Building an Honest Feedback Culture — Part 1
It is 10 am in the Emergency Department. The psychiatry intern completes the patient interview and leaves the room to discuss the case with his attending physician.
After he completes presenting the information he obtained, the attending asks, “What did you say when the patient said his brother died by suicide five years ago?”
“I said, ‘I’m sorry.”
“What was the next thing you asked?”
“I asked about his sleep and appetite.”
“You missed it.”
“Missed what?”
“He told you his brother died by suicide five years ago. You said, ‘I’m sorry,’ and you moved on. That was the most emotionally salient thing he said in forty minutes, and you walked past it.”
“I was trying to finish the diagnostic screen…”
“The screen is a tool, not a script. When a patient hands you something that big, you stop. You sit with it. You say, ‘Tell me about your brother.’ Otherwise, you’re filling out a form. You’re not doing a clinical interview.”
The intern nods, looking at the floor.
“Go back in. Bring it up. Explore its meaning for the patient at the time it happened. Find out what it means for him today.”
Fast forward six hours. Same attending. Department meeting. A colleague has just shared a proposal that, frankly, won’t work. The numbers don’t add up. The timeline is unrealistic. Everyone in the room knows it.
The attending opens his mouth and says, “Interesting idea. Let’s keep thinking about it.”
Same person. Same day. Two completely different communication styles.
What’s going on?
The Easy Answer Isn’t Quite Right
The obvious explanation is that doctors are honest in clinical settings because lives are on the line, and polite in administrative settings because no one’s bleeding.
That’s part of it. But it’s not the whole story.
Watch the same attending at a dinner party. Watch him with his teenager. Watch him with a peer at a national conference. He’s not consistently honest in life-or-death moments and consistently polite everywhere else. Something more is going on.
To understand this, you need to look at three factors that quietly shape who receives honest feedback from us and who does not.
Factor 1: Hierarchy
It’s easier to give feedback to people below us than to people above us or alongside us.
The attending tells the resident she missed the cue. The resident does not tell the attending that he interrupted her too quickly. The department chair tells the new hire that her notes need work. The new hire does not tell the chair that his emails are too long.
This isn’t a doctor problem. It’s a human problem.
Parents will gladly edit their kid’s college essay sentence by sentence. They will not edit their spouse’s work presentation in the same way. A manager will tell a direct report exactly where they fell short on a project. She will sit silently through a peer manager’s far worse presentation an hour later.
It is counterintuitive, but hierarchy often gives us permission to be honest (depending on where you sit in it), while equality takes it away.
Factor 2: Responsibility
We find it easier to give feedback when we feel formally responsible for someone’s growth.
An attending will critique a resident’s note because the attending signs the note. An attending will let a peer’s note go uncommented because the attending is not responsible for the peer.
Same person. Same skill. Same setting. The presence or absence of formal responsibility changes everything.
This explains why we will edit our teenager’s college essay but not our adult sibling’s business plan, why we give honest feedback to a protege but not to a peer, and why hospitals require every resident to be evaluated by their attending, but rely entirely on goodwill for peer-to-peer learning between attendings.
When responsibility is structured in, feedback flows. When it isn’t, feedback dies.
Factor 3: Setting
Some environments authorize honest feedback. Others discourage it.
The operating room authorizes honesty. The hallway doesn’t.
The patient room authorizes it. The committee room doesn’t.
The M&M conference sort of authorizes it. The post-conference lunch doesn’t.
The setting sends a signal: honesty is either welcome or it feels awkward. Most professional environments default to the second message, so being honest often feels like going against the flow.
This Is Everywhere
Pause and notice that what I’ve described is not unique to medicine.
The family that critiques a teenager’s grades and tiptoes around a grandparent’s failing memory.
The relationship where one person gives notes on the other’s wardrobe but rarely on their parenting.
The friend group that roasts each other for hours but cannot tell one member that he drinks too much.
The boardroom where everyone agrees with the CEO and then disagrees with each other in the parking lot.
The pattern is universal. We give honest feedback within the structures that authorize it. Outside those structures, most of us go quiet.
Toastmasters, The Place That Solved It
Here’s what makes this puzzle personal for me.
I joined Toastmasters a couple of years ago. I realized very early that it is the most fun learning environment I have ever been part of. It took me almost two years to figure out the reason.
If you’ve never been to a Toastmasters club meeting, here’s the part that surprises people. Every speech is publicly evaluated. Your fellow club members stand up and tell you what worked, what didn’t, and what to try next time. The evaluator might be twenty years older or twenty years younger than you. They might be a CEO or a college student. None of that matters. Everyone evaluates everyone.
And it is, hands down, the most enjoyable couple of hours I spend every couple of weeks.
Why?
Because Toastmasters has quietly addressed all three factors I just described.
The hierarchy is flat. A senior member’s speech can be evaluated by a newer member, and no one thinks that’s strange. The CEO and the college student trade notes as equals.
The responsibility of giving feedback is shared. In every meeting, multiple people volunteer for roles that make them responsible for someone else’s growth:
- The Timer reports on every speaker’s use of the allotted time.
- The Grammarian reports on grammatical errors and on the use of the “word of the day.”
- The Ah-counter reports on the use of filler words.
- The Speech Evaluators evaluate each prepared speech.
- A General Evaluator evaluates the whole meeting.
The second half of every club meeting is entirely devoted to feedback. You do not have to find the courage to be honest because the structure expects it from you before you even arrive.
Take those three factors away, and Toastmasters would be like every other group: polite, awkward, and quietly mediocre. Build those three factors in, and feedback stops being painful and starts being fun.
I did not fully realize how rare this was until I had been a member for a few years. Then I started noticing that nearly every other room I was in — clinical, administrative, or social — lacked what Toastmasters offered. Almost every complaint I heard from other physician leaders about their teams came back to this same missing element.
It’s the experience that has shaped my thinking about feedback culture more than any book I’ve read.
What This Means for Healthcare Leaders
If you want a team that gives and receives honest feedback, you cannot just exhort people to be more candid. You cannot send everyone to a workshop and expect the culture to change.
You have to build the structure.
You have to make feedback expected, not optional. Frequent, safe, and reciprocal. Instead of annual, punitive, and one-way.
That means designing the meeting structures, role definitions, evaluation routines, and language norms so that the three factors blocking feedback in most workplaces are quietly removed.
Most healthcare organizations have not done this. Annual performance reviews are not a feedback structure. Peer review committees are not a feedback structure. M&M conferences are a partial one at best.
What is missing is what Toastmasters has: feedback woven into every gathering. So giving and receiving it becomes a normal part of being in the room, rather than something you have to brace yourself for.
That is a leadership responsibility. It starts with the leader recognizing that the feedback culture they have is one they have built, based on what they require, tolerate, and model.
What’s Still Missing
Building the structure is half the battle. The other half is knowing what good feedback looks like when you actually open your mouth. Even inside the best structure in the world, you still need a framework for the words that come out of you.
That’s where Kim Scott comes in. Her book Radical Candor offers one of the clearest models I’ve found for what honest, caring feedback looks like in practice. We’ll look at that framework in the next post.
This is the first of three posts in Building An Honest Feedback Culture, a short series on what it actually takes to build one in physician-led teams.