When Feedback Stops Helping | Yahir Santiago-Lastra, MD

One of the things I appreciate most about surgery is that we still teach through apprenticeship. Residents learn by working alongside people who have spent years developing technical judgment, clinical instincts, and habits that simply can’t be learned from a textbook. That relationship between teacher and learner is one of the greatest strengths of our profession.

It also means we inherit a lot of our teaching style from the people who trained us.

I’ve been thinking about that recently after coming across a series of illustrations by educator Alex Rinehart describing five teaching archetypes: The Nitpicker, The Mind Reader, The Time Traveler, The Cruel Master, and Why? Why? Why? The illustrations are funny, but they capture something serious. They don’t describe bad teachers. They describe teaching habits that many well-intentioned educators can fall into, especially under stress.

The Nitpicker tries to correct every mistake, no matter how small, until the learner leaves remembering none of them. The Mind Reader assumes they know why a learner did something instead of asking what they were thinking. The Time Traveler takes today’s mistake and turns it into a prediction about tomorrow, with comments like, “We don’t expect to see this performance from a fourth-year resident.” The Cruel Master believes intimidation creates excellence and mistakes fear for respect. And then there is Why? Why? Why?, the teacher who keeps asking “why” until curiosity begins to sound more like cross-examination than coaching.

What struck me wasn’t that I had encountered all of these teachers during training. It was that, under the right circumstances, I could recognize pieces of myself in every one of them.

During intern year, I struggled with laparoscopy like every new surgical trainee. There was one case in particular where my attending and fellow made fun of my laparoscopic skills. It wasn’t a pattern throughout my training, and I don’t think either of them intended to be cruel. But that one experience was enough that, years later, I remember how I felt during that operation far more clearly than I remember the operation itself.

Around that same time, some of my co-residents pulled up a Family Guy clip that made fun of female Hispanic physicians. I don’t remember anyone intending it to be malicious, but I do remember wondering whether that was how people saw me too. As a young Puerto Rican woman in surgery, those moments had a way of lingering long after everyone else had moved on.

For a long time, I told myself what many surgeons tell themselves.

“It made me stronger.”

Maybe it did. That laparoscopic case certainly motivated me to practice. I spent countless hours working on those skills because I never wanted to feel that exposed again. But over the years I’ve come to think there is an important difference between learning from a difficult experience and learning because of humiliation. I don’t know that those are the same thing.

As I became an attending, I realized how easy it is to fall back on the teaching style you grew up with.

There have absolutely been moments where I’ve been more critical than I needed to be. I’ve asked a resident, “Why?” and then followed it with another “Why?” and another, genuinely trying to understand their reasoning. Looking back, I don’t think I was really helping them think. I think I was conducting more of an inquisition than a coaching conversation.

The resident wasn’t growing more insightful with each question. They were getting quieter.

That realization was uncomfortable because my intention was never to embarrass anyone. I cared about the resident. I cared about the patient. I cared about teaching. But intention doesn’t always match impact.

It made me ask a question I hadn’t really considered before: What does the evidence actually say about effective feedback?

As surgeons, we like evidence before we change our practice. Teaching shouldn’t be any different.

As I started reading more about feedback in medical education, I was struck by how consistent the literature is. Good feedback is specific. It focuses on behaviors rather than personality. It is intended to improve the next attempt, not criticize the last one. Learners retain more when they receive one or two actionable coaching points than when every imperfection is corrected in real time. People are also far more likely to ask questions, acknowledge uncertainty, and speak up about potential problems when they feel psychologically safe.

None of those findings argue for lowering standards.

If anything, they argue for being more intentional. Correct the mistake that matters most. Explain why it matters. Then let the learner try again.

Some of the best teachers I had weren’t nationally known surgeons at the time, though many have since become leaders in our field. They were my senior co-residents, Sarah, Jai, and Mike. They expected a lot from me, but they also remembered what it felt like to be new. If I made five mistakes, they usually picked one to work on. If I needed guidance, they asked what I was seeing before telling me what I was missing. They corrected me constantly, but I never left an operation wondering whether I belonged there. I left with one clear thing to work on and the confidence that I could learn it.

I still think about them when I’m teaching.

As residency program director, I spend a lot of time thinking about culture. Not the culture we talk about during retreats or write about in accreditation documents, but the culture that develops in ordinary moments. It’s the comment made after a difficult case. The way an attending responds when a resident struggles. Whether we assume the best or the worst about their intentions. Whether a learner feels comfortable saying, “I don’t know,” before uncertainty becomes a patient safety issue.

Culture isn’t built through mission statements. It’s built one interaction at a time.

I still expect excellence. I still stop unsafe behavior immediately. I still believe residents should be challenged, prepared, and accountable. Those expectations haven’t changed.

What has changed is how I think about feedback.

I’ve become much more comfortable saying less. One coaching point is often more effective than five. A genuine question is usually more productive than an inquisition. I’ve learned that it is possible to hold someone to an exceptionally high standard without making them feel small in the process.

I’m still working on it. There are days when I catch myself slipping back into old habits, usually when the operating room gets busy or my own stress level rises. Those moments have become reminders to pause, reset, and remember what I was actually trying to accomplish in the first place. My goal isn’t simply to correct mistakes. It’s to help someone become a better surgeon.

Every resident eventually becomes an attending. They’ll inherit some of my teaching habits, just as I inherited some of my own teachers’. I hope the ones they choose to carry forward are the ones that help people grow.

Long after they’ve forgotten exactly what I said about a needle angle or a camera position, I hope they’ll remember that they worked in an operating room where they were challenged, respected, and never made to feel small for learning.

If that’s part of the culture they pass on, I think we’re teaching the right lessons.

Further Reading