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  • Communication,

    Fragile Snowflakes or Feedback-Starved Learners? Finding the Middle Ground in Medical Education

    Faculty today often feel like they’re walking a tightrope when it comes to giving feedback to medical students. On one hand, students consistently express a desire for more feedback. On the other, their responses (especially to constructive or feedback they deem to be more a criticism) can leave educators feeling demoralized, cautious, or even labeled as “toxic.” This tension often drives educators into what Kim Scott calls “Ruinous Empathy”, where feedback is diluted with niceties, lacking the clarity necessary for growth (1,2). 

    Giving meaningful feedback is an emotional labor. It demands vulnerability, courage, and a strong sense of responsibility. Faculty don’t want to be the villain in a student’s narrative, especially in an era where student well-being is prioritized—rightly so—but sometimes conflated with emotional protection from professional critique, and where “negative” feedback, if it finds itself into the student’s narrative record, can reduce opportunities to match for a residency. Yet Scott reminds us that honest feedback doesn’t have to be cruel. In fact, the hallmark of “Radical Candor” is the ability to “…challenge directly while caring personally” (1).

    Consider the now-famous anecdote of Sheryl Sandberg giving feedback to Scott after a successful presentation. After offering praise, Sandberg added, “But you said *um* a lot… it makes you sound stupid.” It was blunt—but it came from a place of trust and investment in Scott’s growth (2,3). The lesson is that radical candor is not about brutal honesty. It’s about building relationships where truth and compassion coexist.

    In medical education, we often talk a lot about the importance of feedback. But what’s missing is what has been referred to as feedback literacy, for faculty AND for learners. Students must be taught how to interpret, process, and apply feedback without collapsing into shame or defensiveness, and to expect it as a significant component towards their professional growth. As Indiana Lee (4) argues, empathy in the workplace isn’t about avoiding discomfort—it’s about engaging with it productively. Emotional responses like frustration and hurt are human. But if students are conditioned to view all constructive feedback as a threat, they will lose invaluable opportunities for learning and increased self-awareness.

    Faculty, too, need support in learning how to navigate these moments. Avoiding critical conversations under the guise of being “nice” is not kindness (1,5). Ruinous Empathy not only undermines student development but ultimately erodes trust. As one study cited by Scott noted, mentors and advisors who challenged their mentees while showing care built stronger, more effective relationships, whether in finance, teaching, or leadership (5,6).

    Psychological safety must be the foundation of educational environments (7). That means faculty must both validate student emotions and hold up a mirror to them. Feedback, as Scott reminds us, is simply information. It’s what we do with it that counts (1). By modeling care and candor ourselves, we can foster a culture where feedback is welcomed as a gift rather than feared as judgment. On the student side, the school must establish and foster the perception of psychological safety by the students and create the environment in which the student learn to expect frank feedback and are given tools to accept it as it is offered. 

    Are students ready to receive honest feedback? Not always. But can they learn to be? Absolutely! The school needs to own preparation of the student to receive and synthesize feedback. Individual faculty need to prepare the student for how they communicate feedback.

    And are we, as educators, ready to stop using ruinous empathy as a shield? Because while it may feel like kindness in the moment, avoiding honest feedback ultimately does more harm than good. 

    Let’s stop confusing kindness with comfort. Real kindness is helping someone grow—even when it’s uncomfortable in the moment. In fact, there’s good evidence that discomfort is a path to growth (8).

    • What do you readers think?  How can we address the following questions?
      How might you create a no-nonsense zone in your teaching or clinical environment—where truth is welcomed and compassion is assumed?
    • When was the last time you withheld feedback out of fear? What might have changed if you had used Radical Candor instead?
    • What would it look like to teach students explicitly how to receive feedback as a professional skill?

    References

    1. Scott K. Video Tip: What is Radical Candor? Learn the Basic Principles In 6 Minutes. Available at https://www.radicalcandor.com/blog/what-is-radical-candor/. Accessed on April 18, 2025.
    2. Steiner W. Radical Candor: The Importance of Guidance vs Feedback. 2017. Available at https://executivecoachingconcepts.com/radical-candor/. Accessed on April 18, 2025.
    3. Raso R. Using Radical Candor. Nursing Mgmt 2018; 49(12):5.
    4. Lee I. What Is Empathy In the Workplace? (Not to Be Confused with Ruinous Empathy). 2023. Available at https://www.radicalcandor.com/blog/empathy-in-the-workplace/. Accessed April 18, 2025.
    5. Scott K. Ruinous Empathy Can Wreck Client Relationships. 2021. Available at https://www.radicalcandor.com/blog/ruinous-empathy-client-relationships/. Accessed on April 18, 2025.
    6. Scott K. What is Ruinous Empathy? Available at https://www.radicalcandor.com/faq/what-is-ruinous-empathy/. Accessed on April 18, 2025.
    7. Johnson CE, Keating JL, Molloy EK. Psychological safety in feedback: What does it look like and how can educators work with learners to foster it? Med Educ. 2020 Jun;54(6):559-570.
    8. Wilson B. Discomfort: A Pathway to Growth. 2023. Available at https://www.psychologytoday.com/us/blog/explorations-in-positive-psychology/202307/discomfort-a-pathway-to-growth. Accessed on April 18, 2025.

    Author: Gary L. Beck Dallaghan, Ph.D.; Alliance for Clinical Education

  • Communication

    What Did You Just Say? Fostering Civil Discourse in Medical Education

    Let’s talk about talking.  It seems given the current environment in the U.S., we’re walking on eggshells, not really sure what we can or should say. These challenges with conversing have resulted in a pressure cooker within academic health centers amongst many other places. Stress, long hours, and differing opinions can sometimes lead to terse discourse (1,2). Whether it’s a vigorous debate during rounds, a classroom discussion has gone awry, or a tense exchange between colleagues, communication seems to be broken. The ability to de-escalate conflict and promote respectful conversations is paramount. As medical educators, we must model and cultivate civil discourse to create a positive learning environment and equip future healthcare professionals with essential communication skills.

    Are you still with me?  Good! In Robert Livingston’s book The Conversation (3), he references cognitive heuristics that we use. A heuristic is a tendency to overweight information readily available in your mind when making a decision. As clinicians, illness scripts are a medical application of a cognitive heuristic. You’ve seen many presenting with nearly identical symptoms, so you immediately go to the diagnosis you believe it is. Without additional contrary evidence to sway you, you proceed to treat accordingly (and of course run the risks associated with premature closure).

    Where cognitive heuristics occur in normal discourse, these have been built over time based on an individual’s experiences and knowledge. When confronted, for example, with an initiative related to diversity and inclusion, their heuristics may lead them to believe diversity of thought is a bad thing, something undesirable. Why? Who knows? The reaction may then be the polar opposite of what you expect and will clearly interfere with what you hope to accomplish. This can even occur in simple conversations.

    The bigger question is how can we break this cycle of high-tension communication? How do we gain an understanding and respect of others’ experiences to converse in a civil manner? How can we carry on conversations that seek to find mutual understanding and maintain mutual respect (even if we do not agree)?

    As you can well imagine, there are a lot of approaches described online. When a conversation becomes heated, it’s crucial to act as a calming influence. Here are some techniques to de-escalate:

    • Establish Psychological Safety: Remind everyone that you’re on the same team and want to find a resolution together. Use inclusive language and express a willingness to work through the issue collaboratively.
    • Ask Open-Ended Questions: Encourage reflection and sharing of perspectives. Instead of accusatory questions, try “Can you help me understand your perspective on this?” or “What’s most important to you in this situation?”.

    Finding common ground is essential for moving past conflict and fostering understanding, which is a key premise of Livingston’s book (3). Probably the most important advice offered in several other articles is active listening. Truly listen to understand, not just to respond. You have to avoid the temptation to be contemplating your response when they are speaking. Pay careful attention to the underlying concerns or values being expressed (4,5). Don’t worry if there’s a gap, a brief silence, in a conversation.

    Livingston’s framework for structuring dialogue to promote deeper understanding and collaboration involves asking deliberate, thoughtful questions to elicit information and encourage reflection (3). These are a few that may help:

    • Start with “What Happened?” or “What’s the issue we’re facing?”: Encourage a factual recounting of events or perspectives to establish a shared understanding of the situation.
    • Move to “Feelings”: Ask about the emotions involved: “How did that make you feel?”. Acknowledging feelings can help de-escalate tension and build empathy.
    • Explore “Identity”: Consider how the situation impacts individuals’ sense of self and their role within the group. This can help uncover underlying motivations and perspectives.
    • Examples of Dialogue-Enhancing Questions:
      • “Can you tell me more about how you see it impacting the situation?”
      • “What would a successful resolution look like for you, and how can we work toward that?”
      • “What are some other approaches we could consider here?”

    The house of medicine has to interact with people of varied backgrounds. Although some of those people may not share any of our own values, it is essential to be able to converse with one another in a respectful, caring manner.

    This Med Ed Chat blog is a bit different, but it felt needed in our current environment. Here are some questions for you to consider:

    • How can we, as medical educators, create a culture that encourages open and respectful dialogue, even when discussing contentious issues?
    • What strategies can we implement to ensure that all voices are heard and valued in discussions about diversity, equity, and inclusion?
    • How can we equip future healthcare professionals to navigate and resolve conflicts that arise from differing perspectives and experiences?
    • How can we prepare when someone is intransigent? What might that conversation look like – especially if you’re the intransigent one?

    Thank you for indulging my musings on this topic.

    References:

    1. May H. Create a CULTURE of belonging. HR Future 2022 (6); 46-47.
    2. Medina FJ, Benitez M. Effective behaviors to de-escalate organizational conflicts in the process of escalation. Sp J Psychol 2011; 14(2):789-797.
    3. Livingston R. The Conversation. New York, NY: Currency, 2021.
    4. Del Bel JC. De-escalating workplace aggression. Nurs Mgmt 2003 (9); 30-34.
    5. Albardiaz R. De-escalating emotions: A process. Educ Primary Care 2017; 28(1):54-55.

    Blog Author: Gary L. Beck Dallaghan, Ph.D.; Administrative Director, Alliance for Clinical Education.