Radical Candor in Medical Education

From the August 4, 2023 issue of the Transformational Times

Radical Candor in Medical Education 

 

Kathlyn E. Fletcher, MD MA – Program Director, Internal Medicine Residency 

 

 
Dr. Fletcher highlights a Kern offering to new interns to prepare them for their role as educators. These sessions took place during orientation and combined a workshop on how to show learners that they matter with a workshop on how to give effective feedback.  These are the building blocks of medical education radical candor ...

 

My introduction to radical candor 

 

I first heard the concept of radical candor from my sister Julia, who is a retired Navy intelligence officer. I must have been talking with her about how hard I thought it was to give feedback, when she got out a piece of paper. She drew a 2 x 2 table that is the central figure in a book about how to be a great supervisor. She explained that to give impactful feedback, you must 1) care about the person you are talking to and 2) be honest.  

 

I proceeded in my usual path to change -- somewhat slowly. I bought the book Julia was referring to called Radical Candor by Kim Scott and started reading it. I got about halfway through before I dropped it in the bathtub and decided that I had read enough to “get” it.

 

A few concepts in the book specifically resonated with me.  

 

First, the quadrant in which we care about the person, and we are honest is called “radical candor.”  The quadrant in which we care about the person, and we are NOT honest is called “ruinous empathy.”  

Ruinous empathy struck a chord because I thought about all the times that I had convinced myself I didn’t need to be completely honest in my feedback. Phrases went through my brain like, “I’m sure she will get better; it is so hard being a July intern.” Or “It’s impossible to know everything as a third year medical student; I am sure he will fill in that knowledge eventually.”  I spent SO MUCH time in ruinous empathy.   

 

As I began trying out radical candor, I came to see that if I believed in someone’s ability to improve, then I had to be honest about how they could do so. I started framing my feedback by saying “I wouldn’t suggest this to you if I didn’t think you were capable of it.” I think many learners were grateful for the careful attention to how they could improve. 

 

Developing medical education radical candor skills in the residents 

 

For the second year in a row, the Kern Institute has sponsored half-day workshops for incoming residents to allow them time to focus on their skills as teachers. In 2022, interns from five residency programs participated. In 2023, thirteen programs participated.  

 

These workshops focused on two skills: how to make learners feel like they matter and how to give effective feedback. Medical education radical candor skills!  

 

The two sessions on “mattering” this year were run by Karen Marcdante/Rachel Ashworth and Andrea Maxwell/Caitlin Patten. 

 

When the facilitators asked participants to describe times on clinical teams when they felt like they didn’t matter, the interns shared poignant moments that have stayed with them for years. The interns also described times that they knew they mattered. 

 

As I sat through these sessions, I noticed how small things made a big difference toward making someone feel that they mattered: calling them by name, giving them meaningful work to do, asking them about their life. Importantly, it doesn’t take long to establish that you care. You can set the stage in less than a minute, which means you can give honest feedback without waiting days or weeks to assure yourself that learners know you care about them.  

 

After the mattering sessions, interns learned how to give effective feedback. Himanshu Agrawal ran one workshop on feedback this year, and Seth Bodden ran the other. Their frameworks for how to give effective feedback included being timely, actionable, and (of course) honest. As with mattering, the intern participants could recall both helpful and not helpful feedback (“read more,” “good job”). Making time and finding space to give personalized feedback is itself an act of caring. 

 

The concept of radical candor reminds us to show learners that we care and that we must be honest in our feedback.  

 

I would take it one step further and say that giving honest, effective feedback is an extension of our caring and demonstrates our belief in the learner’s potential for flourishing in medicine. 

 

It was so freeing for me to realize that if I cared, then I had to be honest. No more ruinous empathy. Bring on the radical candor.  

 

 

Kathlyn E. Fletcher, MD, MA, is a professor in the Department of Internal Medicine at MCW. She is the program director for the Internal Medicine residency program and co-director of the GME pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.  

 

 

 

 

 

 

 

 

Building a Culture of Health in Health Care and our Community

From the August 4, 2023 issue of the Transformational Times

 

Building a Culture of Health in Health Care and our Community 

Kajua Lor, PharmD, BCACP 

 

We as healthcare professionals and leaders need to recognize that to build a culture of health, we must take off our white coats and meet the community… The neighborhoods we live in, the places we work and play, impact the health of our community…

George Floyd. A Black man who died on May 25, 2020, as a white police officer in Minneapolis knelt on his neck for nearly nine minutes. A name that goes does down in history as a flashpoint of inequities faced by people of color and vulnerable communities. A death captured by a bystander on a video that went viral and sparked one of the largest protest movements in U.S. history, as well as a movement within health care.   

Together, George Floyd and the COVID-19 pandemic revealed the true colors of our broken healthcare systems and the inequities faced by people of color and people disadvantaged by the system.   

 

 

My experience as a Hmong American refugee 

 

As a Hmong American refugee growing up here in Wisconsin, I was oftentimes the only person of color in the room, the only woman in the room, the only pharmacist in the room. I struggled with my identities and many times would feel like I was “lucky,” and I was the “underdog” in many of the spaces that I was in personally and professionally. 

 

Being the “first” and or the “only” person made me question if I could be my own authentic self in the spaces that I was in. Early on in my professional career, I would hide myself and my identities as I felt that showing any vulnerability would mean that I may not be good enough.  

 

Since the COVID-19 pandemic, I’ve learned that life is so precious, that there are so many things to be grateful for, that I can show up as my own authentic self and that I need to know my allies, people who support and are able to create positive influences around me.    

 

When I saw the video of George Floyd’s death, I was shocked, angry and, then, sad. I felt disappointed in humanity. How can I influence change? Where is the love for humankind? What can I do to make things better where I live, work, and play? 

 

I remember a white coworker who said to me, “I don’t understand why those Black people are so angry.” And I thought about my own privilege as an Asian American. Why did they feel comfortable speaking with me? Was it because I was Asian American?

 

I remember being part of a virtual listening circle to create safe spaces to hear from others from the MCW community after the death of George Floyd. I volunteered to participate as a note taker for the circle. I appreciated being a part of this circle as I learned from others in the room about their stories. As the only person of color, I realized that this was a safe space with many allies, raised my “virtual” hand, and said, “As an Asian American woman and leader, I experience microaggressions almost every day at MCW. There hasn’t been one week that I have not had a microaggression.”  

 

Microaggressions happen and are real. Psychologist Derald Wing Sue, who has written two books on microaggressions, defines the term: "The everyday slights, indignities, put-downs, and insults that people of color, women, LGBT populations, or those who are marginalized experience in their day-to-day interactions with people.” 

 

Research has shown that microaggressions, although seemingly small and sometimes innocent offenses, can take a real psychological toll on the mental health of their recipients. This toll can lead to anger and depression and can even lower work productivity and problem-solving abilities. 

 

Some microaggressions I have experienced:  

 

• Patients asking me “Where are you from?”  
• Direct reports seeking recognition from male leadership as my recognition as a woman leader was not “good enough.” 
• After returning from maternity leave, a coworker stated, “hope you had a nice vacation.” 
• A staff member referring to Asian Americans as “Oriental.”  
• After sharing that I was attending a blessing ceremony over the weekend, a colleague saying, “Oooooo! Spooky”  
• A staff member’s written comment about a candidate that they “didn’t speak English good enough.” 

 

Mountain or mole hill? I’ve learned to pick my battles. Will I be working with them in the long term? Is it worth it to say anything?  

 

I learned that one of the officers in the video who was a bystander, watching the death of George Floyd, was Hmong. I remember the hatred toward the Hmong community for letting George Floyd’s death happen. Many Hmong were targeted with death threats. It seemed that there was a perception the inaction by one member of the Hmong community reflected the entire Hmong community. 

 

How do we create change with people who “don’t see color?” How do we change when there are differences in opinion on the approach to building inclusion and belonging? How do we learn from one another and embrace our differences? How can we move forward when we remain behind in the work that we do? 

 

Race was created as a social construct, not a biological construct. 

 

We as healthcare professionals and leaders need to recognize that to build a culture of health, we must take off our white coats and meet the community. 

 

According to the Robert Wood Johnson Foundation, “Building a Culture of Health means working together to dismantle structural racism and other barriers so that everyone has the chance to live the healthiest life possible.” 

 

The neighborhoods we live in, the places we work and play, impact the health of our community.  

 

I’ve learned over the years, working with community, that I can be my own authentic self in the spaces that I’m in and that I need to show up when times get tough as an ally for others. 

 

Each of us has a different story and a different walk of life. We need to embrace each other as humans to be able to “see” one another and develop a deeper understanding -- to learn from one another to be able to move forward.  

 

 

Take action: Practice inclusive leadership  

 

Has the needle moved? Progress has been made; however, the journey has just begun and will continue to be a long one. Many hospitals and healthcare systems have expanded positions and resources to support health equity efforts. Many organizations have provided more budgetary resources and infrastructure in efforts to build health equity.   

 

At MCW, the Office of Diversity and Inclusion developed the Inclusive Excellence Framework. This framework showcases how we all can create communities of safe spaces for others to ensure all feel they belong.   

 

We must develop inclusive leadership skills. Inclusive leadership is defined as “leadership that assures that all community members feel they are treated respectfully and fairly, are valued and sense that they belong, and are confident and inspired.” (“Workplace Inclusion Network – Reflections from our Virtual Roundtables ...”) 

 

Strategies to practice inclusive leadership:  

• Take time to make a personal connection with your team and your patients (if applicable). 
• Develop topic discussions with your team that incorporate inclusive leadership principles. 
• Describe resources for health and well-being. 
• Address fears – listen with empathy. 
• Cultivate compassion for yourself and others.  

 

Spend some time to reflect on equity, diversity, and inclusion:  

• What does diversity mean to me?  
• "When have I or someone else been treated equally, but should have been treated equitably?" (“Discussion Guide DEI: The Basics – Part 1”)  
• Think of a time when you felt excluded. What were your feelings? How did they impact you?  
• Think of a time when you felt included. What were your feelings? How did they impact you?  
• How can I help others to be/feel included? Valued? 

 

Take action:  

In the next month, what one action will I commit to that promotes diversity, equity, and/or inclusion? (i.e., “I will engage in a conversation with someone whose opinions differ from my own.”) (“Discussion Guide DEI: The Basics – Part 1”)  

 

For further exploration: 

 

• This Day in History: George Floyd is Killed by a Police Officer
• Robert Wood Johnson Foundation: Why Build a Culture of Health?

Resources from the MCW Office of Diversity and Inclusion: 

• MCW Office of Community Engagement Introduction and "Quick Links"
• Inclusive Excellence Resources
• Resources to Read and Watch
• MCW Anti-Racism, Equity, Diversity, & Inclusion Glossary

Videos: 

• Reggie Jackson: A History of Race 

Kajua Lor, PharmD, BCACP, is Founding Chair/Associate Professor in the Department of Clinical Sciences at MCW School of Pharmacy. She is a clinical pharmacist at Sixteenth Street Clinic, a federally qualified healthcare center serving Spanish-speaking communities one day per week. Dr. Lor was a fellow of the Robert Wood Johnson Foundation Clinical Scholars Program from 2017 – 2020, a leadership program to build healthier and equitable communities. She is a community-engaged researcher building a culture of health with Hmong refugees.