How to Receive Criticism: Theory and Practice from Cognitive and Cultural Approaches

Abstract

Mistakes in clinical practice may have life-or-death consequences for patients. Training in how to give and receive feedback has been emphasized in medical education for decades, yet medical practitioners continue to struggle with these practices. Giving feedback is difficult because it is not easy for a receiver to receive feedback. Current training programs lack an in-depth understanding of the causes of why receiving feedback is not easy. The purposes of this article are to (1) fill this gap by identifying the shared weaknesses in human nature as the causes underlying the difficulty in receiving feedback, especially criticism, using a cognitive approach; (2) develop logical principles to treat the identified causes; (3) show the shared common wisdom of how to receive criticism through a multicultural approach; and finally, (4) address how these cognitive and multicultural approaches may facilitate receiving criticism in the field of medical education.

Giving and Receiving Feedback are not Easy

Training in how to give and receive feedback is very important in the medical field, where mistakes in medical diagnosis or clinician’s bedside manner may mean the difference between life and death and thus must be corrected. Although this kind of training has been emphasized for decades, medical professionals continue to struggle with these skills [1–6]. Why is the existing training less effective? In this context, this article deals with how to effectively receive feedback, especially criticism, for the following reasons: (1) If a recipient is not well prepared for feedback, giving feedback is not easy or may be less effective as evidenced in the cases provided below; and (2) if adults in the medical profession can be well trained and practiced in receiving criticism, receiving other feedback will not be a problem and giving feedback will be less difficult.

Case 1

A medical student copied the previous day’s patient’s note and made a few minor edits but left outdated information in the plan. The resident who supervised the student admonished the student for his incorrect way of writing the patient’s note. The student was embarrassed and avoided writing a note the next day.

Case 2

A patient arrived at the physician’s office early, then waited an hour to be seen. Once she was in the room, she angrily complained to the resident. The resident was upset and anxious and had difficulty focusing on the issues that prompted the visit.

Case 3

A pharmacist noticed that a physician incorrectly prescribed an antibiotic to which the patient had an allergy. Before filling the prescription, he contacted the physician’s office. The physician spoke angrily to the pharmacist and then sent a different prescription.

Case 4

A new physiology teacher received a low score in student evaluations on a question asking “whether this teacher encouraged students’ questions.” Learning from this feedback, she deliberately allocated specific times for questions during her lectures the next time she taught the class. To her surprise, there was no significant improvement in her score and she felt wronged: “What nonsense! Why are they still complaining about this? These students are so unreasonable.” She didn’t realize that while she was lecturing, she often turned a blind eye to students who raised their hands outside of the allocated question time.

In the first three cases, the recipients were able to realize what was wrong with their responses but lacked the readiness to receive criticism. The recipient in case 4 was originally willing to accept criticism to improve, but because she was not able to realize what was wrong with her behavior, she thought the criticism was wrong. Hence, a recipient’s readiness to receive criticism is not a simple issue.

The difficulty of receiving criticism is also reflected in the coping strategies presented in training materials as well as on the internet. As part of our faculty development, Oakland University William Beaumont School of Medicine’s faculty conducts training every year in how to give and receive feedback or criticism in multiple directions: from clinicians to residents, from course directors to students and course teachers, from students to students, from students to teachers, and so on. Similar training and research on this issue is popular in the field of medical education [1–8]. During this kind of training, trainees are trained to practice the following actions to prepare to accepting criticism: “anticipate,” “keep calm,” “remain an adult,” “listen carefully,” “empathize with your critics,” and “give yourself a confidence boost” [9]. These suggestions prompted us to ask the following questions:

1. Do adults generally have low self-esteem and so cannot keep calm in the face of criticism, thus necessitating a conscious effort to boost their confidence in order to cope?

2. Can a conscious effort truly boost one’s confidence?

These questions are fundamental issues of giving and receiving criticism, but their roots are rarely explored:

• 3.What are the causes of the vulnerability or fragility in adults that prevent them from keeping calm or behaving in a mature and constructive way upon being criticized?
• 4.Is it possible to treat the causes so that adults not only have no anxiety upon facing criticism but are happy to receive it?

In this article, we will identify the common causes underlying adults’ anxiety and unease to receive criticism using a cognitive approach. Based on the identified causes, theoretical and practical principles that logically treat the causes will be developed, followed by a multicultural approach which demonstrates that human beings share a common wisdom about how to receive criticism. Finally, we will address how our cognitive and multicultural approaches may facilitate receiving criticism in the field of medical education.

Two Levels of Human Cognitive Ability are Involved in Responding to Emotionally Charged Stimuli

Cognitive science is an interdisciplinary field founded by scholars from multiple disciplines such as cognitive psychology, computer science, philosophy, linguistics, neuroscience, and anthropology [10], thus has very broad scope. In terms of receiving criticism, the two levels of human cognitive abilities we deal with in this section are limited to how a human responds to emotionally charged stimuli and are outlined based on our daily experience and the findings of neuroscience. The characteristics of the two levels of cognitive abilities and their relationship are also described. Since criticism (as well as praise) is an emotionally charged external stimulus that results in subjective feelings and the terms “emotion” and “feeling” are not defined consistently, in this article, we adopt the neuroscientists’ definitions: “Emotions are automatic, largely unconscious behavioral and cognitive responses triggered when the brain detects a positively or negatively charged significant stimulus. Feelings are the conscious perceptions of emotional responses” [11: 1079].

The Lower and Higher Levels of Human Cognitive Ability

Three kinds of experiences illustrate the lower or instinctive level of cognitive ability common to human beings. (1) If an external stimulus results in a pleasant feeling, our instinct drives us to pursue it. For example, if a certain food is delicious, the desire for the delicious taste often compels one to overeat, despite a feeling of satiety and/or warnings from the rational brain against weight gain. (2) If a stimulus results in an unpleasant or punishing feeling, we instinctively avoid it. For example, seeing a snake results in a feeling of danger that makes us want to move away from it. Stimuli that result in pleasant or unpleasant feelings are emotionally charged or significant [11]. (3) If a stimulus results in neither a pleasant nor unpleasant feeling (neutral or emotionally insignificant), our brains will gradually ignore it (become habituated). For example, upon entering a quiet study room in a library, the ticking of the clock on the wall can be clearly heard. Functional MRI can detect the part(s) of the brain activated by the sound. After a while, however, this sound no longer enters the conscious awareness as the person becomes immersed in study because the original activation in the brain is extinguished. These three patterns of behavioral responses toward external stimuli outline a 3-option primal logic, which is how many animals avoid danger and seek out safety and other benefits from their environments. This animal-level primal cognitive ability is conserved in human beings and tends to be instinctive rather than intellectual.

It is now known that the limbic system of the human brain plays an important role in mediating lower-level cognitive ability (LCA) [11]. It constantly scrutinizes and evaluates input signals (external stimuli), assigns values to them (various emotions such as fear, sadness, elation, and compassion), reports its evaluations to our higher level rational brain in the frontal lobe, and usually orchestrates behavioral responses based on the higher level decision from the rational brain. Occasionally, the limbic system orchestrates behavioral responses on its own. A positive example of this is that when facing extreme danger, the life-saving fight-or-flight response may occur before our conscious awareness of the life-threatening situation; a negative example is that when a person becomes enraged, the rational brain fails to inhibit or stop the primal emotion.

At the higher level, our rational brain supervises the decisions made by the limbic system and then makes a final intellectual decision to allow us to respond appropriately to a stimulus. The final decision of our rational brain may follow, modify, bypass, oppose, or rewrite the decision made by the limbic system. It is this higher level cognitive ability (HCA) that separates human beings from other animals and allows human beings to act in profound and lasting ways that other animals cannot achieve. For example, whereas animals do not actively seek to experience hardship, human beings proactively seek arduous training, such as athletic or military training. This HCA has the power to reverse the animal-level 3-option primal logic and intentionally reinforce a meaningful outlook, attitude, or behavior.

The Characteristics and Relationship of the Two Levels of Cognitive Ability

The LCA tends to be instinctive, emotional, primal, and largely unconscious but can enter our conscious awareness. It may spontaneously reinforce a behavioral response if a stimulus results in either a pleasant or unpleasant feeling; its decisions may be correct or incorrect. The HCA is conscious, rational, analytical, and visionary; it can intentionally reinforce a behavior according to one’s free will, and its decisions may also be correct or incorrect. The LCA is essential for survival. The HCA utilizes or modulates the LCA according to one’s free will. Every day, we experience these two levels of cognition. Our behavioral decisions often result from the interplay between them. The two-level cognitive ability is modeled in the left part of Fig. 1, which maps the unconscious and conscious processing of neuronal information described by neuroscientists [11].

Fig. 1.

A theoretical model of two-level cognitive ability (left part) and the common wisdom shared by multiple cultures (right part) involved in responding to emotionally charged stimuli such as criticism and praise. The common wisdom is to use the great power of the HCA to diametrically oppose the instinctual responses of the LCA

For convenience in analysis and discussion, we will use a comparison to computer programming to describe emotion and feeling: Consider that evolution has “programmed” a pleasant and an unpleasant emotional “program” to benefit survival. Feeling a pleasant or unpleasant emotion is realizing that a corresponding emotional program is running automatically in response to an emotionally charged stimulus. Human beings have a shame program (possibly branching from the unpleasant program) that specifically responds to mistakes being pointed out or realized. When feeling embarrassed or shamed, one flushes; this response enters one’s conscious awareness, but conscious effort cannot suppress or stop its automatic running. The evolutionary purpose of this shame program, like the lower-level unpleasant program in animals, is protective: to help the person avoid making the same mistakes. A concept closely related to the running of the shame program is face. Experientially and phenomenologically, one “gains face” when praised and “loses face” when embarrassed or flushing.

In the next section, we will apply this two-level cognitive model and the phenomenon of face to identify the causes underlying the adult anxiety and unease to receive criticism as exemplified by the four recipients in our cases.

Identify the Causes Underlying Adult Anxiety and Unease Toward Criticism

The judgment made by the LCA or the HCA or both in response to receiving criticism may be wrong. In addition, one may not have been taught how to receive criticism. We will describe and discuss each possibility in the context of giving and receiving constructive feedback in medical education.

Cause 1

The LCA’s tendency to automatically take criticism as a threat to avoid is the first cause simply because criticism (the stimulus) triggers the unpleasant response program. This is a natural, common weakness embedded in human nature in the context of receiving criticism. It should be noted that for many animals, the evolutionary purpose in running the unpleasant program is to directly avoid the harmful stimulus (such as fire or a predator) to protect their survival. In the context of giving and receiving feedback, however, criticism as a stimulus to run the unpleasant program signals that a recipient needs to avoid something (i.e., inappropriate behavior(s)) that may be harmful but not fatal. Hence, giving criticism is meant to protect the recipient and receiving criticism is self-protective. The criticism is not a threat (such as fire or a predator) to avoid; what has been criticized is the threat to the recipient or other people. This understanding is a very simple sense (VSS) that an adult acquires as HCA develops. For example, in case 1 above, the criticism is not a threat to the recipient; it is his irresponsible way of writing the patient’s note that was harmful to the patient and damaged his own image. The problem is that it is very easy to use this VSS to judge others’ behavior or mistakes, but when one is not a judger but a recipient, one loses this VSS. In other words, the VSS, by default, is projected to others but not inwardly toward oneself. We call this problem the HCA’s inward blindness to the VSS, which will be further illustrated in the next cause.

Cause 2

The HCA’s inward blindness to the VSS upon receiving criticism is the second cause or the second common weakness in human nature. Things that are crystal clear to uninvolved bystanders are unclear to those involved. Each recipient in our 4 cases, if asked to comment on the behaviors of the other three, should have no problem to do the job because their VSS is outward. However, when they themselves were being criticized, each lost this VSS and their HCA defaulted to the primal emotional response of the LCA, even when the recipient knows the criticism is valid.

Cause 3

Without an appreciation of the protective role of criticism, the HCA also tends to take criticism negatively as a threat. What does it threaten? One’s job? No. The action or attitude that has been criticized threatens one job and criticism protects one from being dismissed. In this case, what is threatened by criticism? Face. It is not likely that the first three recipients did not know that the criticism they received was appropriate, but they were hijacked by a fear of losing face or an awkward feeling of the loss of face, which drove their defensive or dismissive behavioral responses. This type of negative response seems universal; otherwise, we would not see those action verbs such as “keep calm,” “remain an adult,” and “give yourself a confidence boost” that are widely used in discussing feedback.

Cause 4

Without adequate training, one’s HCA may not think about the idea of differentiating between the criticism, the object of the criticism, and the threat to one’s own face and which one among the three played the dominant role underlying one’s behavioral response toward criticism.

Cause 5

The HCA either fails to realize what the individual has done wrong or considers that the criticism is wrong. In case 4 above, the teacher’s effort to allow more class time for students’ questions didn’t address the underlying problem, so she considered the criticism incorrect. As the saying goes, “You don’t know what you don’t know.” Every person needs someone else to tell them they have a blind spot.

These five causes are all intrinsic causes. They are all weaknesses inherently embedded in human nature and common to each human regardless of gender, ethnicity, and culture. Hence, training to receive criticism is the training to face and overcome these common weaknesses and thus to be less an animal and more a human.

Cause 6

The previous five causes are intrinsic to human nature, but there is an extrinsic cause as well: the lack of effective education and training in how to receive criticism at all levels of education.

The theoretical and practical principles we present below can remediate each of these causes, whether intrinsic or extrinsic.

Treating These Causes Requires Intentional, Effortful, and Persistent Education or Training

Theoretical Principles

First, educate all students to be explicitly aware of the two-level cognitive model that is involved in their response to emotionally charged stimuli.

Second, train people to be explicitly aware of the four common weaknesses inherent in human nature that hinder appropriate responses to criticism. These inherent weaknesses should not be used as an excuse to defend adult anxiety and unease toward criticism. “To conquer others is to have strength; to conquer yourself is to be strong” [12:85].

Third, teach the wisdom that good things can turn bad and bad things can turn good and make this wisdom to be explicit common sense to adults. In this context, good things refer to the things that make one feel pleasant and bad things refer to the things that make one feel unpleasant.

Notice that the word explicitly is prominently used in each theoretical principle. If something is spoken out, it becomes common sense; if not, it is ignored.

Practical Principles

First, use the wisdom and power of the HCA to diametrically oppose the lower-level instinctual responses (right part in Fig. 1): If someone praises you [a good thing], be wary or even fearful to avoid complacency, which turns the praise to be bad; if you have made a mistake [a bad thing] and someone criticizes you [a bad thing judged by the LCA or the HCA or both], be glad and appreciative because the lesson learned from the mistake or the criticism is where the good performance is rooted. This method applies to the intrinsic cause 1 above. It is not the authors’ innovation but common wisdom among multiple cultures. Nevertheless, it is often ignored in current education and will be reviewed in the next section. This practice manifests the unique advantage of the HCA to “program” or “reprogram” new mental programs at the level of conscious feeling: Upon facing praise/criticism, intentionally be wary/glad (the right part of Fig. 1). After intentional, effortful, and persistent practice, upon facing praise/criticism, one will automatically or reflexively be wary/glad. At this point, less or no conscious effort is needed because the “on” or “off” of the wary/glad feeling program has become subconscious. The significance of the programming function of the HCA is that one is no longer the servant of primal emotions but the master of one’s own life! It is not that we lack the ability to respond to criticism correctly and graciously, but rather that we sometimes do not engage our HCA in favor of a primal response.

Second, use real cases (such as our cases above or the cases you have) to make trainees see and reflect on the HCA’s inward blindness to the VSS so that they begin to appreciate and utilize others’ outward VSS that is inward to them. This action of “walking a mile in someone else’s shoes” applies to intrinsic cause 2.

Third, illuminate the natural protective roles of the shame program and concern about face, which applies to intrinsic cause 3.

Fourth, watch and reinforce that the three factors in Table 1 underlying one’s behavioral response toward criticism all play positive roles, which applies to intrinsic cause 4:

1. Emphasize the consequence if the mistake is not corrected.

2. Point out that the wrong behaviors of the three recipients in our cases above are signs of low self-esteem and self-confidence.

3. Vigorously and tirelessly educate that receiving criticism does not tarnish one’s image, but is an act of self-esteem, self-respect, self-worth, self-confidence, and a true demonstration of elevated character, pride, and maturity.

4. Facilitate the above efforts using Table 1.

Table 1.

Three factors underlying one’s behavioral response toward criticism

Factor influencing behavior	Negative role of the factor	Positive role of the factor
1. Criticism	Threatening	Protective
2. What has been criticized	A bad thing	A lesson that good fortune roots in
3. Face	Being defensive for face	Stimulating one’s courage to correct the mistake

Fifth, increase the level of awareness of the human subconscious or unconscious world, which deals with the intrinsic cause 5. Pay attention to others’ and one’s own subconscious, unconscious, or habitual behaviors. If a criticism is unexpected or seems ridiculous or unacceptable, think about whether it signals something about you that you are not aware of. Discover whether any of your unconscious behaviors is a source of conflict.

A story may inspire people to start this journey: Two men are good friends and share a sense of humor. They often tease each other for fun. One day, one asked the other a question: “You always keep a long beard. When you sleep, do you put your beard under your quilt or on top of it?” The man with the long beard didn’t know what to say because he had never noticed or thought about it. That night, when he got under his quilt, he was concerned about whether he should put his beard under his quilt or on top of it. He tried both, but he could not figure out where his beard usually went because it was just an unconscious behavior that he had never been aware of in his conscious mind until his friend brought it up.

If these theoretical and practical approaches can be widely propagated, the extrinsic cause (lack of training) is addressed by implementing this sort of training.

In brief, the question for educators and trainers should be “How can I prepare my students or trainees to be ready to receive criticism?” The related question for recipients is then “Am I ready to receive criticism?”

Multiple Cultural Teachings Highlight the Strength in Human Nature

We have discussed our common human weaknesses. Now it is time to be proud of our common strengths as demonstrated in multiple cultures.

In Western society, we can find many teachings or warnings that are visionary and beneficial. American author Norman Vincent Peale said, “The trouble with most of us is that we’d rather be ruined by praise than saved by criticism” [13]. Former British Prime Minister Winston Churchill once said in an interview, “Criticism may not be agreeable, but it is necessary. It fulfills the same function as pain in the human body; it calls attention to the development of an unhealthy state of things” [14]. Other popular sayings are “only true friends tell you the unpleasant truths” and “a true friend tells you what you need to hear, not what you want to hear.”

For African Americans, receiving criticism as feedback is considered a mechanism for making one better. Individuals are taught to accept criticism graciously and constructively because feedback is typically given in the spirit of improvement [15]. African Americans have historically been marginalized in American society. As such, their culture emphasizes resilience toward criticism. For example, it is common to hear “you have to bounce back, you can’t let this get you down” or “what can you learn from this”?

In Arabic culture, Islam is the major factor for culture production. The Quran teaches to not judge those who critique you and to avoid mistrustfulness. Muslims should receive criticism with open mind and open heart. The prophet Muhammed said, “One believer is a mirror to another”; one of the meanings of this is that a believer should take a peer’s advice as a mirror that reflects on his or her good and bad qualities and thus should be thankful. Moreover, the prophet urged Muslims to avoid arguing even when one is in the right. Another influential teaching was given by Umar ibn al-Khattab, one of the most powerful Muslim leaders in history: “Whosoever shows you your faults, he is your friend. Those that pay you lip service in praise are your executioners” [16].

In the East, a series of Confucius’ teachings are well known due to a very popular tiny volume of children’s rhymes called “standards for being a good student and child.” Two of them are selected: “If criticism makes you angry and compliments make you happy, bad company will come your way. If you are uneasy about compliments and appreciative of criticism, sincere, understanding, virtuous people will gradually be close to you” and once criticism has been given, “if you have made mistakes, correct them; if not, watch out and guard against them” [17].

These teachings from multiple cultures are the very “prescriptions” by the human HCA for the difficulties we face in receiving criticism. By adhering to these “prescriptions,” one will be protected and one’s character will be elevated. The logic of these teachings can become habitual, as long as one takes each criticism seriously as a valuable opportunity to improve.

Foster an Upright Ethos in our Medical Community to Improve Personal Quality and Better Serve Patients

The world is rapidly changing, but human nature (including our common weaknesses and strengths) does not change and the shared wisdom of how to receive criticism endures. Being aware of the unchanging nature and the enduring wisdom in our rapidly changing world suggests that our cognitive and cultural approaches are potentially applicable in different places with different cultures.

In medical education, in fact, the significance of feedback (including criticism) is well-valued, but “despite several decades of accumulated knowledge in this area, the evidence from learners is that we continue to starve them of this critical nutrient [i.e., feedback] for their growth” [2:154], and “our learners deserve to receive it [feedback], and our patients will be the ultimate beneficiaries of the process” [2: 158]. We hope this article facilitates a wider acceptance of criticism as well as habituation in medical education and brings the practice of receiving feedback to a new level. We also hope to nurture compassion for every person and promote self-forgiveness and forgiveness toward others in light of the weaknesses we all share regardless of gender, ethnicity, and culture.

While this article deals with how to receive criticism, it also automatically facilitates giving feedback because it helps prepare recipients for feedback and stimulates givers to enhance their wisdom to judge or know the level of readiness of a recipient and foresee the possible outcome before giving criticism.

Summary and Future Direction

Giving and receiving feedback are not easy in practice, but are valuable and necessary aspects of professionalism in the health care field. From human cognitive abilities (nature) to multiple cultures (nurture), from causes to “prescriptions,” from unchangeable and enduring to changeable, from West to East, we have woven our reflections and shared our perspectives about how to receive criticism with a hope to deepen this practice and emphasize that each human being has the potential and ability to receive constructive criticism correctly.

It should be noted that the theoretical and practical principles we provided for one’s behavior are very basic and the cultural approach in this article is superficial and not all-embracing. Our future direction is to provide extended training that will provide guidance for behavior upon facing a criticism that is wrong or not constructive. In addition, a self-evaluation instrument may be needed to assess the following: How frequently do I follow the primal animal logic of the LCA and waste the power of my HCA? How often do I use my HCA incorrectly, and do I learn from the negative consequence? How often do I use my higher level power appropriately and am I conscious of how I benefited from it?

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethical Approval

NA

Informed Consent

NA