The one cloud on a sunny day: Using emotional intelligence to manage emotions from negative written feedback

Abstract

Physician trainees receive anonymous written feedback about their clinical performance, which can be challenging to interpret. Negative written feedback can evoke a strong emotional response. An educational gap exists on how to handle receiving negative written feedback and the accompanying emotions. Teaching trainees the tenets of emotional intelligence, including emotional self-awareness and self-management, could be an avenue to improve the experience of receiving feedback. Face-to-face coaching may also help improve the emotional experience of receiving written feedback.

Keywords:

• Emotional intelligence
• feedback
• graduate medical education
• medical education

Last spring, an encounter with a resident left me thinking about the importance of managing emotions when receiving negative feedback. Following a summative evaluation, the resident, only a month or so into anesthesia training, came to me distraught stating they received “bad” feedback for the first time. When reviewing the feedback, I scrolled through several positive comments to find a short, vague, unspecific, yet undeniably negative blurb about the trainee’s performance. My reassurances did nothing to alleviate the stress of the situation, as the resident went through endless hoops of mental gymnastics replaying recent clinical interactions to discern what could have prompted the comment and if the feedback held any truth. Without knowing who wrote the feedback, when it was written, or really any context at all, it was challenging to know what to do with the statement while the resident was clearly feeling anxious, defensive, and embarrassed by it. Since every other comment was overwhelmingly positive, I encouraged the resident to let it go. Yet, this is easier said than done, and this one sentence of feedback bothered the resident for months.

This story is not unique. I remember negative comments I received as a resident, often word for word. Many trainees (and attendings) dread opening their written evaluations, which are usually anonymous and aggregated over several months. Although much has been published on how to give and ask for feedback, far less has been written on how to receive the feedback, and specifically, how to handle the accompanying negative emotions that ensue.

Most faculty are familiar with the “feedback sandwich,” a technique that attempts to deliver criticism while protecting the learner’s self-esteem, which has since proven ineffective. The feedback sandwich is a great mnemonic; however, it creates a lot of confusion, although it makes giving feedback less daunting (see what I did there?).¹ Despite its flaws, the feedback sandwich should be credited for its acknowledgment of the emotional process associated with receiving feedback, something often neglected. The intention is to soften feedback, making it easier to receive. However, the format is perceived as lacking authenticity, so like our resident, the receiver does not hear the positives, only the negative portions sandwiched between.

The literature is lacking with regards to the emotional effects of negative written feedback in the health professions.^2,3 One study designed by Saddawi-Konefka et al at our institution included a coach paired with the learner for Learner-Engaged Analysis of Feedback; the coach and resident partner to discuss written feedback in the context of themes or feedback domains. Although emotions are not mentioned in the study, the authors show that learners who engaged in this coaching session had higher satisfaction with their written evaluations.⁴ This technique is still used in our residency program, and during these once-yearly meetings, the resident and program director talk through each individual comment received, both good and bad. Residents categorize the feedback (e.g., technical skills, professionalism, knowledge, etc.), providing a framework for thinking objectively about the comments and how to incorporate them into practice. Perhaps, pairing written feedback with a face-to-face interaction of a coach could mitigate the challenges of receiving negative written feedback by providing learners with additional context that may be lacking in these comments and helping residents focus on overall trends. However, it is important that this interaction is not dominated by the coach. Duitsman et al found that feedback between program directors and residents was more likely to be unidirectional in nature, but when given in a true dialogue, residents were able to better own their strengths and weaknesses.⁵

The Federal Bureau of Investigation cites emotional intelligence as an important feature to leverage when giving and receiving feedback.⁶ The four domains of emotional intelligence are self-awareness, self-management, social awareness, and relationship management.⁷ The two domains of self-awareness and self-management could hold the key to teaching trainees how to handle the emotions related to negative written feedback. Self-awareness can be broken into two main components: internal (how individuals see themselves) and external (individuals’ understanding of how others see them). Both components are key to understanding negative written feedback. Those who cultivate internal self-awareness will be able to get past the unproductive cycle of asking “why” they received negative feedback and focus on “what” they can do to move forward. Those who work on their external self-awareness will understand that they must seek critical feedback from others to be successful.⁸ By doing this, they can better gauge a surprising piece of feedback and take it with an appropriate dose of perspective, rather than it threatening their entire sense of self. Faculty can continue to foster this successful approach by providing timely, specific, and actionable feedback to residents. Additionally, program and departmental leadership can promote a culture in which feedback is perceived holistically and objectively as a mechanism for growth by avoiding punitive responses to individual comments and focusing on overall trends when evaluating residents.

A resident (or attending) with good self-awareness both internally and externally will be able to recognize the emotions occurring while receiving negative feedback and manage them instead of letting them take over. Self-management, if fostered, could allow residents to manage the negative emotions that they previously named as part of their emotional self-awareness. This can be especially challenging for newer trainees, such as our resident, who face higher levels of stress and self-doubt that can lead to a stronger emotional response to negative feedback. Developing early educational opportunities and protected time for residents focused on strategies for incorporating this feedback in a productive way could thus be key. For example, when recognizing that they feel insecure about a piece of feedback, they might take a moment to practice mindfulness or do other self-care (rather than allowing themselves to fall into a negative spiral). A Harvard Business Review article discussing strategies for receiving feedback promotes collecting more data and not rushing to react—both helpful techniques related to emotional self-awareness and self-management.⁹

Strengthening emotional intelligence competency domains may provide an avenue to fortify our trainees as they interpret feedback; however, the best way to do this has not yet been established. Thus, we caution readers from believing that emotional intelligence is the next cure for feedback. Instead, it should be fostered in collaboration with prioritization and protected time to ensure trainees have time to truly develop the skills.¹⁰ Emotional intelligence requires self-reflection and processing time, both of which are often difficult to acquire in a busy trainee schedule. However, the positive effects of professionals with emotional intelligence are numerable and worth the investment.

Disclosure statement/Funding

The authors report no funding or conflicts of interest.