93. Feedback can be hard to give and harder to receive. Here are techniques to do both better.

Feedback comes in many forms and oftentimes we are not even aware that it’s happening. In this episode, medical simulation and communication expert Lon Setnik, MD breaks down the basics of feedback, why cloaked or hidden feedback can be so dangerous, and critical skills for both delivering and receiving feedback.

Guest Bio: Lon Setnik, MD is a community emergency faculty at the Center for Medical Simulation.

Mentioned in this episode: The Awake and Aware Physician conference sponsored by Wild Health. Jan 13-15 Sedona Arizona. Use the code CONSCIOUSPHYSICIAN for 15% off (that’s 15% off the whole package – lodging, meals, the course)

We discuss:

What is feedback?

Feedback is information: at a basic level it is the information the world gives you
about yourself
Feedback is an opportunity to learn
In this context we are talking about interactions between people that are often involve evaluation and can have a negative connotation
Feedback is not a judgment about who you are as a person or an assault on your character

We need evaluation know where we stand

If all we get are appreciation and coaching, we fill in our impression of the evaluation based on those, often incorrectly
Some people can be demotivated by evaluation, where others are motivated
Demotivation can range from having been told one is now good enough or being one is too far from achieving goals.
A master skill for giving feedback is to see if you can help the recipient see that they are in their zone of proximal development – the space between what they can do on their own and what they can do with support and help from others.

Feedback can be cloaked

When feedback happens in the natural flow of a conversation this can be regarded as hidden or cloaked feedback. One example of this is when we don’t say what we are thinking in order to protect the other’s feelings.
Guess what I’m thinking?
- Do you think you might have done something different that time? this approach unfortunately puts their mental energy in figuring you out, what you want, not what they did

Cloaked feedback needs to be recognized for what it is, this can lead to real learning and teaching opportunities
Classic example of being interrupted by a consultant or colleague. That interruption could very well be cloaked feedback to what we have been saying.
True feedback needs to happen in the proper space: this can be in a neutral location, time and especially not in the heat of an emotionally charged moment
When giving or receiving feedback it is important to set some ground rules

The ground rules for feedback

Have respect for the other person
Have high standards for yourself and the other person
Go into the conversation with curiosity
Feedback is not supposed to be confrontational – it is a collegial conversation
It is important to listen to the response that is given when feedback is requested

“Feedback is all just data. We are the ones who superimpose meaning on top of it.”

Rob gets some feedback and we see see it’s dark underbelly

Feedback can elicit a negative emotional response
Hidden feedback or the perception of hidden feedback splits the attention of the conversation and adds an element of emotion
This charged situation dampens the ability to make change and harsh judgment can enter these emotional moments.
This can be heightened by the power dynamics often found in medicine
The attacking style of harsh judgment can shift the conversation into autonomic overload and take the encounter from a learning opportunity to fight or flight situation.
Feedback can start with observations and the intention of creating solutions rather than “a commentary on me as a human being”

Feedback is not mandatory

Be precise when you ask for feedback, are you looking for input or will they get to choose what it is?
You can decide if you want to hear about it at all – sometimes you need to be able to say “Not now.” If you cannot say no then you cannot choose your yeses

Feedback has three forms

Appreciation
Coaching
Evaluation

The Advocacy Inquiry Molecule

A conversational technique or procedure that combines several things together: the preview, the observation, the point of view, and the inquiry
Useful in any situation like negotiation, feedback, debriefing, and conflict management, this approach helps you quickly discover what people are thinking.
The molecule begins with curiosity and a focus on creating solutions
Can be seen as a form of NVC with less emphasis on feelings and needs
Here is the link to our previous podcast on Non Violent Communication

Pendleton model for feedback

This can also be described as an after-action review where we discuss
- What happened
- What went well
- What did not go well
- What can we do differently next time

Self-feedback

We are bad at self-assessment
The difference between single loop and double loop learning – when we focus on why we did something we are more likely to change the behavior next time.
More on double loop learning here, here, and here

Effective receiving of feedback is about the ‘what’ and not the ‘who’

When we begin to separate the ‘who’ from the ‘what’, we can begin to actually receive feedback and model for those around us
Disentangle the relationship from the ideas
There needs to be an opportunity to show that the feedback was received, and that change was enacted

Embrace your hypocrisy

When someone gives you painful feedback, they might be telling you when you are being hypocritical.
We all do it. This is an opportunity to dig deep – why did you say one thing and do another? Likely cultural or identity elements are at play to bring barriers to receiving the feedback. This is a golden opportunity to learn what needs to be overcome for real change to occur.

Barriers to feedback

Relational concerns: it is hardest to give feedback when you are concerned about upsetting someone.
Lack of direct observation: when only the outcome is known, the feedback can be off, or can be too general which is unhelpful.
Trying to move someone too far: narrow, small, achievable pieces are better than wholesale changes.
Self-assessment focused feedback: low-performers over-estimate, high-performers under-estimate (Dunning Kruger, etc.) competence and confidence are not linked.