Ethical Issues in Medicine

BY DAVID J. ALFANDRE, MD, MSPH

Last year, I had just finished a frustrating early morning tennis match with my tennis partner. I had not played up to my expectations, was not executing my shots, and felt like I should be playing better. I don’t even remember the score, just that I had played poorly and that it was a disappointing start to my busy workday. On the car ride home, unsolicited, my tennis partner remarked on my game and described elements that could be improved. I was ornery but still confident when I told him, “I didn’t ask you for feedback.” To which he replied, “I’m not giving you feedback, I’m giving you criticism,” which made us both laugh and actually had the intended effect of moving me out of my funk and on to more productive thoughts to begin my day.

This exchange reminded me of the power and value of feedback and the challenges of giving it. From an ethics perspective, giving and receiving feedback are central to quality improvement at both an individual and institutional level. Health care professionals don’t work in a vacuum: They rely on their colleagues to help them continually improve outcomes for patients. Feedback given to patients helps them learn and improve their health. Feedback from patients (often through standardized postvisit surveys) is a central part of the institutional quality improvement process.

Base Feedback on Observed Behavior

There is an ever-expanding literature on how to give thoughtful, effective, and empathic feedback,1,2 including evidence-based techniques to help people learn, grow, and develop to become competent, kind, ethical, health care professionals. When giving feedback, it’s important to do so with adequate privacy. Most people struggle to incorporate feedback in a public setting in front of watchful eyes of others. Feedback should be timely, concrete, actionable, and based on an observation of behavior, not directed at the person, their personality, or other characteristics. For example, saying, “During that last encounter, I noticed that you interrupted the patient multiple times,” is far preferable to, “You seem like an impatient person.” The former focuses on recently observed behavior and can be intervened on, while the latter is likely to feel like a personal attack. Finally, feedback should be given with humility.

A Challenge to Sense of Identity

How to effectively and respectfully receive feedback is the second half of the feedback equation and arguably more complicated. The fundamental challenge that often interferes with fully embracing this important concept is that while many of us understand that feedback can help us to continually learn and develop personally and professionally, it can also feel unsettling and challenge our sense of self. We want to learn and grow, but we don’t want to get hurt.

As my tennis partner demonstrated, we don’t always get to control when and where feedback comes from. It can come unexpectedly or without permission. Therefore, we should be prepared for how we’re going to manage it including setting boundaries when appropriate. The highly readable and useful book, Thanks for the Feedback: The Science and Art of Receiving Feedback Well, provides both a conceptual like talking about it. Thanks for coming out this morning. I’m looking forward to next week.” This is more likely to prompt a supportive comment from him even if his joke was effective and well-timed. Maybe I’ll be ready for feedback the following week.

Consider the Source

There are other points to consider. Just because someone speaks up about your behavior, doesn’t mean they are

Be Clear About Intent

One overarching strategy to address these challenges is to be clear about the intent of the feedback before giving it. Will the feedback be designed to support the learner and highlight what they are doing well, or will it also be used to honestly identify areas for improvement?

Giving and receiving feedback is essential to all of us in the health care profession. Without good information from our colleagues and patients, it becomes much harder to learn, grow, and continually improve. This requires specific skills — skills that can be learned, practiced, and taught. ■ framework for approaching this issue and tips for making it work.3

Feedback may challenge our sense of identity, threatening to undermine our belief in ourselves. We may not be ready to hear what others have to say about our behavior. Or if the feedback is not executed thoughtfully, we may not want the commentary. Perhaps I could have preempted my tennis partner’s comments by letting him know as we left the court, “I felt like I wasn’t playing my best and I don’t really feel right. Sometimes, how we respond to feedback may depend more on the person giving it than the content of the feedback. One’s reaction may be more a function of that particular relationship rather than the validity of what they’re saying. Further, feedback from one’s spouse may elicit a different reaction than feedback from one’s colleague at work. For all of these scenarios, recognizing our initial triggers to the feedback provide the right foundation to use the information productively.

David

J. Alfandre, MD, MSPH, is a health care ethicist and an Associate Professor in the Department of Population Health at the NYU School of Medicine in New York. The views expressed in this article are those of the author and do not necessarily reflect the position or policy of the VA National Center for Ethics in Health Care or the US Department of Veterans Affairs.