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Emergentology: The Two Most Harmful Words in the English Language

Walker, Graham MD

doi: 10.1097/01.EEM.0000480787.85254.b1
Emergentology

Dr. Walkeris an emergency physician at Kaiser San Francisco. He is the developer and co-creator of MDCalc (www.mdcalc.com), a medical calculator for clinical scores, equations, and risk stratifications, and The NNT (www.thennt.com), a number-needed-to-treat tool to communicate benefit and harm. Follow him @grahamwalker, and read his past columns athttp://emn.online/EmergentologyEMN.

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I saw the trailer for the film “Whiplash,” and didn't think much of it. It's the story of a kid attending music school with a crazy music teacher. I took lessons and played piano and then cello through high school but never fervently, and I didn't think I would be able to relate to the movie.

“Whiplash,” however, just uses the battle between teacher and student to bring up a much bigger dilemma, and was one of the best films I've seen all year. It asks the fundamental question: What is the role of praise and criticism in mastering something? The teacher summarizes his philosophy toward the end of the film: “There are no two words in the English language more harmful than good job.”

Instantly, I realized how this movie applied to me as a learner and a teacher, and it made me wonder if being “the positive guy” was really helping the residents I supervise or the nurses, off-service residents, techs, and even colleagues to whom I give feedback.

When I think back to my own experience during residency about who really helped me grow as a physician, two categories come to mind. First, the role models were just all-around fantastic physicians, and honestly I just copied all of their interactions with patients. These men and women were the easiest to identify because we had similar personalities or just clicked. But there was also a second group of attendings that I don't think I ever appreciated until long after residency. These physicians certainly taught me things, but more often they were critical of me and rarely provided praise. And this probably drove me to read more, learn more, and want to improve. You might have gotten a “not bad” from them after a trauma resuscitation was over, but a “good job, Graham” was rare.

It is a special but critical and sometimes-delicate relationship between teacher and learner. Praise too much or criticize too little and the learner may become complacent or over-confident and lose the drive to improve. Do the opposite and push too hard, and the learner may feel hopeless or give up.

I struggle with this daily, even when I am working without a resident. I may want to give someone feedback about how I think they performed, but I invariably end up saying, “Good job.” I'm sure it's for any number of reasons:

  • I'm the upbeat, joke-cracking, role-with-the-punches, “we can do this!” cheerleader type of emergency physician.
  • I don't want to hurt the person's feelings or upset him or hurt his performance throughout the rest of the shift with other patients.
  • I don't take criticism well. I'm sure my parents or boyfriend can vouch for this, so I don't want to make other people feel bad, either.
  • Today's society has a focus on fairly superficial mental health — that everyone needs to be happy all of the time, and feelings of doubt, sadness, and grief must be immediately remedied.
  • I'm on the older cusp of the younger generation that does not just crave but needs praise and positive feedback. (Think second grade “graduation ceremonies” or measuring one's worth by how many Facebook or Instagram likes one gets.) And in that same vein, I also really just want people to like me.

All of this makes me wonder if I'm actually doing a disservice to my residents and even my department by not being tougher. To paraphrase the music teacher in “Whiplash,” am I depriving the world of the next Charlie Parker by not fueling people's internal drive to improve and be the best? Am I encouraging mediocrity by setting low expectations and not expecting more?

I worry that I am, that we all are. I cringe when I type the phrase “lifelong learner,” but I always want to improve my medical care as well. Clearly, I can be motivated by a need for praise — or conversely, by criticism — and I really do want to know when I could be managing a case better. Don't we all?

So be warned, future residents, medical students, and the poor souls with whom I work: I'm going to do my best to be a little more begrudging with my praise and a little more forward with my criticism. (Don't worry, old habits die hard.) And because you'll be reading this two months after I wrote it (publication lag time!) and I already feel bad about making you feel bad: I'm sorry, but it's for your own good.

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