Three Hiding-In-Plain-Sight Truths About Receiving Feedback

I will say something that is profane in academic medicine: I am not a lifelong learner. I can do the things a life-long learner does, but I do not identify myself as one of those exalted elites. Like most things with a “Why am I the way that I am?” bend, I blame my upbringing. Not my parents, but my schooling. And as physicians, wow, we have been through a ton of schooling.

Traditional education in America may be changing, but during my formative years, questions had one correct answer and a seemingly infinite number of incorrect answers. Being able to memorize things usually got me the correct answer. Somehow, divining good test-taking skills took care of the rest. Those skills solidified my belief that there was only one correct answer to a question. Part of good test-taking is dissecting why the other answer choices are wrong: the “least wrong” choice is likely the one correct answer. Though that mentality has gotten me far, it’s made me an unwilling lifelong learner. Being a lifelong learner requires healthy curiosity. And do you know what healthy curiosity involves? Acknowledging that you may have already chosen the wrong answer.

I can pick natural lifelong learners out of the academic medicine crowd by how they respond to feedback. Giving good feedback involves identifying specific behaviors a learner can improve and giving them actions they could take to improve that behavior. The natural lifelong learners raise their hands immediately when I walk into the workroom at the end of the week and ask, “Who’s ready for feedback?” At the beginning of our service week together, the natural lifelong learners will tell me what they’re working on that week and ask me to have specific feedback about that skill for them at the end of the week. These people have a two-way discussion with me during a feedback session. “What about X?” they’ll ask. Or, “I’ve seen somebody do Y in this situation; is that something I should have tried?” Most telling, lifelong learners will give me feedback during the sessions. That’s how committed they are to the process: they will tell somebody in power how to improve. Commitment, spine, guts, some more vulgar body parts, they have it. People who are unwilling lifelong learners like me treat feedback as a box that must be checked off a to-do list. When I ask them how they think the week has gone, they answer, “Ah…um…fine, I think,” because they haven’t been able to do any internal self-evaluation before our conversation. There is no judgment there. Self-evaluation can be uncomfortable.

So, what are we to do, the ones used to knowing the one correct answer, who assume the worst whenever an attending walks into a workroom and asks the dreaded, “Who’s ready for feedback?” Brace yourself. I will blow your mind with this hiding-in-plain-sight truth: feedback is almost entirely subjective. Unlike the multiple-choice tests I grew up taking, there is no one correct answer.

Let me get your valid argument out of the way right now so we can get to the actual topic at hand. Feedback is “almost entirely” subjective because we sometimes get feedback on very objective things. “You gave vancomycin to treat RSV. I’m giving you feedback that we don’t use antibiotics to treat viral infections because that’s not how antibiotics or viral infections work.” Most feedback is of the variety, “You could have been more efficient when you X, you should have handled the family member by Y, it would have been lovely to see you help out your colleague with Z.”

Let’s take the first example. Whether you think you’re efficient enough is entirely up to you. There’s not a biomarker for efficiency. If I tell you that you should be more efficient, what am I using as my yardstick? Me? Your co-resident? Some abstract idea of how efficient you should be given your level of training and how far you are into the academic year? Whether or not a person is “efficient” is entirely subjective. Also, if the things you’d have to do to become “more” efficient are more painful to you than the current results you’re getting with your baseline efficiency, it will be tough to change things. Some people genuinely don’t mind finishing their clinic notes at home, and they would much rather do that than chart in the room, which requires their looking at a computer screen instead of at their patients when they’re talking. For those people, being “more efficient” would obligate them to do something they really don’t like, and brains cannot sustainably flip that switch without significant motivation. And, mind-blowing hiding-in-plain-sight truth #2, the person giving you feedback can’t actually force you to change anything about yourself. You are a fully autonomous human with the capacity to make decisions for yourself. You could listen to the feedback, thank its giver for their time, and decide you don’t want to incorporate it into your practice. “MD aware,” as it were.

But, say your baseline efficiency level means you missed following up on lab tests that are now over a day old. Your patient from yesterday’s clinic has acute renal failure of unclear etiology and needs to get to the hospital ASAP. Then, your efficiency needs some improvement. But again, that’s up to you to decide (you autonomous agent, you). If having a patient with acute renal failure getting a delayed referral to inpatient care is more painful to you than what it would take to become “more efficient” in checking your lab results, then you’ll change your habits and get more efficient checking your lab results. If, according to your unique values, you checked the labs “soon enough,” because the patient got to the hospital before they had life-threatening electrolyte abnormalities, then you may not change your practice. There is not a single, objectively correct answer.

Receiving, accepting (or not accepting), and incorporating feedback are all completely different. When I receive feedback, I passively listen, thank the feedback giver, and move on with my day. And maybe I don’t even listen to it that well because I’m too busy contemplating when the feedback giver will say “the big, horrible thing,” I’m sure they will say. Or, I don’t move on with my day. I spend it contemplating why the feedback giver didn’t say the “big, horrible thing,” I feel I’m hiding from everybody: Imposter Syndrome, table for one. When I accept feedback, I see the feedback giver’s point, but I choose to keep doing things how I’m doing them because I’m not personally bothered by my performance of the skill on which I was given feedback. When I do not accept feedback, I disagree with what’s being said, and open things up for discussion (or don’t, and just disregard the feedback without a second thought). When I incorporate feedback, I see the point the feedback giver is making, decide that I do want to change the thing I’ve gotten feedback about, and then decide whether I want to take the feedback giver’s suggestions or figure out something different on my own.

When we look at receiving feedback this way, we can see how much agency we have in the matter. It shows that the self-evaluation of our work is much more important than an external evaluation, such as feedback. This leads me to mind-blowing hiding-in-plain-sight truth #3. Suppose internal self-evaluation requires vulnerability and acknowledging that you may have already chosen the wrong answer, and accepting, not accepting, or incorporating feedback requires the same. In that case, it’s probably easier to get really deliberate about working on the former because you’re doing it on your own without fear that somebody is judging you. Which then sets you up for success in doing the latter. Then, the chances are that your feedback-giver isn’t telling you anything you don’t already know (and may have already thought about what you want to do with it). Recognizing feedback is almost entirely subjective, I’ve started wrapping up my feedback sessions by saying, “But look, this is just my opinion. Take what resonates and disregard the rest.” The natural lifelong learners smile and thank me. The unwilling lifelong learners break stride and get a funny look on their faces. Sometimes, you can just see the minds being blown.