PRSonally Speaking

Wednesday, January 29, 2014

The Curse of Positive Feedback
by Devra B. Becker, MD, FACS
I look forward to the comments one of our residents makes during Journal Club. They display a clarity of scientific thought; I usually learn something. In the past, I have told him so—in general terms, saying “I really like your comments. They are smart and insightful. Keep it up!” I called that feedback.
Positive feedback seems easier than negative feedback. After all, who doesn’t like to say—or hear—something good? And as I have written in previous posts, our system of feedback is biased toward the positive.
And then, I went to parent-teacher conferences for my own children. “Your daughter is very smart,” one of my children’s teachers told me, “but she’s behind in my class.”
“I know she’s smart,” I told him. “I see that she’s not doing as well as she could on your tests. That’s why I tell her that she’s smart all the time—to boost her confidence.”
—“Being smart is like having big lungs. You can be a runner with big lungs, or you can be a bum with big lungs.”
That, as it turns out, was my problem. I was conflating an inherent characteristic with her work, and that can be confusing for children. Children who are told they are smart are often afraid to try and fail, because they worry that if they do fail, they aren’t smart after all. Instead, child experts say, adults should praise the specific work that they do, and focus on the action. My father used to tell me when I was growing up—and still tells me—“Being smart is like having big lungs. You can be a runner with big lungs, or you can be a bum with big lungs.” I stopped telling my daughter she was smart. I started telling her I was proud of her for studying hard. I praised small decisions she was making about how and when she studied, like setting up a place to work at the dining room table and removing distractions from the area. Her grades improved.
I noticed something else, though. That type of feedback is more challenging to give, precisely because it requires attention to detail and reflection. I had to spend time focusing on what she was doing. I could no longer get away with being vague. Even praising my children for ‘working hard’ is general. What are they doing? How do I know that they are working hard? What part of working hard was a challenge? I must evaluate which decisions they made that were difficult. If my daughter sits at the table studying when the cable is out, it’s very different from her sitting at the table studying when her favorite TV show is on. I pay attention to these details, and bring them up.
Similarly, with the residents, I have found that the most effective positive feedback has that level of detail. Now, I might tell my resident after Journal Club, “I really liked your comment about the stem cell study. You looked up a detail of the protocol and incorporated that into your analysis, and we all learned from that.”
Just as “You weren’t prepared,” is hollow, “You were well prepared” is hollow. “
What’s interesting is that we inherently do this with negative feedback. We are careful to separate out the specific action from the character of the resident. I wouldn’t consider saying to a resident after Journal Club, “You know, I didn’t really enjoy your comments in Journal Club. Frankly, they weren’t that smart or insightful. Do better next time.” I wouldn’t consider that feedback at all—I would consider that an insult.
The negative feedback I would give to a resident after Journal Club would have the type of detail and specific behavior often missing from positive feedback. “From your comments in Journal Club, it seemed like you hadn’t read the articles carefully or looked up the statistics that you didn’t know.”
Just as “You weren’t prepared,” is hollow, “You were well prepared” is hollow. “I noticed you struggled to identify the ulnar nerve in the forearm. I think it is probably because you did not know the anatomy,” is how I would give negative feedback. I’d invite the resident to tell me about his experience, and what he thought worked and didn’t. Perhaps he has a good anatomy textbook, but didn’t get a chance to prepare. Perhaps he studied from a textbook that isn’t good for the case we did. It is the resident’s response that then guides my feedback further. That type of interaction provides valuable feedback, because the residents learns where he fell short, and I learn about the resident’s learning process, which helps me become a better teacher for him.
For positive feedback, I also continue the conversation. “I noticed you identified the ulnar nerve in the forearm with ease. It is probably because you knew the anatomy. Tell me how you prepared, and what you think was effective about it.”
I also now ask for specifics about myself. If I am praised for a lecture, I ask what specifically the learner found useful. What I think I did well may be different from what she thinks I did well. We all can learn from feedback.