Tossing hand grenades: how to deliver feedback in medicine today.

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)

Master coaches agree with Kegan and Lahey that there may be more than one truth and it is far better to create a context for learning where the parties can have an opportunity to learn from each other. (4)

Instead of starting with suggestions for improvement, the master coach tries to understand how the other person makes sense of the situation so that both can figure out a better way to deal with the problem.

Douglas Stone and others make the point that "what happened is the result of things both people did--or failed to do." (1) Discussing the contribution that both parties made to the situation avoids the blame game that makes people so angry and unreceptive.

How to tailor feedback

Master coaches have a large repertoire of ways to tailor instructions and discuss the difficult situation. (5)

* Ask the other person to describe what happened and what he was thinking. Try to understand the other person's thought processes and why his "mistake" made sense to him.

* Discuss why your view makes sense to you.

* Only concentrate on one issue at a time.

* Discuss the strengths and weaknesses of your way of viewing the situation and his way of viewing the situation.

* Ask open-ended questions.

* Discuss your feelings about the situation and his feelings about the situation.

* Try to get at how each of you has different information, perceptions, interpretations and values that contribute to your difficulty working together.

Master coaches set the climate as a collaboration where both parties can benefit and learn. Klein describes a fire department captain with a firefighter who refused to listen, refused to obey orders and was defiant. After another fire where the man again "messed up," the captain wanted to say "You're incompetent. I'm writing this up so I can document my case when I throw you out of the department." (5)

Instead he tried Klein's approach:

The captain said, "I was surprised at how you handled this last run. I'm wondering what your reasoning was."

The firefighter explained what he was trying to do, and the captain realized it made sense. Just because it wasn't what the captain expected didn't mean it was stupid. The captain explained why he expected a different strategy, and described its advantages, but acknowledged the strengths of the strategy the man had used.

"And you know what?" the captain told us, in the third workshop session. "We've been okay ever since. That firefighter didn't have an attitude problem. I was the attitude problem." (5)

Talk to yourself ... and listen

While it is human nature to second-guess yourself, few of us develop strategies for effectively giving feedback to ourselves. Klein suggests we "take this natural tendency and refine it and discipline it" to better understand how we make decisions.

Klein tries to recover from failures by analyzing what he should have done and by hoping he gets another chance to improve his performance in similar situations that come up in the future. (5)

Stone devotes an entire section to the "identity conversation."

The identity conversation looks inward: it's all about who we are and how we see ourselves. How does what happened affect my self-esteem, my self-image, my sense of who I am in the world? What impact will it have on my future? What self-doubts do I harbor? In short: before, during, and after the difficult conversation, the identity conversation is about what I am saying to myself about me. (1)

Peter Drucker describes the feedback analysis as a critical tool in managing ourselves.

Whenever one makes a key decision, and whenever one does a key action, one writes down what one expects will happen. And nine months or twelve months later one then feeds back from results to expectations. I have been doing this for some 15 to 20 years now. And every time I do it I am surprised. And so is everyone who has ever done this, Drucker wrote. (6)

I was certainly surprised when I took Drucker's advice as I moved from Iowa City to Philadelphia to become professor and chair of pathology at Allegheny University of the Health Sciences. I expected to stay in Philadelphia for about five years, do a great job, and be promoted to dean somewhere else.

What happened was the medical school went bankrupt and I was out of a job. While the feedback analysis did not reveal the causes of the system failure, I did learn that I was a better communicator than listener. I did learn how I had contributed to some of my own problems as a leader.

Actively seeking feedback

Most of us are not surrounded at work by master coaches brimming full of emotional intelligence. Most of us work with imperfect people just like ourselves.

Stone suggests we all admit to three things:

1. You will make mistakes.

2. Your intentions are complex.

3. You have contributed to the problem. (1)

When disagreements arise, how can we effectively seek feedback from our imperfect colleagues?

Klein advises asking the other person about the cues or patterns they noticed to come to their conclusions about the situation. Ask more experienced co-workers to describe how they have handled similar challenges in the past. Ask a lot of "what if" questions to probe deeper into the situation.

Try to stay away from either side expounding on general advice or their pet theories. End the discussion when either party gets bored. Klein believes boredom is a sign that you aren't getting useful insights. (5)

Kegan and Lahey summarize ways to effectively talk to a colleague about a difficult situation. They suggest "knocking before entering" because both parties have to agree to the time and the place to have a serious discussion about an important disagreement. If either party is busy with another topic or feels ambushed, the discussion will not be fruitful. (4)

The next step is called active listening to clarify the gap. The purpose here is to "explicitly-even glaringly-declare just how far apart the two parties are." (4)

After understanding how far apart they are, the two parties need to agree to keep searching and researching. They both agree to keep thinking and discussing this matter. The endpoint of a difficult discussion is to see the conflict as an opportunity for both to learn, "a seminar."

Seminar comes from the Latin word for seed and Kegan and Lahey suggest not resolving conflicts, but turning them into contexts where individuals and organizations can grow and learn from each other. (4)

Conclusion: Creating a Learning Context in Your Office Practice

In a podcast interview at www. soundpractice.net, David C. Leach, MD, the executive director of the Accreditation Council for Graduate Medical Education, quoted the Desert Father Abba Felix: "To teach is to create a space in which obedience to truth is practiced."

I do not think Leach, or Father Felix for that matter, would mind if we extended the thought to "To teach/learn is to create a space--a doctor's office, a hospital, a health system--in which obedience to the truths is practiced."

Conflict and disagreements are inevitable in any group of people doing important things. We all need to learn from each other and embrace conflict as an opportunity to grow and learn.

At its best, the community of truth advances our knowledge through conflict, not competition. Competition is a secretive, zero-sum game played by individuals for private gain; conflict is open and sometimes raucous but always communal, a public encounter in which it is possible for everyone to win by learning and growing.

Conflict is the dynamic by which we test ideas in the open, in a communal effort to stretch each other and make better sense of the world.

The medical world provides a multitude of opportunities for effective feedback to improve efficiency and patient care. The physician will become a better diagnostician if he or she can create a space where feedback is honestly given and received by the patient.

The office administrator will improve staff morale and employee retention if feedback helps us view conflict as the dynamic by which we test ideas in the open.

The insurance specialist in your office will get better results from the third-party payers if feedback about denials is delivered with skill and grace.

All of us will enjoy our work more if critiques of performance are given and received in a learning and teaching context that has as its ultimate goal better patient satisfaction and clinical outcomes.

Kent Bottles, MD, is vice president/chief medical officer of the Iowa Health System in Des Moines, Iowa. He can be reached at 515-241-4017 or by e-mail at [e-mail]

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References

1. Stone D, Patton B, Heen S. Difficult Conversations: How to Discuss What Matters Most. New York: Penguin, 1999.

2. Dorner D. The Logic of Failure. New York: Metropolitan Books, 1996.

3. Weisinger H. The Power of Positive Criticism. New York: AMACOM, 2000.

4. Kegan R, Lahey LL. How the Way We Talk Can Change the Way We Work. San Francisco: Jossey-Bass, 2001.

5. Klein G. Intuition at Work. New York: Doubleday, 2003.

6. Drucker P. Management Challenges for the 21st Century. New York: HarperCollins, 2001.

7. Palmer P. The Courage to Teach. San Francisco: Jossey-Bass, 1998.

By Kent Bottles, MD

RELATED ARTICLE: Ways to Tailor Feedback

* Understand why the mistake made sense to him.

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* Tell him why your approach makes sense to you.

* Concentrate on one issue at a time.

* View encounter as collaboration where you both can learn.

* Ask open-ended questions.

RELATED ARTICLE: How to Get Others To Give You Feedback

* Make sure it is a good time to talk.

* Ask what if questions.

* Focus on a specific incident.

* Stay away from discussing general theories.

* Ask more experienced co-workers what patterns they saw.

* End the discussion when boredom sets in.

* Make sure you understand how far apart you both are from each other.

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Destructive vs. Constructive Criticism

Destructive  Constructive

Vague        Specific
Pessimistic  Optimistic
Threatening  Non-threatening
Not timely   Timely