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Oby: From the campus of Harvard Medical School, this is ThinkResearch, a podcast devoted to the stories behind clinical research. I'm Oby.

Brendan: And I'm Brendan. And we are your hosts. ThinkResearch is brought to you by Harvard Catalyst, Harvard University's Clinical and Translational Science Center.

Oby: And by NCATS, the National Center for Advancing Translational Sciences.

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There are some elements of medical education that are not taught in traditional medical school. Different cultures have an impact on mentorship, feedback, communication styles, and even clinical practice.

Subha Ramani saw that a formalized training in these areas was lacking for medical students and began her research on health professions education and educational research methodologies. Dr. Ramani is an associate professor of medicine at Harvard Medical School.

Hi, Dr. Ramani. Welcome to the show.

Subha Ramani: Thank you for inviting me. I'm looking forward to this conversation.

Oby: Happy to have you. So you're a professor of Health Professions Education. When did you become interested in studying health education?

Subha Ramani: It's a very good question. I really started-- I mean, I'm a clinician, as you know. And I really started with teaching in the clinical setting, having always been interested in teaching.

So the first thing I did-- and this was way back in 2002-- I wanted to really improve my own teaching skills. I come from a family of teachers, my mother, my aunts, and so on. So teaching was very much in my blood.

But then once I went to attend this course at Stanford, the course provided exposure to a lot of professors of education from the Stanford School of Education. And so I knew that I hadn't even touched the tip of the iceberg in terms of the science of education. And that's when I got interested.

Oby: So you did your medical degree in India. And you studied in Europe and the US. What are some of the ways medical education differs in different parts of the world?

Subha Ramani: Actually, I studied in Europe only for my master's in medical education and my PhD. And it was a blended program. So some of it-- it wasn't like a full-time student. I already was in faculty positions.

However, I can certainly tell you some of the differences, which are in North America, medical education starts after a graduate degree. In much of the rest of the world, it's an undergraduate degree. So you can just imagine going to school, medical school, at age 18 versus 22, 23.

And I will say-- and that's how I went to medical school. I was 17 and 1/2, I believe. So no life experience whatsoever. High school to medical school, then residency, and then so on.

So one might argue-- and I've heard these arguments-- that you're not quite so mature when you go into an undergraduate program. On the other hand, one could counter-argue that you actually spend a lot more time immersed in medical education versus the four years here. So it's hard to say.

And so those are the two big differences. So undergrad versus graduate, and then the time you spend in medical school studying the so-called medicine, subjects of medicine, is shorter here and longer elsewhere. So those would be the two big differences.

And I talked about the mental maturity, or lack thereof. But people will have to decide about that.

Oby: In 2018, you received a PhD in Health Professions Education at Maastricht University in the Netherlands.

Subha Ramani: That's right.

Oby: Your research focused on giving feedback in the context of medical education. Can you tell us about why you were interested in studying feedback in particular?

Subha Ramani: Sure. So one of the-- when I started my own professional development as an educator, as a teacher, and in education, I would say, broadly, one of the areas I definitely thought I was lacking skills in was engaging in feedback.

In fact, you said giving and receiving feedback. And in fact, the result of my research, I don't call it giving or receiving. It's actually engaging in a feedback conversation. It is bidirectional. And so I have gone completely away from, "thou shall give and thou shall receive" sort of feedback. [chuckles]

So one, I got interested because I felt my own skills were lacking. In many Asian countries, and perhaps African countries as well, where the students are much more used to scolding, you never get praise. And so I was quite accustomed to that.

But in North America, the students are not used to that. We better not scold anybody here, right?


Subha Ramani: And I said, oh, I don't think I've been given so-called reinforcing or positive feedback growing up. And therefore, I was not necessarily very skilled at it.

And somebody-- and as part of my professional development, I had to tape myself during a teaching session. And experts would view and debrief. And they said, did you notice you give constructive feedback rather politely and respectfully, but I didn't hear a word of positive feedback.


Subha Ramani: And that started me thinking, oh, well, this is a different beast than I knew. And I started engaging in studying the literature on feedback.

Then a lot of wonderful Canadian education researchers have studied-- gone very much away from the skills of giving feedback, and into the culture of feedback and theories, psychosocial theories, that influence the practice of feedback. And I would say I stood on the shoulders of those giants.

And I said, this is fascinating. And I want to add to the-- advance the field of feedback through that sociocultural lens. And that's the long answer to your question.

Oby: No, it was perfect. I really liked what you were saying about engaging in a feedback conversation, that it's bidirectional.

So I work in Ghana in some schools, sometimes, outside of Harvard. And that is such an interesting dichotomy to see, right? Because I grew up in the US and went to school here.

But I can see exactly what you're talking about. It is true. And it's an interesting conversation to even have with the teachers and the educators there. Younger kids, but same concept.

Subha Ramani: I'm curious, too. In Ghana, is it the same as, say, South Asia or East Asia where teachers might say, well, why should I say anything positive to the students? They are supposed to do good work.

Oby: Exactly. That's pretty much it. [laughs] It's a very interesting conversation we have because ethnically, I'm Nigerian and American. So it's always that kind of two-sided brain. But it's interesting.

Subha Ramani: That is interesting. I always like to bring societal culture into the conversation because it makes us who we are much of the time.

Oby: How is feedback incorporated into medical education?

Subha Ramani: Yes. I must confess that after all the conversation we had thus far, in medical education, it's still very much a, how do you give feedback? And much of the faculty development-- and you may have seen this in the medical school as well-- much of feedback workshops are about teachers giving. It's sort of uni-directional, static, in a way.

And I think people are changing. I'm very happy to say that learners' reflections are getting more and more incorporated, or facilitated in the first place. How do you think you did? How can I help you? So there is a bit of exchange going on. But we still have ways to go before we make it truly bidirectional.

And so I would say in Canada, Australia, and many other countries-- and the US is still, I think, wetting its toes in this-- people are talking about bringing coaching principles to the field of feedback in medical education, meaning, what is coaching?

And people have likened it to, say, sports as well as music. A performance is never gauged without observation, whereas in medicine, we do that. We have our learners coming and reporting after the interview with a patient to us. And we haven't verified every aspect of it, for example.

That's very different than sports or music, where the teacher is observing everything that the learner is doing. So that's one, therefore.

Well, the second issue, or challenge, I would say, is, are the teachers and learners on the same page in terms of expectations? What is your expected performance? Because you need to know that. You need to know what the goal is in order to be able to calibrate where you are right now, and then literally calculate the distance between where you are and the goal, right?

And this has to be a bidirectional conversation between the teacher and the learner. Therefore, I think sharing what are your performance expectations very clearly and concisely, and on both sides, and making the teachers and learners make shared decisions-- just like patients and physicians, for example-- that would be a good thing. I don't think we're there yet because it's often people, one party or the other, confused.

So sharing expectations, and then having teachers being trained to facilitate reflections amongst the learners about their current performance. What is a gap in their performance? And then how can we narrow this gap? That is coaching.

But not just that, "how can we narrow the gap?" What are the steps to narrow this gap? Let's discuss.

And then future opportunities. Go on and try this out. Let's do this again. Or if I'm not going to be working with you, someone else needs to do this again with you.

Oby: Right. So in your research, what did you find about giving and receiving feedback?

Subha Ramani: So there were some interesting findings, I would say. One, I studied it at my medical center, at the Brigham, as you know, and I don't think it's that different than any of the other Harvard-affiliated hospitals, maybe minor differences.

So it was very, very fascinating to see my residents say that there is a culture of politeness. No one likes to hurt anybody else. OK? And therefore, what is a consequence, is nobody gives any constructive feedback.

And some researchers have actually examined all the narrative comments, feedback comments, that medical teachers give to their students. And "a pleasure to work with" is the most common, followed closely by "good job."


Subha Ramani: Neither of those allow the learners to grow. So that's one thing. So there was this.

At the same time, although everyone was polite with each other and didn't like to hurt anyone's feelings, I turned around and asked the learners, do you give feedback to your supervisors, your faculty? And they said no.

So if it's truly a culture of politeness and niceness, then there should be bidirectional conversations. So I find that a paradox. OK?

So we're talking about flattening the hierarchy. We're making the environment a very safe learning environment. And yet we're not getting robust feedback or upward feedback. So there is a paradox.

The other piece of information that I have is to question our medical institutions-- not the learners, not the teachers, but the whole culture of medical education. Are we promoting a growth mindset amongst all learners? A spirit of collaboration, a spirit of, oh, if I fail this time, I'm going to work harder and I will succeed. OK? And I'll grow.

Rather than, how do I look to other people? What is my image? Is someone damaging my self-esteem? Do I look bad compared to my peers?

So I think maybe if you compare 10, 15 years ago, it's much better now. But we definitely have a long way to go. So that's another mindset.

And I would talk about honest, meaningful, bidirectional conversations, which do not necessarily instill judgment on people. It's not that you're a bad person. You're a good person.

But really-- this might be interesting. If you think of babies and their milestones, for example, you don't say, you're a bad baby because you didn't hold your head up at a certain time, right? You just say, you're developing.

So that's how we are as human beings. We are developing. And we're going along at different rates. And we'll all get there. So that's sort of my two big points, I think.

Oby: That's a great way to explain it. Yeah. And we started to talk about this a little bit, about culture and how it may affect receiving feedback. How does culture affect giving and receiving feedback?

And I may have a second question embedded in this because when you were talking, I thought about the dynamics of growing up, of instructor versus student, and the way that that is kind of a cornerstone in most cultures, is that there is a relationship there that you listen. You receive. You listen. You don't usually talk back to the teacher.

And so I'm wondering if we can talk about culture and how it affects giving and receiving feedback, about how that element of-- honestly, kind of worldwide, that's feels like a standard, that there is a position for instructor and student.

Subha Ramani: So glad you said that. So I'll tackle the first question first, which is a culture. And when I say "culture," I was referring to the institutional culture, or the learning culture as it's been, not so much societal culture yet.

But so the learning culture I looked into-- or I applied Edgar Schein, Professor Schein from the business school, his work on culture and organizational culture, which he says there are three levels. One is the unwritten. This is how we are. This is the way we do things. Nobody knows. But then if somebody new comes in, they are indoctrinated with this invisible culture.

And then the next is written expectations and mission statements and visions and values. And that's all over. We can see that in our documents at our institutions.

But then there's a most visible level, which is how individuals behave in an organization. And the behavior is also not just based entirely on the values. And they may, in fact, frequently conflict with the values and the mission, because day-to-day emergencies come up. Challenges come up. Barriers are there to behaving a certain way.

And so there are three levels. And all three levels, in some aspects, may coincide. In some aspects, may completely conflict with each other. So that is one fun aspect of thinking about culture.

So when people say, oh, let's change the culture-- that's impossible. You can change one-- tweak one aspect of culture. And in fact, the management world says-- research, especially research at the business school and other schools, they say it takes two years to change one small aspect of culture. And yet we so easily talk about, oh, let's change the culture.

So that's one thing. It's a big beast. And we have to tackle it one thing at a time, and prioritize what aspects of culture we need to change, we absolutely must change, in order to provide a positive learning environment. So that's the first part.

The second corollary would be that the same learning culture is going to vary in different parts of the world. So I was talking to some of my colleagues in Singapore. And I did one research project with a colleague in Thailand. And the same North American research and feedback, which says nobody wants to say anything impolite to their learners, the Thai professors basically said, no, I won't say anything nice to them.

They're supposed to be good. They're supposed to do good work. And I will point out if there is something negative in their performance. So societal culture comes into a lot.

The second question you asked is very, very, very true, which is the hierarchy, the teacher-learner hierarchy and the positions. In fact, there is a theory called positioning theory, which I'm reading about right now and seeing if I can apply it in future research.

So positioning theory came out of, I think, the world of psychology, obviously, how people interact with each other. So when you and I talk, somehow something in the situation makes us assume a certain position.

So you're the interviewer and I'm the interviewee, for example. And therefore, you think in your mind, my behavior, my language, needs to match that of what I think an interviewer should do. And then I think the other way around, from an interviewee.

So we take positions. And then that drives our speech and actions. And there is a story line that evolves in how we are managing our conversation.

So that is very, very true in our medical education environment, which is hierarchical, which used to be terribly hierarchical. And a lot of institutional leaders are making major efforts to flatten the hierarchy a little bit.

But you're absolutely right. It's never, ever going to go completely away because a teacher is a teacher. A learner's a learner. And there will be that gap, that psychological space.

And you asked, how can you encourage learners to talk back or reflect? It has to come from whoever's holding the higher position. It cannot-- most learners are not going to walk up to the professor and say, I am going to give you feedback on your teaching yesterday. Impossible.

Therefore, the professor needs to go and say, look, here are my goals. This is what I'm trying out. I really want you to not only listen to my lecture or my talk, but also look at, am I achieving my own educational goals? And let me know. So there's growth mindset on both sides.

Oby: Right. Completely makes sense. Power dynamics. Another fun and fascinating conversation I love.

So when thinking about your work and what you're talking about, about the bidirectional feedback, how do you use what you've learned about feedback to improve medical education?

Subha Ramani: So there are, I would say, not me-- although I'm peripherally involved with that group-- but there's a great group, or more than one great group, in Canada, a research group. They are bringing in a lot about relationships, the teacher-learner relationships, and coaching principles and trying to anchor feedback conversations in those two principles.

So in terms of relationship, sometimes you work with the learner for a long time. And then you watch them grow. Their relationships make sense to us, right?

But then if you're only going to work with someone for two days, you can still form a relationship, a working relationship. And I will say the language is going to be, what do you find challenging? How can I help you? I think this-- it doesn't have to be exactly that.

But those two questions can really form an educational alliance with the learner and establish that culture of safety. Right? Which means you're normalizing that the learner is going to have challenges. You're normalizing it, not saying, oh, you're good at this and bad at this. No. But you're normalizing.

I notice these are your strengths. What do you find challenging? How can I help? That is the relationship. And then you observe.

The next should be-- it's called an R2C2 model, two Rs and two Cs. The first is "relationship and rapport." The second R is "reaction." So after the encounter, you sit down, allow the learner to react. How did that go? What did you think went well? What did you think didn't go so well?

And that's reaction and reflection. So we're fostering self-reflection. The person in power has to do this. Tell me what you feel.

And then the first C is "content." So the teacher or the supervisor is now saying what they observed, OK? But then they're doing a check-in. So this is what I heard you say. This is what I heard, the language you used, or this is the body of non-verbals I observed.

Can you tell me why you said this or why you did this? Because without assuming that that was wrong thing to do, we can ask, why did you do that? Just inquiring, gentle, respectful inquiry.

And then come up with a shared decision making towards the end and say, OK, so now we are in agreement. It looks like we're on the same page in terms of what you did, what you said, the whole encounter. Why don't you tell me two or three things you would like to work on for the next time?

Now, moving on to the second C, which is "coaching for growth." Now that you've decided, here are two things to work on, let us discuss how. What are the strategies to work on this and improve?

And there are other models. And another from British Columbia, they describe something called the educational alliance, just like the therapeutic alliance. That's where it was based off of. So essentially at every step, the learner is completely invested and engaged in the conversation, including making action plans.

I think this is where we need to go. I have started incorporating so much of this into my day-to-day practice. And I also started doing workshops which focus on relationships and coaching, not so much on, "let me tell you the million things you did wrong just now." So that's, in a nutshell, I would say, this is what I'm incorporating into practice.

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Oby: That is fantastic, and feels like a model that can be used in many different spaces.

Subha Ramani: Exactly. Exactly.

Oby: Dr. Ramani, it's been so great having this conversation with you. Thank you for joining us today.

Subha Ramani: And thank you very much for this lively and engaging conversation.

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Brendan: Thank you for listening. If you've enjoyed this podcast, please rate us on iTunes and help us spread the word about the amazing research taking place across the Harvard community.

Oby: To learn more about the guests on this episode, visit our website, catalyst.harvard.edu/thinkresearch.