CHAPTER 10

Feedback: A Commitment to the Relationship

Every day of our lives, we give and receive feedback. Reactions to feedback range from joy and pride to disdain and defensiveness. For example, your younger sibling might ask you for advice on a resume she is submitting for a new job. When you offer pointers, she may be very receptive and appreciative of your feedback. Conversely, your partner might offer a backhanded compliment on the dinner you just prepared, and you might retaliate with an off-the-cuff comment on how he or she loaded the dishwasher.

In these everyday settings (as well as in professional settings), how we interact with each other when we give or receive feedback can greatly influence the quality of our relationships. In a healthcare system increasingly driven by outcomes, we risk overemphasizing our ends without nurturing or even examining our means. The process of feedback is core to any system’s success. On a human level, providing periodic, authentic, and useful feedback is key to a healthy work and learning environment. Just as reactions to feedback may vary, individuals may also have varied understandings of what feedback means. Some may view feedback strictly as judgmental criticism, while others may see it as an opportunity for growth.

Here, we define effective feedback as specific, nonjudgmental information, comparing a person’s performance with a standard, given with the intent to improve performance.¹ We are constantly providing feedback to others, consciously or unconsciously, skillfully or carelessly. Misunderstandings and conflicts often occur when we interpret other people’s actions as implicit feedback on our performance. Being intentional in our feedback conversations is critical to our success as team members, healthcare clinicians, and educators.

You can also think about feedback as a way of strengthening a commitment to the relationship. If I care about a professional relationship (or a personal relationship, for that matter), giving authentic reinforcing and constructive feedback means I am invested in the other person’s success. With this in mind, feedback conversations can be transformed from something that we dread into something that deepens our connection with others. In this chapter, we will demonstrate how to use relationship-centered communication skills as a framework for giving feedback that helps nurture relationships in healthcare work environments.

Consider this scenario:

Mr. Wilson is a medical assistant in a busy ambulatory practice. The practice institutes a prescription-refill workflow where medical assistants triage refill requests and route them within the electronic health record to the appropriate clinicians. Clinicians, who had previously been handling refills, love the new system because it frees up their time for other clinical tasks. Patients love the new system because their prescriptions are available sooner. Mr. Wilson, however, is feeling exhausted. In between rooming patients, he is frantically routing prescription refill requests and falling behind. Meanwhile, Dr. Garcia, who has been working with Mr. Wilson for years, has noticed his declining performance and feels frustrated that she continually has to room patients herself to pick up the slack. They both notice that their social conversations, which used to be quite rich, have become less frequent and are almost exclusively business-related. After a busy clinic where Dr. Garcia roomed two of her own patients, she is feeling particularly frustrated and decides to provide Mr. Wilson with some feedback.

Feedback is often given in reaction to something that has or has not been achieved. In the above scenario, Dr. Garcia is reacting to Mr. Wilson’s inability to room patients in a timely manner. Right before the feedback exchange, both the doctor and the medical assistant are feeling frustrated and at odds. As a result of their emotional states, the subsequent feedback conversation may go poorly.

Well before starting such a conversation, the individuals might consider engaging in a more useful form of feedback that prioritizes their relationship while offering an opportunity for a successful dialogue. The relationship-centered model of communication can help to inform a rational approach to hosting such a feedback conversation in three steps that mirror the three fundamental communication skill sets (see Chapters 3–5). We will start by setting up the conversation for success in the context of the relationship. Then we move to observation, where we gather information. Only then do we provide the actual feedback, beginning with reinforcing feedback and moving to constructive feedback. After the feedback exchange, we discuss next steps, which are the new goals going forward.

Setup: What You Put in Is What You Get Out

Before offering someone feedback, we must first establish a relationship with that person and intentionally set up the conversation for success. This may seem like a lot of extra work, but it makes a huge difference in how the feedback is received. If you were to go to dinner with a friend, it would be off-putting if you insisted on going to the restaurant of your choice and then told your friend what food to order. In fact, you probably wouldn’t be invited to have dinner again anytime soon. A more relational approach would involve getting your friend’s input, discussing your preferences, and perhaps agreeing on entrées to share so you can both sample different menu options. During this process, you might even learn something about one another that you didn’t know before. Effective feedback conversations are not all that dissimilar from this scenario. The setup is when we set the agenda for the professional relationship (see Chapter 3) and where preferences and expectations are shared on both ends (see Chapter 4). For this approach to be successful, we must address the potential need for confidentiality and make sure the other person is ready to talk.

Let’s go back to our story of Mr. Wilson and Dr. Garcia. Before providing any feedback, Dr. Garcia might first set up the conversation by checking in with Mr. Wilson about how he is handling the recent changes: “It seems like there is a lot going on right now in terms of changes in the clinic. Do you have some time to sit in the break room to talk?” Once they are both seated, she can ask, “How has all this been for you?” She might learn that Mr. Wilson is feeling really stretched thin in terms of his workload. In fact, he is feeling disconnected from the patients, given all of the refills, which is quite distressing to him. In addition, his son is going through a hard time in school because of a learning disability, and Mr. Wilson needs to get home right after his shift to help with some tutoring that his son desperately needs. Given this context, Dr. Garcia could then ask what Mr. Wilson’s expectations and goals are for himself in terms of his work. Mr. Wilson shares that he really wants to be more focused on the patients (instead of the refills) because he really enjoys that part of his job. He also states that he wants to leave on time in order to be available to his son. Here is an opportunity for Dr. Garcia to express empathy via PEARLS (see Chapter 4), saying something like: “Sounds like this has been a tough time for you. I really respect your commitment to our patients and your son.” Now, having heard Mr. Wilson’s perspective, Dr. Garcia can share her expectations of Mr. Wilson: “I also want to run on time and prioritize our patients. I would like to partner with you to find a way to make that happen.” By generating a shared understanding and identifying goals upon which both can agree, the ensuing feedback conversation will be grounded in their relationship and shared alliance. The next step, then, is to observe skillfully.

Observation, Part I: You Can’t Improve What You Don’t Measure

Feedback is based entirely on data. Therefore, honing our observation skills is critical to being effective in our communication. Emotions create intensity that can get in the way of observation. As emotional beings, to paraphrase award-winning novelist Toni Morrison, it’s often easier to remember how somebody made us feel than what that person said or did. In delivering effective feedback, it is critical that we focus not on emotions but on specific activities and behaviors we observed. Emotionally, Dr. Garcia is frustrated. She may feel tempted to blame Mr. Wilson for the clinic running behind schedule and could be thinking, You don’t know how to do your job! The truth is, however, Mr. Wilson knows exactly how to do his job (and is actually quite good at it), but the circumstances have created a difficult situation. If Dr. Garcia leads with judgment and emotion, Mr. Wilson could easily recoil and the conversation could quickly spiral downward. Dr. Garcia’s task is to distill what she observed and share that information with Mr. Wilson with as little judgment as possible. This might seem obvious, but it can prove quite challenging in practice and takes some getting used to. For example, instead of focusing on how she feels, Dr. Garcia might simply note that their second patient of the day showed up on time and waited for 15 minutes after being checked in, after which Dr. Garcia went to the waiting room and brought the patient into the exam room herself. This critical step of data-gathering cannot be overlooked, as the ensuing conversation needs to focus, at least initially, on the observed behavior. Once they identify and agree on the behavior, she can discuss the impact of that behavior (how she felt about it), which they can then process together.

Observation, Part II: Believing Is Seeing

You may have experienced the phenomenon where you learn about something new (e.g., a word, book, or TV show) and then suddenly, you are hearing about it all the time, seemingly out of nowhere. Although it may be coincidence, it is more likely that you have been, as neuroscientists describe it, “primed.” Consider a medical student who is flagged as “a risk” because he or she comes from an underprivileged background and holds a degree from a college not known for its academic rigor. Undue and constant scrutiny of his or her performance reveals some deficiencies, but nothing that wouldn’t otherwise be discovered in other students under the same scrutiny. However, because the observers have been primed, they are only seeing those behaviors in that specific student and not in others. What is seen must be compared to an objective standard that is applied to all.

The opposite is also true with the so-called “halo effect.” Observers may come to believe that a trainee is particularly skilled based on initial, often brief, and sometimes biased exposure. When the observer evaluates the trainee, he or she may write up an unduly positive report despite evidence to the contrary. In this instance, the trainee can do no wrong and wears that sought-after halo.

Dr. Garcia would be well-served to notice some of the things that Mr. Wilson is doing effectively. Although she has recently been focusing on Mr. Wilson’s lack of efficiency, she could also notice a couple of other things. For example, several of their patients have brought gifts specifically for Mr. Wilson over the holidays because of his relationship with them. Recently, he went to a different floor to bring down a wheelchair for an elderly patient who needed help getting to the lab. These pieces of information are important and will help to continue to build a relationship between Mr. Wilson and Dr. Garcia in the next phase.

Reinforcing Feedback: Without It, Good Performance May Decrease

Everyone loves praise, even if they say they don’t—the better if it is specific. There is immense power in being recognized. Giving voice to those behaviors provides important reinforcement as well as implicit respect for the other person. Studies suggest that a 4:1 ratio of reinforcing to corrective feedback is a good benchmark for calibrating how much feedback to provide (in healthy marriages it is closer to 5:1).² Instead of singularly focusing on problems in our relationships, we need to give a healthy dose of authentic reinforcing feedback before even a single piece of corrective feedback is provided.

You will notice that thus far, we haven’t mentioned “positive” or “negative” feedback. This is intentional. As discussed earlier, divorcing ourselves as much as possible from judgment and judgmental language is critical. If we use the term “negative feedback,” one could argue that feedback is something to be ashamed of. Instead, if we focus on actionable behaviors, both parties can move away from judgment and blame to focus on solutions. Conversations can then follow a “keep-stop-start” framework, moving from reinforcing feedback (i.e., keep doing) to constructive feedback (i.e., stop doing) and then to next steps (i.e., start doing).

Additionally, using the ART (Ask, Respond, Tell) skill from Chapter 5 at each stage can be particularly useful.

In the conversation between Dr. Garcia and Mr. Wilson, Dr. Garcia decides first to ask Mr. Wilson what he thinks he is doing effectively. In his typical self-deprecating fashion, because he is having a tough time, Mr. Wilson can’t really come up with much that he is proud of and instead focuses on his deficiencies. Instead of allowing the conversation to go straight to constructive elements, here Dr. Garcia can highlight some of the key behaviors that she authentically values in Mr. Wilson’s performance. She responds (the R of ART) by saying, “There is actually quite a bit that I can think of that I appreciate about your work.” She then tells (the T of ART) her perspective by sharing how much their patients value him as evidenced by their gifts and his commitment to helping those in need. Dr. Garcia is providing a much-needed boost to Mr. Wilson. More important, she is deepening their professional relationship. By simply sharing that she noticed and values these behaviors, she is implicitly stating her alliance with him. Mr. Wilson will be more receptive to the constructive feedback that is coming and will be more likely to view the feedback as coming from a place of shared values rather than judgment.

Constructive Feedback: Courage Is What It Takes to Sit Down and Listen

Having effectively laid the groundwork, now is the time to provide the constructive feedback. Asking for a self-assessment here (as in the prior section using ART) can be very powerful. By starting with an Ask, such as, “What would you like to do differently going forward?,” one can understand what level of insight the person has about his or her performance. Mr. Wilson might answer, “I feel badly that I fell behind in rooming patients today, and I know this has happened before. I am sorry about this. I really want to do better.” Here, Mr. Wilson is keenly aware of where his performance fell short. Dr. Garcia then can respond (the R of ART again) with something like, “Sounds like you are really struggling with competing tasks in the clinic.” Then telling her own perspective (the T in ART): “I agree, let’s talk about some possible solutions” before transitioning to next steps.

If, however, this is a blind spot for the other (as is commonly the case), then pausing and asking about intention may be useful before providing the corrective feedback. For example, when asked by Dr. Garcia about what he would like to do differently, Mr. Wilson might answer that he really doesn’t see anything wrong with how the clinic session went. Here, Dr. Garcia might ask, “I see. I am curious then what your intention was when you were at your computer, and Mr. Smith was checked in and was waiting?” Here, Mr. Wilson has the opportunity then to share that he was trying to complete needed work on his computer and hadn’t realized the patient had been waiting for 15 minutes. At this point, Dr. Garcia can then share how Mr. Wilson’s behavior has impacted her (highlighting how his intention differed from its impact on her). “I am hearing that your intention was to address the medication refills. The impact, however, was that the patient got to the exam room with a delay, and as you know, I can get frustrated with delays.”

Next Steps: Setting the Next Agenda

Setting the next agenda is the real payoff. Here is the opportunity to set new goals and expectations, just as was done in the setup. As the relationship builds, the goals may become more nuanced, ambitious, and deep. Possibilities may emerge that were not explored or even considered before. Moreover, when new challenges arise, the strength of the relationship will provide greater resilience to navigate those challenges.

Returning to our earlier scenario:

Mr. Wilson responds to Dr. Garcia, “I am sorry to hear that you were frustrated. I am frustrated, too. I want our clinic to run more smoothly, but I can’t seem to find the time to do the refills and room the patients.”

Dr. Garcia responds, “That actually makes a lot of sense. I hadn’t realized that the clinic leadership was having you do that while you were rooming patients. I’d like to bring this up at our next team meeting to see if we can find a solution. In the short term, do you have any thoughts on how we can make this work better?”

Mr. Wilson replies, “Maybe I can focus on rooming patients initially and only work on the refills if there is a no-show. Then, once all the patients are roomed, I can spend some time getting as many refills as possible done.”

“That sounds like a good short-term plan. I will be sure to circle back to you after our next team meeting. In the meantime, let me know when you need to get home to your son. Know that I am rooting for you and for him.”

“Thanks, Dr. Garcia. That means a lot.”

Now, they are clear on what their agenda will be for their next encounter and, more important, have deepened their connection with each other.

Conclusion

Skills useful for developing relationships with patients (see Chapters 3–5) also apply to feedback. By using a relationship-centered approach, difficult conversations can be changed into productive, empathic conversations. Our team members and colleagues are our most valuable assets in providing care. Building our relationships with them while continuing to improve the quality of care is key to making a productive and enjoyable work environment.