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#41 Navigating Tough-to-Metabolize Feedback: Strategies and Key Concepts for Educational Leaders

May 29, 2024 | By

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Transcript available via YouTube

With Dana Sall MD, MeD and Allison DeKosky MD

Join us as we discuss responding as a leader when you receive hard to hear feedback with two new guests: Drs. Sall and DeKosky. We cover key points from their respective AIMW24 workshops: “Maintaining PD Wellness: What to Do When the Residents or Faculty are Mad at You,” and “From Whining to Winning: Transforming the Chronic Complainer into a Constructive Champion.”  We specifically highlight the emotional valence related to receiving constructive feedback, extreme ownership and radical transparency, tips for chief residents regarding complaints received, and how to maintain a growth mindset when things get spicy in feedback conversations. 

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Meet our Guests:

Dr. Dana Sall is the program director for the internal medicine residency program at HonorHealth in Scottsdale, Arizona. She has over 10 years of experience in both UME and GME and is passionate about all things Med Ed! 

Dr. Allison DeKosky is a hospitalist clinician-educator who currently serves as Medical Director of UPMC Presbyterian Hospital Medicine. She directs the Hospital Medicine track of the UPMC General Medicine Academic Clinician-Educator Scholars Fellowship and is the APD for Quality and Patient Safety in the Internal Medicine residency program. 

Show Segments

  • Intro, disclaimer, guest bio
  • Updates and Introductions
  • Dr. Sall and Dr. DeKosky’s workshops 
  • Emotional Valence
  • Growth Mindset
  • Psychological Safety
  • Systems Thinker
  • Complaint Triage Framework
  • Seasons of Change
  • Extreme Ownership 
  • Radical Transparency
  • Take-home points
  • Things to Plug
  • Outro

Navigating Tough Feedback as Educational Leaders Pearls

  1. Recognize that experiencing emotions when someone shares a complaint is normal.  Looking at feedback with a growth mindset can help create psychological safety for ourselves and our trainees:  we can give ourselves permission to not be perfect, to make mistakes, and to work together with trainees to address complaints.
  2. Listen authentically to trainees and faculty.  When they know their concerns will be heard without leaders getting defensive, they are more likely to share modifying feedback.
  3. To operate from the perspective of a systems thinker and to remove the emotional time needed to deal with the challenges that come your way as an educational leader, consider using the “complaint triage framework” that breaks things down between no brainers, acknowledgeable, and actionable. 
  4. Use extreme ownership to acknowledge that although you may not be directly involved in a situation, you–as the educational leader– own that outcome.  Taking responsibility when things go wrong is disarming for all involved because it’s no longer a blame game but instead everyone committing to improvement.
  5. Radical transparency–showing end users the why behind all decisions made–can have immediate application to help leaders show stakeholders the complexity of situations. 
  6. Employ the strategy of co-production to address actionable complaints brought to you as an educational leader by engaging key stakeholders (trainees and faculty) from the ground up to produce the innovations.

Navigating Tough Feedback as Educational Leaders Show Notes

Background to guests’ AIMW24 workshops

Drs. Sall and DeKosky reflect on what they enjoyed about the conference, noting specifically the different (positive) energy at AIMW24, and how they came to the topics for their workshops. 

Dr. DeKosky’s favorite part of AIMW24 is seeing the rising chiefs whose energy is palpable. They are smart, excited, and ready to hear about the next best thing AND then do it! AIMW also offers reunions: people reconnecting from across institutions. People are networking, seeing our old friends, and energized by the pockets of excited new leaders (chiefs!).

Dr. Sall shares that last year at AIMW23 she ran into Eric Warm (her co-presenter for the workshop at AIMW24, “Maintaining PD Wellness: What to Do When the Residents or Faculty are Mad at You”). During this conversation (a year ago), they commiserated about how it feels when residents and faculty are angry at you and how hard it is to deal with those emotions. This was the seed for their workshop this year at AIMW24. They realized that everybody probably feels like this, and that they should provide a venue to share those feelings. They wanted to have space for people to learn from each other/crowd-source when you think, “this feedback is hard, what do I do next?”

Dr. DeKosky notes that it’s important for us as future clinician-leaders and current education leaders to remind trainees and faculty that their complaint or tough feedback is rooted in many different problems. Helping people recognize that it’s not about them as the root cause, that we need to be systems thinkers to see that there are many other things involved is integral to managing complaints. Dr. DeKosky came to this area of navigating feedback from her operational leadership role, and her workshop was born out of teaching the important skills of perspective taking and systems reasoning. 

Key Concepts to Navigating Tough Feedback 

Emotional Valence

Everyone in leadership will experience times when the team is upset or you receive tough-to-metabolize feedback. Often our immediate response can be feeling hurt or angry.  Acknowledging the emotional valence during the course of receiving and processing tough feedback as leaders is important.  Dr. Sall reminds us that as wellness and self-care are a core pillar in trainee development, so must it be with faculty.  Looking at the literature, there are many professions discussing emotional wellness of leaders; Brene Brown has great content on the importance of emotional awareness and self care in leadership (Chhaya 2022).

Dr. DeKosky highlights the importance of role-modeling a professional response as a leader because, “if you can’t demonstrate being even-keeled, then you can’t hope for anyone else to feel that way.”  She notes this is especially important for chief residents who are near peers to those they are managing; if you as a leader are mad all the time, it’s hard to lead and not a great example. Important to consider self-reflection (“finding and knowing yourself”) and processing.  Make sure you have an inner circle of trusted peers or mentors with whom you can vent if you’re having strong feelings, before you return to the situation or the person sharing tough feedback. 

Dr. Sall reminds us that there is a space between stimulus and response (quote attributed to Victor Frankl and Stephen Covey), and there is power in that space.  It’s important to take the time to deal with emotions, let things settle, and then come up with concrete plans for action.  Have the patience to recognize that these issues will still be there (when you’ve come through the emotional processing part) and you don’t need to deal with everything right away.  Dr. Sall recognizes that can be tough for her as she feels residents are expecting her to answer things right away, but she’s realized that tomorrow or even the next day is okay to return to those issues. 

Growth Mindset

Dr. Sall’s workshop highlights the role and power of a growth mindset (referencing Carol Dweck’s “self-theories” or mindsets) when hearing tough feedback as a leader.  For more background on this topic, reference our prior Curbsiders Teach episode #10 Holding a Growth Mindset with Dr. Nora Osman.  We ask learners to accept feedback and use that to grow (we aren’t expecting them to be perfect or ‘fully baked’ because that’s what training is for), and yet it’s hard to apply the same lessons to ourselves as faculty.  We need to start looking at leadership through the lens of “I’m going to make mistakes along the way, and I’m going to learn from those mistakes.” Find where your deficits (as a leader and faculty) are, what skills you need to address those areas, and how to build skills over time for competence. Faculty can simultaneously feel pressure to be perfect all the time (just as the residents do) and shame when failing to meet expectations.  Dr. Sall’s workshop named the role of shame, and how to frame the experience as “this is just a skill that I don’t have YET or a task I haven’t succeeded in YET, but I have the tools to be able to do this.”  Dr. Sall puts this into practice by telling her residents, “I didn’t get this quite right this time,” when something didn’t go well.  She hopes this fosters a growth mindset for trainees in their own learning and also role models vulnerability in leadership: I’m not going to get it right every time, but I’m committed to keep on trying to improve.

Psychological Safety

For leaders who want to improve (themselves and their program) and incorporate feedback, psychological safety is a key element to cultivate in the learning environment and in the community you lead.  If your team or trainees know their concerns will be heard in an authentic way without anyone getting defensive, they are more likely to share what’s bothering them, knowing that the leadership has their back.  Psychological safety is also important for leaders; we need to feel safe, too!  We don’t always give ourselves permission to make a mistake or have trust in people not to judge us/the mistake.  Dr. DeKosky emphasizes there’s safety and comfort in sharing challenges with the group and saying, “let’s figure this out together,” especially with a representative democracy (“I’m going to take input and then make a decision” or “we’re going to vote”).   Creating the space to agree or disagree can increase psychological safety.   “I know it’s not perfect, and here are the things I see as part of the problem, what do you think?”  When there’s silence after that question, there’s a problem- your team might not feel safe enough to speak up.   Dr. DeKosky shares the phrase, “What’s the Tone at the Top” to remind us that how we carry ourselves as leaders and how we invite inquiry and feedback is critical (McClintock 2023, Hardie 2022, Edmondson 1999). 

Dr. Sall shares a 2×2 square comparing the intersection between respect and permission. You need to have enough mutual respect among residents and faculty that they feel they can bring up concerns (high safety) and enough permission to be change agents to cross the innovation threshold.  If people are too scared to tell you what’s going on (low respect) or their impression is that they are not a part of fixing the problem (low permission), you as a leader can’t improve.  

Leaders need to authentically listen and not create a 2-problem problem; the first being that you don’t listen, the second being the first problem that your trainee or team came in with in the first place. 

Frameworks 

Systems Thinker

A systems thinker is someone who recognizes the complexity of the system in which we function and that change (and its effects) is not unidirectional.  Multiple factors go into changes we make, and recognizing that allows for the awareness of the complicated world in which we live and work. We can’t reduce hard decisions to something very simple.  Dr. DeKosky discourages people on her team from saying, “Why don’t we just…?” given that if it was that simple, they would have done it already (Henry 2023, Peters 2014). 

“Complaint” Triage Framework

Dr. DeKosky shares a framework that helps to categorize the asks (or “complaints”) and to reduce the emotional time needed to deal with the challenges as an educational leader.  Her workshop reviewed the “complaint triage framework” for educational leaders to break things down between no brainers, acknowledgeable, and actionable.  

No brainers are things already supported by policy; you don’t need to think a lot about it because you already know what to do here. For example, a jeopardy shift assigned to a resident whose family is in town and they are asking to be excused from this. It’s a no brainer: the resident still has to come in because that is the explicit expectation.

Acknowledgeable asks are the “maybe you have a point”- situations where you didn’t think about it in the way the learner is sharing, so you want to look into it more.  An example of this is when ACGME removed the emergency medicine (EM) requirement for internal medicine (IM) residents. Let’s say your program chose to keep the EM rotation, and the IM residents complain that it is a hard rotation because of the weekends and nights.  In this example, Dr. DeKosky reframed the trainees’ concerns to share why the EM rotation was valuable AND simultaneously acknowledging that it was a pain point for residents and there are changes to be implemented based on their feedback.   

Actionable items make it clear that the leader needs to bring stakeholders together and consider this item ASAP.  Examples of this could be program duty hour violations or a resident or faculty member who is at risk or acting erratically.  For these issues, you need to “call in the calvary” to talk to your leadership team about next steps. 

Middle Manager Role

Many in educational leadership (especially chief residents) can be caught in the “chief squeeze” or feeling the middle manager role (Berg 2007). Dr. DeKosky shares her expert opinion to manage the chief squeeze: setting clear expectations at the beginning.  Consider what is the job description, what are your roles?  Program Directors (PDs) and Associate Program Directors (APDs) need to work with chiefs to be as explicit as possible on when leadership needs to be involved and what they want to immediately hear about.  Similarly, anyone in educational leadership roles need to know when and to whom to escalate issues.  When in doubt, just ask.  When the stakes are high (e.g. issues involving resident safety, other services), consult first!  Just as we do this in our clinical roles (“I’m the attending this week, and this is what I want to know about…”), Dr. DeKosky recommends we do this in our non-clinical roles with colleagues, trainees, and early career leaders as well.  

Seasons of Change: “We must think less like managers and more like biologists.” 

Dr. Sall highlights the idea from her workshop that changes occur slowly over time in programs, and trainees or new faculty may only be seeing a small snapshot of what’s happening.  When they come to leaders with a problem to be solved, it can be a tough conversation to share that change can take a lot longer (than expected) to get things right/better than the three years that the resident is there.  The biologist vs manager quote reminds us that while a manager may be task- or Band-Aid-focused, we as leaders need to think more like a biologist to recognize the seasons of change in our programs: that our program won’t look like it does now 5 years from now (and how much it has already changed from 5 years before).  Being able to communicate that good things take time and that we’re here for the journey is key to being an educational leader (Senge 1999).  

Extreme Ownership

Extreme Ownership is the concept that as the leader, you are responsible for every aspect of your team or program.  This comes from the book Extreme Ownership by Jocko Willink and Leif Babin about the lessons they learned as Navy Seals.  The application to medical education, in Dr. Sall’s expert opinion, is that as a PD or an educational leader, there are a lot of things going on that may not be directly related to you (e.g. a faculty-resident interaction that didn’t go well or a resident didn’t match into the fellowship they were hoping for). This lens of extreme ownership encourages us as leaders to say, “I’m going to own that outcome.”  Taking responsibility for an outcome is disarming for all involved because it’s not the blame game but instead you saying that we didn’t get it right and I have a role here to improve things next time. 

Radical Transparency 

Radical transparency is when the leader shows the end users (e.g. residents and faculty) the why behind all the decisions made.  Dr Sall shares an example of a procedural complication that happened with a resident in their program. The leadership response combined extreme ownership (the faculty hadn’t set up the resident for success to safely do the procedure) with radical transparency (showing data around residents’ procedural skills declining over time).  The residents–seeing that even after they were trained up, their skill still decayed over time–were able to have that lightbulb moment around the safety and educational factors to consider before performing a procedure.   Dr DeKosky highlights the importance of transparency in that we as educational leaders need to communicate to stakeholders what we can and can’t control- there may be times we want to support our team with changes, but those are outside of our scope. 

Co-Production

Dr. Sall also highlights co-production in her workshop; the idea that when there’s a problem, you have to get everyone involved in working to address it (Batalden 2016).  If you only use a top down approach, your team will be less engaged with what you’re doing/suggesting.  What makes for more successful change and innovation in health professions education is when you can get trainees and faculty to produce the innovations with you as the educational leader from the beginning and then get feedback.  Dr. Sall gives the example of residents not doing well in the fellowship match; if that’s the case, we need to go to the residents and faculty and ask what kinds of mentorship is needed? What rotations should we offer? How should we integrate away rotations?  You need input and expertise from the end users. Dr. DeKosky shares an example from her institution where residents felt they needed more support with the fellowship match (that seemed incongruent with a successful match list). Their leadership team needed to engage the residents to ask what support they needed and where they thought the problem was (doing a root cause analysis–do they need to do CV and interview practice earlier? Are people uncomfortable with virtual interviews? Is there too much chatter on listservs and there needs to be some control of the narrative)? The same co-production approach can be taken with the annual program survey–triage the things that have been identified, acknowledge that you can’t address all these things, and share the data to co-create next steps.  You could say something like, “feedback shows you weren’t happy with this (e.g. fellowship match prep) and the objective evidence that we have is that it actually went okay.  Is this still something you think we need to focus on or should we triage our time to concerns where we don’t have good outcomes?” Asking also “what support looks like” to residents can help engage everyone in co-production.

Dr. DeKosky mentions the recommendation to chief residents (and all learners/teachers) to find your people: find the people who you can trust because you can’t do this leadership work alone. Your team can come to you and you can be creative together; you can’t do that co-production if you’re taking it on all on your own.

Take home points:

It’s okay to struggle in a leadership position– get meta about having a growth mindset: I have to have a growth mindset about having a growth mindset!

Listen authentically to your residents and faculty. If they’re coming to you with a problem, it’s a good thing because they feel safe bringing it up to you.  It’s normal to have emotions in the moment, but it’s not personal.  Let yourself feel the emotions, but then move on from them, and use the frameworks of extreme ownership and co-production to turn some of that angst into positive action.

Apply a system’s outlook to how you respond to critique once you’ve pulled yourself out of that initial (visceral) reaction.  Continue to recognize the outcome isn’t just you (even though you own it).  You as the leader have the agency to either change it or foster the change with the right people. Autonomy as an educational leader can fluctuate and making sure everyone in your sphere understands the constraints you’re under can help to smooth the process toward meaningful change.

Plugs from Drs. DeKosky and Sall: 

Dr. Sall highlights DEI curriculum work coming out in partnership with their LGBTQ and indigenous communities that they will hopefully be sharing at the next APDIM meeting.  

Dr. DeKosky shares her Clinician Educator Scholars Program fellows, Drs Dylan Yang and Justin Wang, work on psychological safety (how MS3’s feel about being graded and how they are studying for shelf exams, respectively). 


Links

  1. Amazon link to the book called Extreme Ownership by Jocko Willink and Leif Babin

Goal

After listening to this episode listeners will effectively respond to tough feedback in educational leadership roles, fostering professional growth and development.

Learning objectives

After listening to this episode listeners will be able to…

  1. Recognize the importance of managing emotional responses to criticism in educational leadership roles.
  2. Apply actionable strategies to navigate and respond to difficult feedback.
  3. Evaluate frameworks for triaging complaints and balancing consultative decision-making processes in leadership roles.

Disclosures

Drs. Sall and DeKosky report no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Kryzhanovskaya E, Heublein M, DeKosky A, Sall D, Kinnear B. “#41 Navigating Tough-to-Metabolize Feedback: Strategies and Key Concepts for Educational Leaders”. The Curbsiders Teach Podcast. https://thecurbsiders.com/teach.  May 29, 2024.

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Episode Credits

Producer/Writer/Infographics/CME: Era Kryzhanovskaya MD
Hosts: Molly Heublein MD/ Era Kryzhanovskaya MD
Reviewer: Ben Kinnear MD, MEd
Guests: Dana Sall, MD MEd; Allison DeKosky, MD
Technical support: Podpaste
Theme Music: MorsyMusic

CME Partner

vcuhealth

The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit.

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