How to get people to do what you want

Aka It Took Me 24 Years to Learn How to Give Effective Constructive Criticism

I have been doing this wrong. For decades. 

Despite the fact that I have had a passion for teaching, mentoring and coaching for 24 years, I only learned this week in July of 2024 how to effectively give constructive criticism. Thankfully, a business podcast by Leila Hormozi finally taught me the difference between critiques that shut people down and those which build people up.  I am very excited to share it with you today. 

What is even more interesting is that she even framed it in such a way that I realized that my standard method of giving feedback makes people feel bad or insulted instead of helping them get better or critiqued. And this mindset has been part of the reason that my method of communicating sometimes results in shutting down the people I was most trying to help.

I also have to say that my idea of helpful and direct feedback has also not resulted in words of adoration from my wife or children and I never really understood why my good intentions were not being understood.  Until now.

When I was in training, I had many great mentors and colleagues who were invested and thoughtful and kind, but the standard method to give feedback was mostly negative with many comments sounding like “you need to do a better job of…”.  (this is the PG version 🙂)

In an attempt to do a better job, I joined many people who pivoted to the feedback sandwich. However, as this became the model for “constructive criticism” a number of problems emerged. 

1. The feedback sandwich often feels inauthentic or manipulative and wasn't a great way to foster  trust
2. This approach dilutes the impact of your message - diminishing the positive feedback that you are imparting and minimizing the areas where you are looking for improvement
3. The sandwich method may create confusion about the actual areas needing improvement.

My AHA Moment comes NOW.

• Critique Don’t Insult

With that in mind, Leila recommends that instead of telling people what they are doing wrong (i.e. insulting them) that we focus on comparing their performance to ideal performance (i.e. critique them)and educate them while giving them specific things to work on to improve.

And it's that simple. I seriously cannot believe that I never understood this!

Even more ironic to me is that this is exactly what I hope to get when I ask for feedback. 

So put into action, examples of bad feedback might be:

• You didn't do a good job with the HPI during that clinic visit 

Or a slightly better version might be

• You need to do a better job documenting pain in the HPI

However, an example of good feedback would more likely look this this:

• When interviewing the patient about pain, be sure to include a description (using the patients words) about the character (such as sharp, dull, burning, or cramping), severity, location, onset, and exacerbating and relieving factors.

Unfortunately I can tell you that i have given lots of feedback that sounds exactly like the bad example. So, if you are reading this and I did this to you - I AM SORRY!

With this basic concept in mind, I want to give you a few pointers that I gleaned so that we all do a better job giving useful feedback that helps people get better. 

• Be direct about areas needing improvement without unnecessary sugarcoating
• This allows people to focus on the behavior and the solution
• Clearly state the observed behavior or outcome that requires attention
• Giving general feedback does not allow people to fully understand your concerns and makes it far less likely that your critique will allow them to improve

• Explain the impact of the behavior or outcome on patient care, team dynamics, or personal growth

• This gives people context and allows them to remember your feedback better, as stories can be powerful memory aids
• Give the feedback comparing the observed behavior to the ideal and what would make it better
• This allow them to focus on future behavior and keeps them on track
• Frame feedback in terms of specific actions that can be taken to improve
• You may also find directing people to reinforcing resources can be useful
• Examples are definitely useful

• Avoid generalizations or comments about personality traits

• An example of this might be "Your perfectionism is slowing down the team." which does not provide any actionable feedback or give them tools to improve efficiency or prioritization.
• Another example might be commenting that someone is " a disorganized person" which suggests a fixed trait rather than addressing specific organizational skills that could be improved
• Separate positive feedback from criticism to ensure both receive proper attention
• This is important so that you can reinforce behaviors that are allowing people to excel and they do not get lost in the mix
• Provide resources or suggest strategies for improvement when possible
• Luckily in medicine this is often easy to do

• Real-Time Feedback 

For good measure, Ms. Hormozi also talked about the importance of giving feedback or kudos in real time based on the principle that immediate feedback is more effective in shaping behavior.

There are a number of reasons why it is effective which include:

- Recency: The behavior is fresh in the recipient's mind, making it easier to understand and reflect upon

- Context: The situational factors are still relevant, allowing for a more nuanced discussion

- Reinforcement: Positive behaviors can be immediately reinforced, increasing the likelihood of repetition

- Course Correction: Negative behaviors can be addressed before they become habitual

These tips can be implemented in academic medicine fairly easily by:

- Providing brief feedback immediately after rounds or procedures

- Using quick debriefing sessions after critical incidents or challenging patient interactions

- Implementing a system for real-time peer feedback during collaborative work

• Future-Focused Feedback

Hormozi also advocates for feedback that is oriented towards future improvement rather than dwelling on past mistakes. This approach aligns with the growth mindset and is more likely to motivate positive change.

It has been shown to be effective because it is:

- Constructive: It frames feedback as an opportunity for growth rather than punishment

- Actionable: It provides clear direction for improvement

- Motivating: It focuses on potential and progress, which can be encouraging

- Reduces Defensiveness: By not dwelling on past errors, it can make recipients more receptive to feedback

This aspect can also be Implemented in academic medicine with examples as follows:

- Instead of saying "You misdiagnosed the patient," say "In future cases like this, consider these additional diagnostic criteria."

- Rather than "Your presentation was disorganized," try "For your next presentation, let's work on a structure that highlights key points more effectively."

- Replace "You've been late to rounds three times this week" with "Moving forward, what strategies can we implement to ensure you arrive on time?"

Summary:

Integrating all 3 principles results in the best version of critique or feedback which is given without insulting, in real-time and future-focused. These 3 factors are useful to create a powerful approach to constructive criticism in academic medicine. 

Combined tips regarding how to implement this include: 

1.  Focusing on Immediate Acknowledgment: Briefly acknowledge the behavior or performance as soon as possible after it occurs
2.  Scheduling a Follow-up: If a more in-depth discussion is needed, schedule it as soon as feasible while the event is still fresh. If not, schedule a time to reinforce the new learning. 
3.  Future-Oriented Discussion: In your follow-up, focus the conversation on future improvements rather than past mistakes. This will allow for a productive conversation that does not cause alarm bells for the person being critiqued.
4.  Collaborative Planning: Work with the individual to develop specific, actionable strategies for implementing the feedback in future situations. Ask the person being coached what they think will work best and allow them to come up with the plan so that they are excited and invested in the solution.
5.  Ongoing Support: Offer resources, mentorship, or check-ins to support the implementation of new strategies.

Example:

Immediately after a difficult patient interaction you might say: "I noticed some challenges in that conversation. Let's debrief this afternoon."

During the debrief you can follow up with a conversation that allows them to brainstorm like: "Moving forward, how might we approach similar situations to ensure the patient feels heard while also conveying critical information efficiently? Let's brainstorm some communication strategies you could try next time."

By combining real-time feedback with a future-focused approach, you create an environment that promotes continuous improvement and growth. This method not only addresses immediate concerns but also fosters long-term development of skills and behaviors crucial in academic medicine.

Summary:

 Effective Feedback :

1.  Compare the behavior or outcome to the ideal when giving your critique
2. Include specific steps or information to do a better job next time
3. Give it as soon as possible after the behavior or outcome occurs (Ideally in real time)
4.  Focus on future behavior