What Makes Feedback Productive?

When my youngest daughter returns home from acting or dancing rehearsals, she talks about “notes” that she or the company received that day. Discussing them with her, I appreciate that giving notes to performers after rehearsal or even after a show is standard theater practice. The notes may be from the assistant stage director commenting on lines that were missed, mangled, or perfected. They also could be from the director concerning stage position or behaviors, or they may be about character development or a clarification about the emotions in a particular scene. They are written out as specific references to a certain line or segment of the script. Some directors write them on sticky memos so that they can actually be added to the actor’s script. Others keep their notes on index cards that can be sorted and handed out to the designated performer. My daughter works hard during the first part of the rehearsal process to get as few notes as possible, but at the end of the rehearsal process or during the run of the show, she likes getting notes as a reflection of how she is being perceived and to facilitate fine-tuning her performance.

Giving written notes in our offices to our colleagues, trainees, and staff after a day’s work is not likely to be productive; however, there are parts of this process that dermatologists can utilize. The notes give feedback that is timely and specific. They can be given to individuals or to the entire troupe. I also noticed that my daughter appeared to have a positive relationship with the note givers and looked for their feedback to improve her performance. When residents are on a procedural rotation with me, I endeavor to give them feedback every day about some part of their surgical technique to help them finesse their skills. I am not, however, as rigorous about giving feedback concerning other aspects of the practice, and so this editorial serves the purpose of reminding me that giving feedback is an important skill that we can and should use on a daily basis.

There are many guides for giving feedback. The Center for Creative Leadership developed a feedback technique called Situation-Behavior-Impact (S-B-I).¹ Similar to performance notes, it is simple, direct, and timely. Step 1: Capture the situation (S). Step 2: Describe the behavior (B). Step 3: Deliver the impact (I). For example, I have given the following feedback to many fellows when they are working with the resident: (S) “This morning when you two were finishing the repair, (B) you were talking about the lack of efficiency of the clinic in another hospital. (I) It made me uncomfortable because I believe the patient is the center of attention, and yet this was not a conversation that included him. I also worried that he would become nervous or anxious to hear about problems in a medical facility.” Another conversation could go: (S) “This morning with the patient with the eyelid tumor, (B) you told the patient that you would send the eye surgeon a photo so she could be prepared for the repair, and (I) I noticed the patient’s hands immediately relaxed.”

These are straightforward examples. There are more complicated situations that seem to require longer analysis; however, if we acquire the habit of immediate and specific feedback, there will be less need for more difficult conversations. Situation-Behavior-Impact is about behavior; it is not judgmental of the person, and it leaves room for the recipient to think about what happened without being defensive and to take action to create productive behaviors and improve performance. The Center for Creative Leadership recommends that feedback be framed as an observation, which further diminishes the development of a defensive rejection of the information.¹

Feedback is such an important loop for all of us professionally and personally because it is the mechanism that gives us the opportunity to improve our performance, so why don’t we always hear it in a constructive thought-provoking way? Stone and Heen² point out 3 triggers that escalate rejection of feedback: truth, relationship, and identity. They also can be described as immediate reactions: “You are wrong about your assessment,” “I don’t like you anyway,” and “You’re messing with who I am.” For those of you who want to up your game in any of your professional or personal arenas, Thanks for the Feedback: The Science and Art of Receiving Feedback Well² will open you up to seek out and take in feedback. Feedback-seeking behavior has been linked to higher job satisfaction, greater creativity on the job, and faster adaptation to change, while negative feedback has been linked to improved job performance.³ Interestingly, it also helps in our personal lives; a husband’s openness to influence and input from his spouse is a key predictor of marital health and stability^.4

In an effort to decrease resistance to hearing feedback, there are proponents of the sandwich technique in which a positive comment is made, then the negative feedback is given, followed by another positive comment. In my experience, this technique does not work. First, you have to give some thought to the appropriate items to bring to the discussion, so the conversation might be delayed long enough to obscure the memory of the details involved in the situations. Second, if you employ it often, the receiver tenses up with the first positive comment, knowing a negative comment will ensue, and so he/she is primed to reject the feedback before it is even offered. Finally, it confuses the priorities for the conversation. However, working over time to give more positive feedback than negative feedback (an average of 4–5 to 1) allows for the development of trust and mutual respect and quiets the urge to immediately reject the negative messages. In my experience, positive feedback is especially effective in creating engagement as well as validating and promoting desirable behaviors. Physicians may have to work deliberately to offer positive feedback because it is more natural for us to diagnose problems than to identify good health.

What impresses me most about the theater culture surrounding notes is that giving and receiving feedback is an expected element of the artistic process. As practitioners, wouldn’t we as well as our patients benefit if the culture of medicine also expected that we were giving each other feedback on a daily basis?

When my youngest daughter returns home from acting or dancing rehearsals, she talks about “notes” that she or the company received that day. Discussing them with her, I appreciate that giving notes to performers after rehearsal or even after a show is standard theater practice. The notes may be from the assistant stage director commenting on lines that were missed, mangled, or perfected. They also could be from the director concerning stage position or behaviors, or they may be about character development or a clarification about the emotions in a particular scene. They are written out as specific references to a certain line or segment of the script. Some directors write them on sticky memos so that they can actually be added to the actor’s script. Others keep their notes on index cards that can be sorted and handed out to the designated performer. My daughter works hard during the first part of the rehearsal process to get as few notes as possible, but at the end of the rehearsal process or during the run of the show, she likes getting notes as a reflection of how she is being perceived and to facilitate fine-tuning her performance.

Giving written notes in our offices to our colleagues, trainees, and staff after a day’s work is not likely to be productive; however, there are parts of this process that dermatologists can utilize. The notes give feedback that is timely and specific. They can be given to individuals or to the entire troupe. I also noticed that my daughter appeared to have a positive relationship with the note givers and looked for their feedback to improve her performance. When residents are on a procedural rotation with me, I endeavor to give them feedback every day about some part of their surgical technique to help them finesse their skills. I am not, however, as rigorous about giving feedback concerning other aspects of the practice, and so this editorial serves the purpose of reminding me that giving feedback is an important skill that we can and should use on a daily basis.

There are many guides for giving feedback. The Center for Creative Leadership developed a feedback technique called Situation-Behavior-Impact (S-B-I).¹ Similar to performance notes, it is simple, direct, and timely. Step 1: Capture the situation (S). Step 2: Describe the behavior (B). Step 3: Deliver the impact (I). For example, I have given the following feedback to many fellows when they are working with the resident: (S) “This morning when you two were finishing the repair, (B) you were talking about the lack of efficiency of the clinic in another hospital. (I) It made me uncomfortable because I believe the patient is the center of attention, and yet this was not a conversation that included him. I also worried that he would become nervous or anxious to hear about problems in a medical facility.” Another conversation could go: (S) “This morning with the patient with the eyelid tumor, (B) you told the patient that you would send the eye surgeon a photo so she could be prepared for the repair, and (I) I noticed the patient’s hands immediately relaxed.”

These are straightforward examples. There are more complicated situations that seem to require longer analysis; however, if we acquire the habit of immediate and specific feedback, there will be less need for more difficult conversations. Situation-Behavior-Impact is about behavior; it is not judgmental of the person, and it leaves room for the recipient to think about what happened without being defensive and to take action to create productive behaviors and improve performance. The Center for Creative Leadership recommends that feedback be framed as an observation, which further diminishes the development of a defensive rejection of the information.¹

Feedback is such an important loop for all of us professionally and personally because it is the mechanism that gives us the opportunity to improve our performance, so why don’t we always hear it in a constructive thought-provoking way? Stone and Heen² point out 3 triggers that escalate rejection of feedback: truth, relationship, and identity. They also can be described as immediate reactions: “You are wrong about your assessment,” “I don’t like you anyway,” and “You’re messing with who I am.” For those of you who want to up your game in any of your professional or personal arenas, Thanks for the Feedback: The Science and Art of Receiving Feedback Well² will open you up to seek out and take in feedback. Feedback-seeking behavior has been linked to higher job satisfaction, greater creativity on the job, and faster adaptation to change, while negative feedback has been linked to improved job performance.³ Interestingly, it also helps in our personal lives; a husband’s openness to influence and input from his spouse is a key predictor of marital health and stability^.4

In an effort to decrease resistance to hearing feedback, there are proponents of the sandwich technique in which a positive comment is made, then the negative feedback is given, followed by another positive comment. In my experience, this technique does not work. First, you have to give some thought to the appropriate items to bring to the discussion, so the conversation might be delayed long enough to obscure the memory of the details involved in the situations. Second, if you employ it often, the receiver tenses up with the first positive comment, knowing a negative comment will ensue, and so he/she is primed to reject the feedback before it is even offered. Finally, it confuses the priorities for the conversation. However, working over time to give more positive feedback than negative feedback (an average of 4–5 to 1) allows for the development of trust and mutual respect and quiets the urge to immediately reject the negative messages. In my experience, positive feedback is especially effective in creating engagement as well as validating and promoting desirable behaviors. Physicians may have to work deliberately to offer positive feedback because it is more natural for us to diagnose problems than to identify good health.

What impresses me most about the theater culture surrounding notes is that giving and receiving feedback is an expected element of the artistic process. As practitioners, wouldn’t we as well as our patients benefit if the culture of medicine also expected that we were giving each other feedback on a daily basis?

When my youngest daughter returns home from acting or dancing rehearsals, she talks about “notes” that she or the company received that day. Discussing them with her, I appreciate that giving notes to performers after rehearsal or even after a show is standard theater practice. The notes may be from the assistant stage director commenting on lines that were missed, mangled, or perfected. They also could be from the director concerning stage position or behaviors, or they may be about character development or a clarification about the emotions in a particular scene. They are written out as specific references to a certain line or segment of the script. Some directors write them on sticky memos so that they can actually be added to the actor’s script. Others keep their notes on index cards that can be sorted and handed out to the designated performer. My daughter works hard during the first part of the rehearsal process to get as few notes as possible, but at the end of the rehearsal process or during the run of the show, she likes getting notes as a reflection of how she is being perceived and to facilitate fine-tuning her performance.

Giving written notes in our offices to our colleagues, trainees, and staff after a day’s work is not likely to be productive; however, there are parts of this process that dermatologists can utilize. The notes give feedback that is timely and specific. They can be given to individuals or to the entire troupe. I also noticed that my daughter appeared to have a positive relationship with the note givers and looked for their feedback to improve her performance. When residents are on a procedural rotation with me, I endeavor to give them feedback every day about some part of their surgical technique to help them finesse their skills. I am not, however, as rigorous about giving feedback concerning other aspects of the practice, and so this editorial serves the purpose of reminding me that giving feedback is an important skill that we can and should use on a daily basis.

There are many guides for giving feedback. The Center for Creative Leadership developed a feedback technique called Situation-Behavior-Impact (S-B-I).¹ Similar to performance notes, it is simple, direct, and timely. Step 1: Capture the situation (S). Step 2: Describe the behavior (B). Step 3: Deliver the impact (I). For example, I have given the following feedback to many fellows when they are working with the resident: (S) “This morning when you two were finishing the repair, (B) you were talking about the lack of efficiency of the clinic in another hospital. (I) It made me uncomfortable because I believe the patient is the center of attention, and yet this was not a conversation that included him. I also worried that he would become nervous or anxious to hear about problems in a medical facility.” Another conversation could go: (S) “This morning with the patient with the eyelid tumor, (B) you told the patient that you would send the eye surgeon a photo so she could be prepared for the repair, and (I) I noticed the patient’s hands immediately relaxed.”

These are straightforward examples. There are more complicated situations that seem to require longer analysis; however, if we acquire the habit of immediate and specific feedback, there will be less need for more difficult conversations. Situation-Behavior-Impact is about behavior; it is not judgmental of the person, and it leaves room for the recipient to think about what happened without being defensive and to take action to create productive behaviors and improve performance. The Center for Creative Leadership recommends that feedback be framed as an observation, which further diminishes the development of a defensive rejection of the information.¹

Feedback is such an important loop for all of us professionally and personally because it is the mechanism that gives us the opportunity to improve our performance, so why don’t we always hear it in a constructive thought-provoking way? Stone and Heen² point out 3 triggers that escalate rejection of feedback: truth, relationship, and identity. They also can be described as immediate reactions: “You are wrong about your assessment,” “I don’t like you anyway,” and “You’re messing with who I am.” For those of you who want to up your game in any of your professional or personal arenas, Thanks for the Feedback: The Science and Art of Receiving Feedback Well² will open you up to seek out and take in feedback. Feedback-seeking behavior has been linked to higher job satisfaction, greater creativity on the job, and faster adaptation to change, while negative feedback has been linked to improved job performance.³ Interestingly, it also helps in our personal lives; a husband’s openness to influence and input from his spouse is a key predictor of marital health and stability^.4

In an effort to decrease resistance to hearing feedback, there are proponents of the sandwich technique in which a positive comment is made, then the negative feedback is given, followed by another positive comment. In my experience, this technique does not work. First, you have to give some thought to the appropriate items to bring to the discussion, so the conversation might be delayed long enough to obscure the memory of the details involved in the situations. Second, if you employ it often, the receiver tenses up with the first positive comment, knowing a negative comment will ensue, and so he/she is primed to reject the feedback before it is even offered. Finally, it confuses the priorities for the conversation. However, working over time to give more positive feedback than negative feedback (an average of 4–5 to 1) allows for the development of trust and mutual respect and quiets the urge to immediately reject the negative messages. In my experience, positive feedback is especially effective in creating engagement as well as validating and promoting desirable behaviors. Physicians may have to work deliberately to offer positive feedback because it is more natural for us to diagnose problems than to identify good health.

What impresses me most about the theater culture surrounding notes is that giving and receiving feedback is an expected element of the artistic process. As practitioners, wouldn’t we as well as our patients benefit if the culture of medicine also expected that we were giving each other feedback on a daily basis?