Hello, I'm Joan.

I'm a Canadian family physician who also works as a restorative, medical educator, facilitator and coach.

I create spaces that rehumanize the work of healthcare.

I'm creating this podcast to remind myself, as well as anyone else working in a helping profession that that when you are working and caring for your human patients, you are the other human in the room.

Hey there, healthcare Human.

Today's podcast guest is a fellow co founder of the Hippocratic Collective, a brand new podcasting network made by Physicians for Physicians.

I am thrilled to announce that the other human in the room is joining the Hippocratic Collective alongside other physician creators who are are inspired to use their voice to humanize healthcare.

Physicians need to be heard, not just consulted.

Together, we're here to Change that.

Visit HippocraticCollective.org to learn more.

Hello there, healthcare humans.

Thank you so much for coming back for another episode of the Other Human in the Room.

I am so excited to be talking to this particular healthcare human who I've only actually met virtually once before.

But I feel like I know a little bit because I've started following him on Instagram and TikTok and getting into his hilarious content on that platform.

So something you'll probably have heard something before this recording that talks a bit more about the details of how we've come to know each other through this mutual project that's super exciting, connecting healthcare humans.

But through that initial conversation that we had talking with these other co founders of this collective, we're going to be a part of, I.

My ears perked up, Paul, when I heard you talking about your passion for feedback.

And so that is gonna be the main topic, I think, of this conversation.

But before we dive into it, I would love for you to introduce yourself to everyone listening.

Well, it's a privilege to be on and to talk about the thing that no one really likes to talk about, which is feedback and no one wants to be a part of.

But my name is Paul.

I go by Paul.

I made a deal with my nurse that I have to go by Dr.

Tran with my patients and families.

And I say families because I'm a pediatric gastroenterologist.

I'm in, I would say, a 50, 50 situation of my life where I'm 50% clinician, 50% educator, and that's been my platform.

You mentioned TikTok, Instagram.

I have a platform that's really dedicated to medical learners.

So students, residents, fellows, making them feel seen, heard, appreciated.

And my mission is really empower and equip them.

And I try to do that in every single piece of content that I do, whether it's entertainment or education, I try to address them.

And I've been really fortunate to have some educational opportunities.

I'm a co creator, director of a pediatric clerkship.

I teach first and second year med students, do mentor and education research.

So it's been a really cool start to my career.

That's amazing.

Yeah.

I think the topic of feedback, the fact that you're so passionate about it, but like you say, like people don't want to talk about it, they kind of wish it wasn't needed.

I probably not everyone, but lots of people, that's like the general vibe I've experienced as well.

So like you know, as a family physician as well as an educator.

So I'm faculty at my local university and I just took on my first resident to be with me kind of full time this past year and I noticed myself getting kind of like sweaty about.

Oh my gosh.

Oh no, no.

I have to give them feedback all the time.

Even though, you know, I'm a coach, I am passionate about education.

Actually I haven't necessarily had that much experience with like that kind of one on one side by side feedback.

And it was really interesting the kind of like socialized anxiety that came through my head of like, what if I hurt their feelings?

If I don't deliver feedback enough, I'm going to be the reason that they're a bad doctor.

But if I deliver in a bad way, I'm going to traumatize them forever.

Right.

My brain gets very dramatic and I could think of past experiences going through as a learner myself where like I think I would say mostly I like maybe wasn't given that much feedback and then the most memorable feedback I was given was not memorable for good reason.

And I don't know that I actually learned anything other than to like try and hide and not do things around scary, mean preceptors, you know.

So that's the like energy I bring to this conversation.

I also think this would be relevant even if folks aren't medical educators.

Like a lot of us are on teams.

Like I am also like I employ nurses and staff and I am like a colleague as well.

And we also bulk at giving feedback to our team members, to our, to employees.

Even though that's a really great important part of employing people is to give them feedback.

So I imagine that a lot of what you can share with us would apply across like a lot of different ways.

But yeah, I'D love to hear your initial thoughts of just like, what I shared in terms of is my mindset and some of my, like, social anxiety about giving feedback something that you've experienced or heard from others that they experience.

Oh, that was the first thing on the tip of my tongue.

Yeah.

You are not crazy and you are not alone and you're not dramatic.

This is every single person's experience.

Every single person's experience, whether you're in education or not.

The analogy that I use is kale.

Starts with kale.

Okay, tell me.

You'Re a health conscious person, you have kale salad for lunch, you feel great about yourself.

It's a you thing, right?

Like, I could have had the quesadilla, but I chose to have the kale salad.

And you go about your day after eating that, feeling great about yourself.

You see patients, you talk to your team, you have a podcast recording, you're on a teams or zoom meeting.

And then it's not until you, you get ready for bed, brushing your teeth, you realize you've had a piece of kale stuck in your teeth all day.

The nightmare.

Yes, all day.

All day.

And 20 people had the opportunity to say, hey, Joan, just even a little gesture, but no one said anything to you.

So that experience is.

Is probably more common that you mentioned, the not getting feedback than the feedback that shakes your foundation, that makes you question your identity.

It's the absence of feedback.

I think that's more prevalent than the overwhelmingly traumatic feedback.

And it's insidious.

No one calls out lack of feedback.

You can kind of stand up for yourself and say, that feedback that you gave me was inappropriate.

It was discriminatory.

I think it's a lot easier to say that when it's very blatant.

But the absence or apathetic feedback, very difficult to call out.

That's like the first thing I think of.

But the second thing I think of is actually goes back to why I really feel strongly about being called Paul, especially on a healthcare team.

Because if I'm working with my nurse, a team member, anyone, I want to remove even that little bit of friction where if I make a mistake, the difference between Dr.

Tran, I don't think that this was appropriate or whatever, or, hey, Paul, I gotta tell you something.

You know that tiny little bit of friction by having some familiarity to say, Paul removes a little bit of that kind of artificial hierarchy within a team.

So that's my kind of personal style when you, when you mention a team.

I love that.

Yeah, Actually, I think that's an important element to bring in.

Like, why, like, exploring why we hesitate to give feedback.

Right.

Like, depending on our role, either we're the person with power of some kind and we perceive that if we give feedback, it will be almost, like, taken too harshly, or we feel nervous about.

We have.

We haven't found our way to feel comfortable about, like, the fact that there's a certain amount of power or differential or something in the room and, like, how to deal with that.

And on the flip side, if.

If we are feeling whether it's true or not, but we're feeling a power differential in the other direction.

So, like, say we are a learner and we have feedback that we'd like to give to our preceptor.

Or even, like, I think for myself, I work with colleagues who are more senior than me.

And like, certainly especially when I first started, I was like, I'm the new one here.

I can't give them feedback.

Like, like, and I would.

I would feel nervous to do so.

And so, like, kind of naming and finding ways to at least diminish the power differential.

It sounds like that's one of your strategies that helping helps to encourage feedback.

Hey, yeah.

It's called upward feedback.

In the at least medical education literature, when you give feedback to a superior or someone who's precepting, and there's a lot of the obvious reasons why you don't want to do that.

Ramifications.

I think the two things in one study that was done a couple years ago where they interviewed residents was really, I don't want to give feedback to someone who holds my future in the palm of their hand.

Classic.

And I don't want to give feedback to someone wasting my breath when it's not going to change anything.

So it's this fear of ramification and fear of lack of response, I guess.

Yeah.

Oh, that's so interesting.

Yeah.

So what would you say then?

I.

I think one of the best ways then to get over that fear that we may have, like, if we recognize, right, feedback's important.

Right.

Maybe actually speak to that.

Why do you think feedback is important?

Why can't we just keep going on the way that we're going now?

Like, what's missing?

What are we missing out on?

Because we're not taking the time to get skillful with our feedback.

I think we are missing on the thing that's most important to me and my values, my moral code.

Even when I bring in my faith, it's kindness.

To me, kindness is the most important quality.

I have three Boys, a newborn and our family creed.

My wife and I, while we were in the hospital, thought of one.

And kindness is the most important value to us.

We are kind with our words and our actions is kind of the first line of that.

And kindness is mistaken as niceness or they're not interchangeable.

They are definitely overlapping, but it's rectangle square situation.

I think a lot of people think, oh, I want to be nice.

And it's actually in the literature called niceties or politeness concepts.

I want to be nice.

So Joan, I'm going to be nice and say good job.

And say good job.

Whereas kindness, I think is very important.

And kindness can be honest, kind of.

Kindness can be candid.

Kindness can be like, hey, you made a mistake and I need you to be accountable for it.

But here's how I'm going to help you improve.

Here's why it's so important that you are accountable for this mistake, this accident, whatever it is.

So I think we miss out on opportunities to a be kind and to serve other people.

If we don't give feedback, I think we miss out on opportunities to just improve communication and build that flourishing team.

A team should have its own back.

Like each member should be supporting and watching out for every member of their team.

And I think if we can't give the feedback, that communication lapse is actually detrimental to team cohesion and function.

So those are two things.

And then you mentioned coaching.

I think for me, when I think about coaching, a good coach knows how to help their coachee, their client, their student see their own blind spots.

We can't recognize our blind spots.

I think unconscious incompetence, I don't know what I don't know or can't do.

So a good coach or someone who can give me feedback helps me see for myself what I don't know so that I can move from unconscious incompetence to conscious incompetence.

I'm very conscious about what my gaps are.

They don't have to help me fill the gaps.

I think they're just helping me self realize what my gaps are.

And then I can move my own, on my own towards addressing those gaps, whether I need help or not.

I think those are the three things I think about when you miss out on feedback.

And I'm sure there's lots of other things that we're missing out on or we could really benefit from having better conversations.

I think you're just really highlighting how like it's an essential part of being in relationship with whatever relationship you're having, whether it's like, you know, mentor, mentee, relationship, or a staff member or colleague, I mean even patient, clinician potentially in terms of feedback that can be given.

Like if we think holding our tongue is how you maintain the relationship over time, that's gonna build up.

I know for myself, like as an employer, I've learned, you know, you can be like, oh, it's probably fine.

Oh, it's probably fine.

But then what happens is over time, then suddenly you've reached your breaking point and maybe you're more likely to deliver feedback in a way that's less ideal in terms of like out of frustration or even if it's done calmly, you know, if you wait for the year mark when you've lived literally not given any other feedback along the way, the person's going to be blindsided and we've missed out on all those opportunities for them to actually learn and grow along the way.

So the more we retreat from it, the harder it gets.

Plus we also don't have practice doing it.

So then we are probably aren't going to be as skillful at it.

Right.

So that's right.

Probably.

It's probably better than purposeful.

Yes.

Oh my gosh.

Exactly.

And it, and well, as I've practiced doing it more, I've noticed that it doesn't have to feel so scary.

One of the things I would love to know if you have thoughts on is like, if you think about and in some ways, whether it's like diffuse or like facilitate some of like the shame based ideas that can make feedback feel really tricky.

So an idea.

I often see that like learners or people who are still learning, which is literally everyone, like being, being told you've made a mistake depending on that person's like what they have heard before about what mistakes mean about them as a person, like can feel devastating anyway.

Like even if you deliver it kindly, if someone's like, I'm not allowed to make a mistake because of my past experiences, that can still like pack a punch, if you will.

Yeah.

Have you encountered that and what are some of the ways that you kind of think of and manage this idea that we have this really inhuman shame based idea that we're not allowed to make mistakes, we're bad if we make mistakes, we're failures if we make mistakes.

Like that kind of thing.

Yeah.

I promise this is not the approach that I take with my learners, but the first thought I had was actually my son, my oldest son.

So it's not a paternalistic parental relationship.

But again, I Shared that we say above all we need to be kind, that that's our family value.

Well, I think one of the things that my wife and I have really tried to do is speak identity into our son.

Our oldest is five, very conscientious.

He is a incredibly emotionally attuned person.

He can read emotions, he can see emotions on someone's face or in their words and just know exactly.

But he takes on of that emotion.

Yeah.

And what we say all the time is when he does something like mimic his younger brother, the toddler little blurts out something rude, we say, jack, you're very kind.

And what you said just now was not kind, but you are a kind person.

So do you know, do you know how that's wrong or do you see why that's wrong?

Yeah.

And I think that has really been important for us to be able to acknowledge that this does not define you.

This mistake, this incident, this event, however egregious, is not your identity.

Yeah.

And I think a lot of that mindset applies to things outside of feedback.

Right.

Like how many of us fail an exam, a board exam, or the MCAT or like bomb something, and that our identity is like, I will never be a physician, I will never be a board certified blank.

I mean we take that on.

It's kind of like the medical personality, right?

Yeah.

It's so deeply ingrained that like that making mistakes is outside of what is an acceptable part of our identity as physicians.

And you kind of get it in that, of course, the collective goal is to make as few errors as possible.

Like, you know, especially that impact patients.

Of course.

And we are human and we are learning.

And even if we're at the top of our game, errors will happen, surprises will happen, flukes happen.

Right.

So how do you talk about mistakes then with your learners directly?

Well, I think the mindset is progress over perfection.

You can strive for perfection, but you should expect progress, I guess, or maybe the other way around.

But I think the number one thing is acknowledging that.

Well, just from a mathematical sense and semantics that words do matter.

Mistake tells me intrinsically or inherently that it's an exception.

Because if you're making mistakes all the time, that's a problem.

So that is.

Now that's like you.

If you're making mistakes, the majority of the time, something is very wrong globally.

But when I say mistake, you 90 to 99% of the time are like this.

This was erroneous, anomalous, this was exceptional.

I think that is a way to say this is something that is, I Want to be a one off and how do we progress from here?

So one of the ways that I like to do it is again, speak identity.

Hey, you are usually very diligent.

One of the things I've really appreciated is how on top of things you are.

And you really missed some things today.

Tell me about that.

Is something different?

Is there something I can help with?

Point it out.

And it's not the feedback sandwich.

It's not.

You are good, but you did bad, but you are good.

The sandwich, that's a classic.

The sandwich sucks.

Actually, there's a study of third year medical students.

They examined the traditional sandwich.

Good, bad, good or praise.

Constructive praise.

They examined the open face sandwich, constructive criticism and then praise, and then they just did the naked sandwich, which is essentially just constructive criticism.

And interestingly, medical students thought that perceived that the sandwich was better.

They perceived that the more breading there is, the better tolerated the feedback.

That was their perception.

But when they looked at actual assessments, it didn't change outcomes.

So the perception is that, oh, this feedback is more effective, it's more tolerable, but.

But it's actually not effective.

It doesn't change how well the message is received.

If you're sandwiching or not sandwiching.

Is that what you mean?

I guess it is.

I guess the kind of addendum would be it is received better, but it's not implemented or it doesn't affect change any better.

Interesting.

Which ultimately isn't that, isn't that half of the feedback.

Half of the feedback is, as you said, relational communication.

And I want to be able to build, even if the feedback isn't implemented, it's contributing to our relationship and building trust.

The foundation of trust.

Credibility.

Yes.

I think that's half of it.

The other half though is when I'm giving feedback, I want to help affect change.

Yes.

Right at the end of the day.

So I think we need both to support them.

Yeah, yeah.

So what are you as a feedback passionate person, are you aware then of like methodologies of giving feedback that appear to actually support the person to make change?

Like what it's maybe what they're.

They're hearing it, but also like activating them to make changes more effectively?

Yes, yes, yes.

The coolest thing.

The absolute coolest thing.

I read this in Adam Grant's book Hidden Potential.

Oh, cool.

I love Adam Grant.

He is to me one of the foremost thought leaders.

He's a organizational psychologist at Wharton, author, and I think he was the youngest tenured professor at Wharton.

Wow.

Ever.

He.

He explains this Incredible study.

They had kids in the Midwest somewhere.

They had kids across the racial spectrum.

They.

They thought that, well, you know, there are levels of mistrust, and mistrust affects feedback.

Like, if I don't trust the person giving me feedback, I'm not going to take it as well and.

Or implement it as effectively.

So they accounted for that and they said, well, we have this effect, like, can we do something about the feedback?

So they tested something they called wise feedback.

They had, I believe, seventh graders write an essay about their hero.

And the typical school assignment was write the essay and then submit it for revisions and the teacher will revise it and give it back to you.

That's all they had to do.

Optionally, they could give in a second draft based on the teacher's comments, but they did not have to.

It was just, do they turn in their assignment?

And the intervention was kind of genius.

Two sticky notes, randomized and I think blinded.

It was double blinded.

The first control was I am giving you these comments as feedback for your paper.

That's it.

And it was just a sticky note that they put on with the teacher's red pen.

The other sticky note was the wise feedback intervention, which was 19 words.

And Daniel Pink, Adam Grant have talked about these, like, magical 19 words.

I am giving you this feedback because I have very high expectations, but I know that you will reach them or I am confident that you will reach them.

And what did they find?

They found that the students who got the wise feedback, regardless of race, were more likely to turn in a second draft.

So they were more likely to engage with the feedback.

Yeah, but that's not it.

The second part was not only were they more likely to turn in objectively, by a rubric, they were better.

The people who turned in the second draft were better when they got wise feedback.

So it not only affected the engagement with the feedback, but it actually affected change.

So, wow, like, it's.

That blew my mind because like, the, the thought is that, like, again, all these studies are perception, right?

The recipient perceives better.

Oh, the sandwich is so nice.

Oh, like, oh, Dr.

Tran is so kind to give me feedback.

But does it do anything?

Yeah, this, this change and cause.

Cause them to actually improve.

I also wonder, I would maybe not in that study, but like, if, if someone said that to me, I would also feel good.

Like, I wouldn't then be like, what a meanie.

Like that.

To me, in some ways it's.

It's a.

I don't even think it's a compliment or praise, but like, it's it's an affirmative, encouraging coaching.

Like, it's speaking to your belief in the other person to grow.

Like, to me, that can also absolutely be a relationship builder.

But that actually isn't just to soothe, but is to engage.

But like, it still feels like a very like, positive, relational thing to say to a person.

Did they, like, look at perception of the teacher?

You know?

Yeah, I don't know.

I didn't, I didn't look at the discussion as much I should.

But when you say that, I think to myself, it's promoting, not placating.

I'm not just.

Yes.

I'm not just placating you and saying, you did like, here's your feedback.

You did great.

Good job.

Yeah.

There's nothing meaningful about.

I'm investing in you.

Hey, yeah.

I have high standards of you, I have high expectations.

But I also promote, I encourage, I empower.

But the reason it almost is like intrinsically in there, the reason why is because I know that you have the potential for better.

I know that you can do better.

I'm confident that you can do better.

And then I think to supplement that feedback and I'll help you get better.

Right.

Not just by saying this, but I'm going to help you achieve.

I'm going to help you meet those high expectations.

Yeah.

Oh, that's beautiful.

It's really good.

So after reading that, have you, you know, been experimenting with such approaches with your learners?

Like, what does that look like for you?

Has that changed how you've been giving feedback?

Yeah, I tweak it slightly and I kind of do it in a.

I do it in a way where they know, like, it's kind of like with a wink and a smile.

I say, hey, do you want to be good enough?

Are you okay with being good enough?

And that's kind of the wink.

And they're like, no.

I was like, so what do you want to do?

What do you want to be?

Like, what kind of doctor do you want to be?

What kind of endoscopist do you want to be?

I want to be great.

Okay, you want to strive for better?

Good enough is not good enough for you.

You don't want to just be like, eh, my doctor is good enough.

No, I want to be really good.

I want to be excellent.

Okay, great.

Start there, Start there.

We are now on the same page because for.

And if people kind of look at me, you know, and sometimes it's not, it doesn't land right away.

And I'll just be like, well, if you and I Kind of step out of the conversation a little bit and I get a little meta and I say, the reason why I ask is if you want to be good enough, what you're doing is probably going to get you to good enough.

I can give you feedback, I can help get you, I can help get you to where you want to go, but it's really where do you want to go?

And it's eliciting a little bit of their goals.

Because some people don't want to be excellent in that domain.

And these are domain specific, right?

Yeah, I say that broadly overall, but I think it's very important to say, look, if you are a clinician, do you need to have advanced suturing skills and know how to close an abdomen?

No.

So you're going to be fine.

Just be good enough to close in your surgery rotation as a medical student.

Right.

If you are a, look, I'm going to be a uber specialist in this area.

Endoscopy is a huge part of your job, but it's only a kind of cursory job of mine.

I don't need to be excellent.

Good enough for my patients is, okay, great.

I don't need to push to higher, higher, higher, higher standards so I can level the expectation a little bit.

So I start with that.

What is the mutual goal?

Is it excellent?

And then, all right, well, I'm going to hold you to a high standard.

I'm going to have high expectations.

But I know that A, you have the motivation to rise to that standard and meet those expectations and you have the potential to.

So you have the desire and the potential.

And now let me equip you so together we can get there.

I actually hear like multiple really like important points in, in how you've molded and shared it.

One piece of it I think of that I think can get in a lot of people's way is if as the feedback giver, we make assumptions about what someone else's goals or motivations is.

Or it's like, I'm gonna have the same expectations of every person and almost like force everyone to have the same expectations for themselves.

Like there's certain standards where it's like, like literally what's good enough?

What is, you could say mediocre or like, you know, what's the baseline?

That means you're practicing safe care.

And like everyone's got to reach that.

Otherwise maybe they needed remediation or a different profession.

Right.

Like that's fine.

But then assuming everyone's, that's like say, say especially someone who was giving Feedback had perfectionistic tendencies, was like, no one's allowed to make a mistake, so just that that could get in your way.

Right?

And so what your approach is offering is like, it's actually, I can have expectations and I can make an assessment of someone's skill level to assume how well they could do.

But actually just if not more important is like, what is the other person's goals, what motivates them, and then partnering with them and then.

And tailoring your feedback to that.

I can actually think of a few examples.

Like when I was in residency, one of the best things that happened on my, like, OB rotation was the.

When the preceptors would ask me, like, are you interested in like, catching babies or like forever?

Or are you interested in like, getting the experience so you know how.

And I was a get the experience please person.

Like, I was not planning to do OB later on.

I wasn't wasting their time.

They're not thinking they have to like, you know, put.

Put their best foot forward and tell me and teach me all the little nuance.

They're tired, they're overworked, right?

Like, they could then tailor their teaching and experience to me and my goals.

And actually then it's mutually beneficial.

And then if someone else comes along and is like, I'm going to be your future colleague, I actually want to be one of you.

They're going to put a different kind of effort, give different kinds of feedback, and they know it will be effective because they have the right, you know, they're planting the seed in the right kind of soil, if you will.

I just think, oh my gosh, that's.

Something to really consider, right?

Like, if we think it's going to be the same for every person, we've missed out the point of feedback.

Feedback is for the person we're giving it to, right?

So it's in service of them.

So that means we have to know what it is that they want us to help them with.

The operative word you're saying is think about the feed in feedback, the meal.

Everyone has different tastes.

Oh, that's so good.

I love an analogy.

So great.

I think.

And one of the things that we're talking about is actually the biggest implementation practically for both educators and learners that I could talk about.

It actually happened after I gave a grand rounds on feedback.

One of the questions afterwards pertain to one of the kind of practical tips that I gave, which is set goals.

To have an effective feedback conversation, you need to have mutual goals, negotiate mutual goals.

So I told learners, like, set Goals.

I told educators, try to elicit goals and have that conversation before.

And one of the residents raised their hand and we would work together a good bit.

And she said, hey, I love this.

However, practically speaking, we can't set goals when we don't know what your expectations are.

Like, we don't know where to start with goals.

If I'm coming on as someone not interested in GI and I'm doing a GI elective, what's a reasonable goal?

Like, is my goal too lofty?

And then she's like, that mutual conversation is great in theory, but in practice it doesn't really happen.

So how do we do that?

And I thought about it and I said, that's a great point.

So what I have started doing is on the first day with a learner and usually I try to make it so that it's like for the day together or for the week, tailor it to the time that we're going to have.

I tell them, here are two points for you to consider.

Here are my minimum expectations for someone of your level.

Minimum expectations.

So let's talk about a resident that you have.

Right.

Minimum expectations for a family medicine resident.

And I'm like, these are bare minimum foundation.

None of this is groundbreaking.

You should be able to talk with some level of professionalism and politeness to a patient.

You should say, you should be able to elicit their name.

You should be able to say why they are coming in to see you.

You should be able to close the encounter.

You should be able to not be rude.

Like, again, we're talking about bare minimum.

But if I'm tailoring it to more to.

I usually say something like that.

To say like, this is so foundational to understand where I'm coming from.

And then I say, for your level, I expect you to be able to come have an interview that doesn't take the entire visit.

Like at your level of training, if you have a 20 minute visit, I don't.

You should be able to do the interview in at least 75% of the visit.

Five minutes for education, for anticipatory guidance, whatever it is.

I think that you should be able to present to me in a SOAP format with some logical flow.

And I think that you should be able to both verbalize it and then document it.

And that's it.

Foundational.

And I say, is that fair?

They're like, yeah, yeah.

I mean, duh, right?

Usually it's so foundational, that's not a surprise.

But I'm like, is that fair or am I missing the mark?

Here, right?

Yeah, that's the first step.

But then I say, let me tell you what an exemplary resident looks like.

Let me tell you the exemplar.

Now, this is not an expectation, and I clarify that this is not my expectation of you.

This is just what I see collectively from really exceptional residents.

They are anticipating step A through D.

This is my plan for today.

But if this fails, I want them to come back in a month, in two months, if this is my next step.

They're thinking about that.

They are someone who owns the patient.

As in they are saying, hey, you know what, I'm going to go ahead and schedule the call or the follow up.

I'm going to go ahead and send them out.

The paperwork's already done.

I already talked to the social worker, whatever.

They're kind of all the things that I could help with, they're already doing or putting into play.

And the exceptional residents are not waiting for me to talk to the patient when I staff.

They have already run through every single thing and they're like, hey, this preceptor is going to come in and they're just going to wave, ask you if they have any questions.

And then the last part of that is when you hear that, is there any of those things that really stands out to you?

Any one of those that you really want to work towards anything?

Any one of those facets that you think, oh, like, I want to be that, but I'm not there yet.

And that's how we start our goal setting.

So expectations exemplar.

So it's like the ease, expectations and exemplary first and then elicit goals.

Yeah.

And then the encounter and then entertain feedback.

Gotta have another E.

But you wanna, I wanna make it a D, like debrief.

Like just as like, I just love how much this approach, it requires that like initial foundational building.

But that's the piece that like people are like, ah.

Like often by the time we get to feedback, because we haven't built the foundation, we don't really have the relationship.

And then it's just all like, you did this wrong, you did this wrong.

Perhaps they were like, I didn't even know that was an expectation.

Like, literally, I would never have guessed, you know, and like so this way everyone's clear on the parameters in which they're expected to be working.

And so that means they won't be shocked if, if they're actually operating outside of those parameters, they'll at least be at some kind of conversation coming.

Not that you're going to shame them and scream at them, but being like, hey, so remember how one of the baseline expectations is this.

I'm documentation.

I'm noticing that you actually have several open charts and you haven't documented, like, so what's going on there?

Let's talk about that, like, because we've already established it as an expectation, is how can I support you with that?

Again?

It's still not like shaming or making them feel bad or anything like that, but you've already established that this is something that was meant to be a mutual goal.

So then it just makes the problem.

Not them or you, but something you can, like, work on together.

That's right.

That's right.

That's so cool.

I love.

I love that foundational.

I love that foundational.

Do you need to pause one second?

Yeah, one second.

Just now it's getting.

My toddler has his TV volume on a.

I'm, like, trying to.

I'm, like, trying to even hear myself think.

Because before it was just like, background noise, but then it, like, suddenly was like, there's a party happening.

The.

The foundation minimum expectation.

And then the exemplary goal, I think is so great to have up front.

And then revisit, as you said, let's say.

Let's use that resident.

Right.

You mentioned documentation.

And then let's say their goal is.

Let's say their goal is like, I want to think of step A through D.

I want to anticipate complications or things like all the forks in the road if this happens, if thens, then you can come back.

Let's say that resident doesn't finish charts on time.

Hey, Tim, your goal was to anticipate, which I think that you're doing a really good job of.

Remember, though, that one of the minimum expectations, as you said, is documentation.

Yeah.

Now link them together to be effective in anticipating A through D.

One of the important foundational aspects of that is documentation of those things in a timely manner.

And let me tell you why.

Link them and explain.

Give your reason.

Is it because my expectation is I need to bill, or is it something that they could actually take with them?

Here's why it's important, because you might think that and say it to the patient, but you need to make sure that your team knows.

So when this patient calls back in a week and.

And they're calling and talking to your nurse over the phone, and your nurse says, I have no idea what you're talking about.

This contingency plan wasn't there.

Well, Dr.

Blank told me this really important that you have timely documentation because A, it helps the team patients are reading the chart.

B, it helps the patient reinforce what you said.

C, helps you self preservation.

Yes.

In a week you won't remember all the details.

So documentation.

This is why it's really important.

That's why it's foundational for me.

Yeah.

A lot easier to hear than you need to get your charts in on time.

Yeah.

You're making me look bad or something.

Like the reason that's you're shame.

Not only it's shaming, it feels bad and also it like even if shame wasn't a thing though, it totally isn't.

It's so important.

Like even if we're just talking about effectiveness, what actually helps motivate someone to change their behavior.

You're speaking to their motivation and of everyone is self centered.

That is normal.

That is how it is supposed to be.

Like my body and my brain are focused my energy on keeping myself well.

If you, you know.

And so therefore make it mean something to me and then I'm likely to do it because now I understand why it's important for me to do.

That's right.

Yeah.

Yeah.

That's so cool.

I wonder if you have heard but Paul, I don't have time to do all this chatty chatty with all these learners and with all these staff.

I'm busy.

Yeah.

What have you heard that before?

Oh, all the time.

Yeah.

100%.

What's your like counter argument if you will or like what do you to speak to knowing like there's a million things we could be doing with our time.

Why is this an important thing to invest our time in?

I think what is.

What is usually on people's minds is a pain point.

They're bringing up time as hey, the pain point is I have a clinic flow, I have a surgery workflow.

I need to stay in my workflow because at the end of the day it's patients.

Like I can't sacrifice my patient care for this learner's sake.

Like I know it's important but at the end of the day I'm a physician and my patients in front of me I think that people are thinking about the pain point.

So you address the pain point directly.

Well, if time is the pain point because of really at the end of the day it's because of workflow.

What are ways that we can integrate this in the workflow?

Usually people are thinking of the traditional feedback conversation set the stage after clinic.

I don't.

I've got documentation.

I've got a meeting.

I don't have 20 minutes to check in.

How would that go?

What?

You know, I don't have time for that.

Well, eliminate that microfeedback.

You go see a patient right after.

If you think it, say it.

If it takes.

It's like the two minute rule.

If it takes less than two minutes, just do it right there, right then and there.

And that's actually what I do when I staff Fellows Clinic now, right after a presentation.

Hey, that was definitely a lot easier to follow along than the first patient.

I think you're already starting to integrate some of those analogies that we talked about.

I like that.

And I think I can hear that as a patient better.

Cool.

Let's go staff the patient just like that.

And then you can have a much quicker debrief at the end.

Hey, Joan.

At the end of clinic.

Joan, we already talked about this.

I saw the analogies today.

I'm still waiting for.

I'm still not quite hearing you deliver it as well.

You're staffing with me, but in the room together, I feel like the patient needs to follow.

So definitely something to work on for next time.

That could be a goal that we talk about next time.

But I do like how you're already incorporating that just in one clinic session, right?

Yeah.

Very quick.

Very, very, very quick.

You're already talked about goals.

You already talk about expectations to me.

I love as a GI doc, I kind of get to put on my surgeon, you know, my OR cap a little bit, so I get to think like a procedural list, not just as a clinician.

I love this duality that I have in my field.

Well, every single or every single procedure needs a timeout and a debrief.

What if we implemented the feedback educational and I've talked about this timeout debrief.

Yeah.

The timeout is at the beginning of your clinic session.

Hey, these are expectations here.

It's very quick.

It's just go through.

We've got a busy day in clinic 10.

I'm going to have you see these patients when you usually talk about that flow with a learner anyway, you talk about your flow through the day, talk about the educational flow after each patient.

I'm gonna give you just a little bit.

I want you to hold big questions for when we have gaps.

If we have a no show or a cancellation or at the end of clinic, I want to carve out about five minutes to touch base, have that workflow, have those expectations of the actual conversation.

I don't think effective feedback conversations need to take that long.

And I think two minutes is sufficient.

You have two minutes.

Yeah.

You can find two minutes in a morning.

Yeah.

And it's worth it.

Right.

So first of all, if you're going to work with this learner, over time, this is going to help this learner grow and be more effective.

Other times when, like, make it less likely, you'll have to have longer conversations later, if you will.

Right.

And you're investing up front.

Exactly.

And even just thinking globally.

So like now this person, whether they're your teammate or they'll go out somewhere else in the healthcare world because they're a learner and they'll go graduate.

Like, investing in them now means that we're going to have a more activated, empowered, skillful healthcare collective that we're, that we're all working within.

And so it's like making, it's helping your future self have like a colleague.

That's going to be really effective because you've invested little droplets of your time now.

Right?

That's right.

Treat learners like they are the future colleagues, the future consultants, the future people who will consult you.

Treat people like where they're going and not where they are.

That's good.

Is that.

Did someone else say that?

Otherwise you should like put that a T shirt.

I don't think someone has said, I take a lot from thought leaders.

I don't think someone said that.

But a lot of people have espoused on that.

Concepts like that.

But like, we need to do that in medicine.

Like, yeah, I think that's a problem.

That's one of the big problems of training and I think that's how culture changes.

Yes.

Because we are like these learners, they're.

They're just like little.

Well, I remember as a learner, I would off you'd feel like a little like scutt monkey.

You just feel like you're serving the big master.

I.

There were, there certainly were preceptors who viewed me as like, you're gonna be a doctor, you're gonna be a doctor.

Or like, you're a doctor now, you're in, you know, you're in residency, you are my colleague already.

And I felt the difference when they were treating me as like either a future peer or like literally appear that they just have more knowledge than me.

It was a completely different experience than someone who's like, you are my minion for the day.

That's not teaching.

I don't know what we think that is, but no, not my preferred approach.

It's task giving, not teaching.

Ugh.

World of difference.

That, that there's A difference.

And, you know, we're going to go full circle here, because how do you incorporate that in just approaching a conversation?

How do you.

And approaching that level of discomfort?

Yeah.

Well, if you view the learner, the recipient, as a colleague, it shifts the mindset.

Because I hold my colleagues to a higher standard.

Why?

Because they're, you know, they're professionals.

And, like, if I view you as a colleague, I'm gonna feel comfortable if you're my partner in the business.

Right.

Like, hey, I have to have hard conversations with you.

Because we, like, our business, will flounder, will fail if we're not on the same page here.

Same thing.

So one of the ways that we can approach learners as is a.

We can more confidently talk about those high standards and expectations.

But also, I think one of the things I've said is I don't want a night alone.

Like, a night where you're alone and getting this call to be the first time you think about this or the first time you hear about this.

Yeah, hey, buddy.

We got a little glass of milk there or something?

I think when you.

I've heard mentors do that to me, and I've started implementing that.

I don't want this first call a year into being an attending for you, the first time to deal with this emergency.

I don't want you to go into your career and not get feedback and not hear that you do this.

I want to point this out in kindness because I care about you and I care about how good you are.

I want you to do this.

I want to invest in you.

And then I also.

I've also put a lot of.

That's actually how I teach.

I do what's called situational awareness.

I do a lot of.

You have a patient, you get called about this.

A nurse pages you about this.

What do you think?

What do you do?

Put them in the scenario.

It's like verbal simulation.

But I'll say a lot for feedback, too.

Like, you are so close.

You're so much closer to being alone than starting your journey.

And by being alone, like, you realize that you're never truly alone.

You have mentors you can reach out to.

You can always reach out to me, but I won't be making the decision for you.

I'll be giving guidance, but I won't be making the decision.

Yeah.

So let's assume now when.

When I'm here and it's safe, you make the decision.

What are you going to do?

Or you need to make a better decision, or you.

You.

You feel uncomfortable with the decision.

How can we help you with that decision now when it's safe rather than later when you are losing sleep for a month because you think you made the wrong decision decision and giving some of that future thinking, that empowerment of like, hey, I'm thinking about you in a month or you in a year or you in three years rather than you right now.

That's, I think, how we can incorporate this future colleague idea.

I love it.

I feel like that in everything you've said, like that Adam Grant study blew my mind.

And then, and then building on that, like the way of thinking in this future colleagues, like, I think that has just permanently shifted.

Highly feedback.

So thank you.

I won't be alone.

Cuz like, you know, you, you just get in your head and you're like, they're going to feel sad or I'm going to be uncomfortable.

But like, yes, emotions will happen.

People might have reactions.

Who knows?

And like, why is it worth it to work through those?

Why does the, does that mean we don't have to shy away from it?

Like, why is it still important to find a way through?

It's because they are our current or future colleagues.

These are people, people that we will rely on and they will rely on us.

And like, it just, it just really activated the concept for me.

So thank you.

Of course.

Of course.

Yeah.

Lovely.

There's a study, I think it was at the Brigham.

I think it was the Brigham and Women's Psychiatry residents.

I might be quoting the wrong study, but they, they asked.

There was a qualitative study where they asked, they asked what were like, what was the perception of the interaction, the feedback interaction.

And one of the themes that they found in this qualitative study was that the residents are less likely to value or implement the feedback when they feel like the giver doesn't see them as a colleague, doesn't treat them as a colleague.

They're just like, well then it matters less to me.

You're less invested in me.

Yeah, that was one.

And it was like, how well do you know me as a person and a professional?

What are my goals?

So again, all of this incorporates and we've talked about a lot, yet the conversation doesn't have to be like modular.

Like we are now moving from the mutual goal setting expectation to now goal setting, you know, part of our programming.

It can feel very natural.

Like it is just getting to know someone and caring about them as a person.

Yeah, basically.

Okay, I could talk to you about this for like another hour, but I try and keep these to an hour.

So I'm gonna wrap it up.

Thank you so much.

This has been like such a rich conversation is really I feel very empowered to kind of in some ways be more explicit with my feedback.

As in like really think about like that clear, kind specific feedback that is meaningful to my learners in a way that I'm really excited to like do with even more finesse and intention.

The last question I ask any.

Well I guess two questions.

So one would be if folks want to find you, there's going to be a new place they're going to find you and me coming soon.

But beyond that collective space, where can folks find you if they want to follow you, see what you're up to and who and tell maybe talk a bit more about like who your primary audience would be for those spaces.

Yeah.

So my platform on TikTok and Instagram it's easy.

Elementary school, where does that come from?

Elementary is GI tract and in school because me as an educator, like I thought it was a fun pun but elementary school is Instagram and TikTok.

That's my audience there is primarily the learners, students, residents.

I mean it's generational.

That's where generation is the the content that I want to produce on YouTube long form content and whether video podcasts coming and my newsletter and my website are more this educational insights and talking more about from a serious standpoint less entertainment skits and more educational like well there is a problem that you clearly delineate in your shorts.

What can we do about it?

Or how am I empowered as a learner?

So YouTube Elementary School.

My website is the elementary school.com and I have a new substack where I have a newsletter which is elementary schoolubstack.com and I think the name of my newsletter and will be my video podcast too is advances tolerated because we, we kind of feel like a person on a conveyor belt at times.

Enter med school and then you just kind of conveyor belt your way into your job and you're like all right now what?

I hope I got equipped correctly on the way or adequately on the way.

And I think if I can help provide learners especially or you know, my peers with insights, advice, tips and tricks, just anecdotes that help them advance whether through medical training or into their career in a easily digestible format, then I think I think I'm really staying on my mission.

And and I think that's those are the places you can find me and stay tuned.

I love it.

That's also like a pun about scopes though, right?

Like, oh, yeah, like it's part of my, part of my professional contract, like when I became a pediatric GI doc was like, you have to insert at least two to three puns into conversation or practice in a given, like half day session.

I think that is an obligation.

It's, it's like in your writer, if you will.

Like, yeah, that's great.

So good.

All right.

My last question I always ask is thinking about the audience, which some are learners too, actually, and others are, you know, just lifelong learners working in healthcare or adjacent fields that are like they're feeling dehumanized.

They're feeling like they don't know how to be them, their full selves in their workplace because of the pressures of the system.

And I can see, like that's the reason I imagine people struggle with feedback is because they think other things have to come first.

The, you know, that sort of thing.

So any words of wisdom or encouragement you want to give to those listening who may you maybe have heard they listen to a podcast.

They're like, okay, but I'm, I don't, I'm nervous about it.

Or I'm feeling so stressed.

Like, what would advice would you want to give them?

I think the.

I talked a little bit about, about this with our friend and colleague Francis May Harden, who's been on your podcast.

We're workshopping the grammar of this.

But my concept is an idea that just kind of hit me, which is the phrase maybe stop focusing on if you're doing good enough or if you are good enough and think about if you're doing enough good.

Which for me is if you're listening or watching, you're probably like both of us, like everyone thinking at some point through imposter syndrome.

Am I doing good enough to belong next to these giants?

Am I doing good enough to be in this place, to have this promotion?

It might be achievement focus.

Am I doing good enough to be an associate professor, A professor to hold this role, to be tenured, to have this position or title.

And it's very, I think, intrinsically self focused in thinking about feedback and the rest of her career.

If we shift that to thinking about if we're affecting enough change, doing enough good.

Yeah, it focuses on someone else.

Yes.

Other centric.

It's service oriented.

And I think to me, if I'm having feedback with someone, is my feedback good enough?

Well, maybe if I say, I know it will help help them here and I can do some good, that is, that is how can I benefit this person better rather than how, how are they perceiving what I'm saying?

It's less me, it's them.

It's just refocusing on your why, like why are you doing it to begin with?

Because yes, you could listen to a whole conversation about anything like giving good feedback and you could hear great.

Another thing that I get to fail at and even sometimes sort of socializing can condition to think that way and it just doesn't serve us or anyone else because now we are just anxious.

We're worried, we forget that probably we're doing a pretty good job already, honestly and already doing lots of good in the world.

And so while we're doing that good, how can we be most effective?

Probably in a way that ends up saving us time, energy and making it more pleasurable for everyone.

Like your approach sounds like it'll be kind of more fun to do so if we're focused on like the good we're doing through our actions versus how others might perceive us.

Such an important shift to always be reminded of.

Thank you so much.

Oh of course, of course.

This has been a great conversation.

Thank you for having me.

And, and, and talking about something that I think is needs to be talked about more.

It needs to be everywhere.

This is ubiquitous.

It's not just education is it is business.

It is your day to day.

It's as a professional and honestly as a person.

So important.

So important.

I so agree.

All right, well thanks everyone.

Definitely go follow follow Paul in all the places with the puns and for everyone listening, thanks again for joining us and talk to you next week.

Bye bye.

I would love to take this work deeper with you.

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