“The resident evaluation committee is concerned that Josh's sarcasm could be disruptive to team dynamics as he progresses from intern to senior resident.”
Sarcastic—I've heard this before and I don't like it as my sole descriptor in this context. I've never been furnished with any specifics, and I don't agree with this assessment of me. I do, however, employ a certain amount of sarcasm, but many of my peers are more sarcastic than I am, and I don't think this is the feedback they receive.
I am confident. On occasion I am (unintentionally) arrogant. Of course I think I'm right. If I thought I was wrong, I would be doing things differently. I am, however, acutely aware of where I am in my training. I know that I am often not right. It is your job to show me that I am wrong and how I may be right. I can take this, I promise you. I depend on this.
I am competitive. I want to be smarter. I want to acquire more knowledge, and I want to take better care of patients.
I am challenging. I will ask for clarification. I will play the skeptic. I will bring up opposing viewpoints if I have them. Going with the flow does not necessarily change things for the better: best-selling author, Malcolm Gladwell, calls this “disagreeableness,” and claims that it is a necessary trait of innovators.1
I ruthlessly prioritize. I am passionate about the things that I care about, and I am indifferent to the things that I do not care about. My priorities can certainly change, and do quite often. You may not agree with how I have prioritized something, but I consider an appropriately arranged priorities list to be 1 of the primary goals of my medical education. I am realistic; I know that there are gradations. I'm working on my comfort level within the shades of gray.
Excellent feedback has long been recognized as a key to growth and learning for medical professionals. In Dr Jack Ende's 1983 seminal article on feedback in medical education, he outlined a set of doomsday scenarios for a medical system that failed to properly provide feedback to its learners, and wrote that: “Without feedback, mistakes go uncorrected, good performance is not reinforced, and clinical competence is achieved empirically or not at all . . . the student whose reaction to uncertainty is one of overdependence or arrogance may gain a totally unwarranted sense of approval.”2 The importance of feedback is further highlighted in a 2006 meta-analysis3 that showed that physicians with the most confidence in their abilities often had the lowest competence—not only are we incapable of accurate self-assessment, the correlation seems to be inverse.
The specifics regarding content of excellent feedback and its ground rules for delivery were outlined by Dr Ende2 in 1983 and are still germane today—most notably, feedback should be well-timed and expected, it should be based on specific firsthand information or witnessed behaviors and not on generalizations, and it should be limited to behaviors that can be remediated.
Feedback that deals in the abstract or future (ie, “could be disruptive”) is poor feedback. Feedback on personality (ie, “sarcastic”) is poor feedback. Feedback on personality, when the cogent personality traits are mischaracterized is something altogether different—it is maddening.
Feedback is important, and Dr Ende2 has given us guidelines for its quality, but at the end of the day, what is the point of feedback in our medical education system? Why do we even go through this exercise, which too often seems antagonistic? I would say that the point of the individual feedback that I have received was to identify something (or many things) in my medical practice that needed attention. I consider this feedback about my sarcasm to be a mischaracterization, and when received feedback did not suggest any ways to improve, I found it to be extremely frustrating. On the other hand, this feedback did achieve its objective, by identifying something real that could be tweaked to make me a better physician.
The identification of this “something real” prompted a great deal of self-reflection—a mentor of mine calls this “metacognition.”4 Self-reflection is perhaps the most critical aspect of the growth process, and is entirely incumbent on the learner. Feedback about my sarcasm was not delivered in the exact manner I would have preferred, but it's out there now. People that I love, respect, and admire said this about me. So, what should I make of it?
I am not sarcastic. I am challenging, sometimes to the point that I need to remember my place and keep my mouth shut. I am confident, sometimes to the point of arrogance, and I need to remember that my medical knowledge is miniscule. I am competitive, sometimes to the point that I need a reminder we all play for the same team. I ruthlessly prioritize, sometimes to the point that important things do not even get my attention. I can identify examples when all of these were true, and how I hope to handle them differently in the future.
After much self-reflection, I decided not to focus on changing my sarcasm at all. Instead, I made a concentrated effort to tone down my intensity, and not take the contrarian argument just for the sake of it. I also made a concentrated effort to stay humble without losing my confidence, and to keep our team working toward common goals.
With these changes in my attitude, I had 1 of the best months of my entire residency. I hope that teachers will continue to improve on the delivery of their feedback; if learners will take even imperfect feedback seriously and pursue self-reflection, the dividends can be enormous. If the point of feedback is to highlight something that can be changed for the better and to somehow induce that change, then I received truly excellent feedback.
References
Author notes
Joshua Cowgill, MD, is PGY-4 Internal Medicine–Pediatrics Resident, Departments of Internal Medicine and Pediatrics, Maine Medical Center.
