4. Base feedback on objective observations: Once I receive feedback, I prepare to give feedback, usually immediately after a patient encounter. I always base my comments on observations, such as, “I noticed that smoking status was not addressed,” or “I noticed the word inflammation was used a lot during explanations.” (The more specific the observation, the higher quality the feedback.)
These observations inform the comments I deliver next. For example, following the smoking observation, I might comment, “It’s important to start the discussion on smoking because coronary artery disease is one of the most common causes of death in rheumatic diseases, and smokers are at increased risk.” Following the inflammation observation, I might comment, “Patients often have different ideas about what inflammation means. It may be better to say ‘swelling’ or ‘pain’ instead.” I also employ “I” and other personal pronouns to signify my ownership of the observations to ensure objectivity. This may seem excessively strict, but making the feedback more personal helps check our potential subconscious biases and prejudices.
Finally, I leave learners to evaluate the validity of the comments and never force them to agree—something I resented deeply as a trainee.
5. Don’t serve a crap sandwich: The crap sandwich, to those who don’t know, is a common way of relaying comments by starting with vague compliments, such as, “You did a good job,” followed by judgmental criticism, such as, “You look at the computer too much,” and ending with an equally worthless, “But you’re improving.” The crap sandwich is like comfort food, because it’s easy to make and feels natural. Most of us have been fed such fare throughout the course of our medical education. But if you examine it closely, it’s just as artificial as the observation-and-comment approach. And worse, it destroys the teacher–learner bond and promotes a culture of insincerity.
Nobody is so clueless they can’t see through the general vagaries of positive feedback that couch a lot of nastiness. For certain fellows, it may provoke a lot of unneeded stress and anxiety as they wait for the crap part of the sandwich. Nevertheless, the allure is so great I often find myself tempted to say, “Good job.” Whenever I do, I swallow those words and express my observations about why I felt the learner did a good job.
6. Express appreciation (but don’t call it feedback): That’s not to say anyone should become a feedback robot. Whenever I’ve seen exceptional behavior, I make sure the learner knows how much I appreciate it. Often, I inform the program director and division chair about such commendable personality characteristics. But this isn’t feedback, and I make sure I say so. Expressing appreciation is a way to build a culture of positivity and sincerity to ensure the feedback is effective. Moreover, everyone likes to work and learn in an environment in which their contributions are acknowledged and respected.
