The Negativity Tendency

The late Hans Rosling gave an amazingly popular TED talk back in 2006 (and many other popular talks since). You may have seen it. It’s the one showing recent human progress by following counties over time as a series of bubbles. It’s not all rosy, but it shows us how counterintuitive reality can be compared with our usually grimmer assumptions. One could summarize: things can be bad but still be improving. Trajectories matter.

In his follow-up book, Factfulness, Rosling discusses the fact that almost all “news” by definition is bad news. His helpful grounding suggestion: When you hear bad news, ask yourself if similar good news would be able to reach you.

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In healthcare, M&M is full of bad outcomes. Do you hear about the patients who recover uneventfully in the hospital? Not really. Do people gossip about the patients who go home after surgery with well-healed incisions? No, they do not. As a radiologist, I only hear about my misses. About once a year, someone congratulates me on a good catch, and usually, that’s coming from another radiologist who read the follow-up.

As an attending evaluating my residents’ overnight work, I have to grade every change. We have grades for verbiage changes, incidental additions, small relevant misses, and big emergent misses. There’s nothing forcing me to tell my residents that I recognize the great job they’re doing tackling a large volume of complex cases. Most of what they see is negative feedback, even though that parade of bad news doesn’t really tell them an accurate story about the work they’re doing.

When I was a resident, my program had a separate grade for doing an amazing job. You could receive a coveted “1” on the 1-4 scale for crushing a subtle case, performing at a subspecialty level, etc. 1’s were rare.

One evening as I logged in for another shift, I was reviewing my grades from the night before and I saw I’d received a 1. Exhaustion aside, I was always excited when I earned a 1. The comment said, “Everyone deserves a 1 every now and again, so here’s yours.” I didn’t know how to parse that cryptic statement, so I clicked on the link to see the case.

It was a completely normal head CT in a young patient.

I hadn’t changed a word of the template.

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We learn medicine through the slow accumulation of emotional microtrauma. As an educator, it takes special effort to try to really teach through praise and positive reinforcement; usually the vague “great jobs” show up on end-of-rotation evaluations. I’ll be the first to admit I can be too far on the pedantic curmudgeon spectrum.

Yes, feedback–even negative feedback–is a critical component of the learning process. But, when you’re beating yourself up about your mistakes and questioning your skills/growth, you also need to ask yourself:

What are the odds that I’m receiving the true positive side of the same coin?

The answer is you’re probably not.

Things can be bad and still be improving. Trajectories matter.

You can have a lot to learn and a long way to go and still be doing a great job.

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