Our most striking finding is that attending physicians usually did not respond in any observable way to the problematic behaviors they identified as red flags for negative attitudes. A precise rate of responding cannot be meaningfully calculated, as both numerator (responses) and denominator (problematic behaviors) are subject to interpretation. But these attending physicians certainly let the great majority of these incidents pass without comment. When they did respond, they relied on nonverbal cues and on three indirect verbal techniques: humor, appealing to learners’ self-interest, and medicalization of interpersonal issues. The generalizability of the particular techniques we observed may be limited by the small number of teams studied in a single setting; however, their common features are consonant with the difficulty of giving specific, critical behavioral feedback.212,3–24
Attending physicians saw explicit talk about attitudes as personal, punitive, and likely to be pointless, and as contrary to their own best interests. The feedback they did offer was subtle and often appeared to go unnoticed or be misinterpreted by learners.
The observed verbal feedback techniques avoid moral language, do not address or assume underlying negative attitudes, and leave room for face-saving positive reinterpretations of the precipitating problematic behavior. There are positive aspects to this strategy, but also hazards. Humor, for example, may convey the impression that the attending physician believes the behavior to have been meant jokingly in the first place, or is at least willing to give the benefit of the doubt to that interpretation. The door is thus opened to a tacit social reorientation whereby learners can change course and behave as if that indeed was what they had meant all along. Unfortunately, as we observed, learners may also interpret humor as endorsing their actions.
Appealing to self-interest cushions implicit criticism in an equally ingenious, though perhaps inadvertent, fashion. Far from being reprimanded for being insensitive to patients, the implication is that the learner, in her hard-working zeal, has neglected herself
by behaving in a way that might bring criticism on her. Self-sacrifice and self-neglect in the pursuit of excellent patient care are powerful shared values in medical training.21
A potential moral criticism is thus given a subtle “positive spin” and transformed into moral praise. It is well established that negative feedback may be more acceptable and effective when accompanied by positive feedback.22
But does such a remarkable transformation of negative feedback into positive feedback represent a legitimate pedagogic tool, or simply avoidance of a difficult but essential task in professional education?
Medicalization serves similarly to put the learner’s motivations beyond reproach, and to move the content of feedback into a domain in which teacher and learner feel more comfortable. Human interaction is discussed, not as a goal in itself, but as a technique that novices must master in order to optimize data collection and patient cooperation. This orientation permits criticism to be recast in terms of the culturally endorsed aim of excellent technical patient care. Behaviors open to criticism are not the products of negative attitudes, but are simply errors. In Bosk’s terms, normative errors—unacceptable lapses in attitude, effort, or obedience to group norms—are reframed as nonnormative ones, as understandable and expected errors in technical performance, resulting from lack of skill and amenable to improvement with experience.25
Such skill-based criticism may be far less threatening to both teacher and learner. But if concerns about how patients are treated are not to be normative in medicine, what is? Translating feedback about attitudes and demeanor into blander, more palatable terms may leave learners with the impression that there are and can be no meaningful standards of attitude or value in the profession.
While attending physicians had well-intentioned and humane reasons for not directly confronting problematic behaviors, their confidence that nonverbal and indirect feedback techniques adequately conveyed their concerns appeared misplaced. Feedback is more readily accepted when it is low in inference—that is, aimed at observable behavior rather than inferred motives.21
Attending physicians may have operated intuitively according to a similar principle. But while their oblique techniques imply little or no judgment on the teacher’s
part, they require extremely high degrees of inference by learners
for their intent to be understood. Ende et al. found that preceptors in an ambulatory setting used similarly complicated and indirect feedback methods that minimized exposing learner errors.23
They point out that although indirect, nonconfrontational feedback helps preserve learners’ self-esteem, it may require too much inference on the part of learners, and therefore may not reliably provide them with the information necessary for accurate self-assessment.23
Ende et al. described this as “vanishing feedback”: the well-intentioned teacher, sensitive to the impact of criticism on the learner, offers feedback so indirect that nothing of value is transmitted.24
Attending physicians predicate much of their reluctance to offer direct feedback on a set of faulty assumptions. First, contrary to the belief that personalities are immutable, the years of early adulthood may be a time of tremendous moral development and attitudinal change.8
The very real pedagogic difficulties of engineering attitudinal change, and the moral difficulties of choosing the changes to encourage, should not be confused with an imagined psychological impossibility of change itself. Second, in the absence of any model of effective moral pedagogy, attending physicians turn to a passive conception of role modeling, which simply demands performing the desired behaviors oneself in the hope that learners will somehow absorb them. But compassion and respect are not discrete, specifiable behaviors; rather, they are expressed in highly complex and contextualized social interactions. Both theory 26
and empirical evidence 27
suggest that role modeling in such complex situations is more effective when teachers call attention to what they are modeling. Attending physicians may need to tell learners explicitly that they value the compassionate treatment of patients, and may need to narrate or review specific instances of deliberate modeling: “Notice that I always pull the curtain before examining the patient”; or “What I was trying to do in there was …”
Third, feedback can be direct yet remain nonjudgmental and positive. Feedback should be ideally descriptive rather than interpretive or evaluative, be undertaken in a collaborative spirit, and offer timely, brief, specific, performance-related information based on first-hand observation of remediable behaviors.24
Feedback, both positive and negative, should therefore be offered in response to individual episodes, not to overall patterns of behavior. Attending physicians could uncouple feedback about problematic behaviors from judgements about good or bad character, either by focusing on observable characteristics of the behavior, or by describing their own emotional responses.22
For example, rather than say, “That was disrespectful of you,” one might say, “You used a term which many people find offensive,” or “I really don’t like that word, because …”
Several institutional changes might facilitate more effective responses by attending physicians. Clinical teaching can be restructured to provide more time to observe learners interacting with patients and more opportunity for longitudinal teacher-learner relationships that might provide a safer context for meaningful feedback. Second, faculty development programs can provide opportunities to learn and practice concrete skills such as giving specific feedback. Third, the dimensions of attitude and role modeling can be built explicitly and seriously into the evaluation and promotion of both faculty and trainees. Fourth, making professional attitudes a frequent and legitimate topic of explicit discussion may help demonstrate their importance. Feedback about attitudes takes place in the context of the “hidden curriculum” that expresses the values of the institution.28
Commitment to compassion and respect must therefore be given conspicuous and credible priority by those in positions of influence.
Finally, perhaps the most important type of modeling is to treat learners with the compassion and respect with which we want them to treat their patients.29
Although there is room in such relationships for discretion and reserve, a high premium must be placed on forthrightness. Respectful professional education provides learners the opportunity to see clearly when their behaviors do and do not meet professional and ethical expectations, and assists them in shaping an identity of which they can be proud.
The central dilemma illuminated by our findings is whether the indirect responses observed are adequate to shape learners’ professional attitudes, or whether more explicit feedback and talk about values are called for. Our observations suggest that attending physicians are missing priceless teaching opportunities, albeit with commendable intentions. We propose that the values to which medicine professes should be made explicit to learners, not swept under the rug. In the absence of outcomes data regarding changes in learner attitudes and behavior, we acknowledge that there is room for honest disagreement over the best ways to provide moral guidance. We hope that our findings spark explicit debate among teaching faculty, and between faculty and learners, regarding the desirability of various attitudes and behaviors, the appropriateness and effectiveness of different kinds of feedback, the nature and impact of modeling, and the content of the hidden curriculum. What is not debatable is our responsibility as teachers of medicine to take seriously the transmission of professional values.