methods and the giver but on how it’s received. 


Thankfully over the last few years, there has been an emphasis on quality feedback processes in residency training.  I personally feel it’s better than 20 years ago - intentional encouragement for feedback to be specific, timely, positive, and constructive, involving the resident's self-reflection of the resident, with mutually designed goals and action plans. If you want to read a great method for feedback, see this study. I also know in the world of academics, it’s not perfect every time. In fact, we know that there is inherent implicit bias.  But the effort is in place in improving the giving of it. So, this blog will not focus on the giving of feedback. Instead, we will focus on the receiving even when it's not done in the above manner.


I don't feel that we often give tips for residents to receive feedback well. In my years as core faculty and now in coaching, I recognize the opportunity to speak to user feedback to harness growth. 


I was reflecting on this recently while using an app to learn French. In the beginning easy stage of “hello” and “goodbye,” it was fun to realize my 2 years of high school French weren’t a complete waste. I kept getting questions right with a pleasant little celebratory sound.  However, it wasn’t long until my conditioned physician brain started cringing when I would miss a question.


But why? Why would I expect that even though I never became proficient with 2 years of formal instruction that I should answer perfectly now, decades later, with 2 weeks using an app? Well, because it’s in my conditioned physician brain nature. I was taking a wrong answer (along with the disappointing sound it makes) personally. In my mind, I could see Duo, the owl, rolling his eyes and shaking his head, saying, “she’s hopeless.” It was a judgment of my performance in my mind.


I reflected on receiving feedback in my own residency training – it was the same.  I wanted to hear I was doing great; I loved people-pleasing and depended on external validation. Constructive feedback in my brain at that time meant failure - an indictment on my very worth.


As I continued to advance in my French app recently, I recognized that each time I missed something, I learned something.  Brilliant. I remember Dr. Alpert, cardiology’s gift to medical students, making us commit to an EKG interpretation before he would give us the answer. “Put your quarter on the table, so I know you’re invested.”  We don’t have to view getting something wrong as failing. It’s an amazing tool for learning. The more we committed to an answer the more deeply the lesson stuck, whether right or wrong.


The same is true with informal or formal feedback.  When you get a review, here’s how I like to encourage residents to look at it.


Since you likely first reflect on the constructive feedback, we will start there. Recognize that it’s easy to view it as negative and as a criticism. But what if you start to train yourself to see it as an opportunity to grow and excel? If you never get constructive feedback, does that mean you have no room to progress? Have you peaked in your ability to be a great physician so early?  Why wouldn’t you want to see it as the opportunity to grow rather than a stick to beat yourself with? Don’t let the inner critic hijack this opportunity.


Examine it. Can you let your defense mechanisms down to see it objectively? What part of the ‘negative’ feedback is true? What can you learn from it? Make a mental note and plan to grow in that area. Is there something you objectively disagree with? Ask for clarification from a place of curiosity. Once you have been objective, had a good exploratory conversation about it, if there remains something you disagree with, then let it go. You don’t have to own it. There is no need to ruminate or perseverate. 


Constructive feedback summary: Step 1. Be objective, open, and curious. Try it on. Step 2. Learn and commit to growth on the pieces that ring true. Step 3. Move on. The stuff that doesn't fit, let it go and let people have their right to a different perspective. Shift to the future of how you want to grow and do things the next time.


Now, even more important, at least with most of the residents I’ve interacted with, is the positive feedback. Trainees so quickly dismiss it. I feel like they know the “sandwich” method involves positive comments on both sides of the “negative” observations, and they assume the attending is cavalierly giving obligatory positives to get to the “problem.” I can tell you that in 14 years of interacting with faculty, I don’t know of any who have ever made up something positive just to deliver a Reuben.  


A few things are going on here.


First, historically the brain is hard-wired to remember negatives over positives. Recognizing the sounds of a saber-tooth tiger was a bit more important than remembering the best-smelling flower. In addition, many physicians are prone to having a mental filter –  a thought distortion where all the good is filtered out, and the negative is magnified.  When used in a feedback session, it leads to reinforced self-doubt, negative self-talk, and shame. None of which are useful for growth. The other is the impostor phenomenon, also known as impostor syndrome, where the resident really believes it was some fluke that someone put a positive comment down at all. They are waiting to be discovered as being a fraud.  


In any case, becoming aware that you dismiss the positive is very important. Then, you have to begin to train yourself to make space for the positive.  Since it’s so ingrained and automatically dismissed, you have to learn to give room to consider it. Pause. Reflect on it. Ask your brain for examples of how the positive observations are true. You already have your brain pointed in the direction of reinforcing negatives, but I’m asking you to redirect your brain. See the positives that others do. Quiet the inner critic. Own the positives. We need each and every one.  Don’t give the balance over to constructive feedback. Celebrate the wins! And SAVOR them. Dwell on them. Give at least equal air time in your mind to the positives if not more. 


Those who really struggle with impostor syndrome should consider writing and keeping a record of all the positives and reviewing them regularly. Become aware of all the gimmicks your brain is using to dismiss it. Ask yourself what will happen if you accept the positive thing as true? Address those thoughts that come up. Many have almost a superstitious underlying belief that if they think they are good in an area or are excelling, they will become complacent or be set up for failure when the other shoe drops. This is your brain lying to you because it is trying to keep you safe.  


Positive feedback summary: Step 1. Become and remain aware of positive dismissal. Step 2. Pause, give space for it in your mind. Reflect. Step 3. Look for evidence that it’s true. Step 4. Celebrate and Savor!


The great thing about feedback is YOU get to decide what it means to you. No matter the intent of the giver. And as always, there's usually good that comes from assuming positive intent. If you consistently choose the most helpful way to interpret the feedback, you’ll reach greater heights. Atteindre l’excellence avec un esprit de croissance.  


Have a joy-filled day,  Tonya

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