Being critical is a central part of me. It has been crucial to my work as an editor, a teacher, an advisor, a consultant, a reviewer and an author.  We are not talking trivial, gratuitous, knee-jerk or offensive criticism. Rather, it is being critical from a standpoint of knowledge and understanding in which the process includes an analysis of a particular position (eg a proposal, finding, presentation), an assessment of the strengths and weakness of the details (facts, arguments) presented, and then the formulation and expression of a reasoned opinion (for or against) or the clarification of errors or misunderstandings. In my view this process is central to intellectual advance, without which academic disciplines such as science and medicine would simply stagnate. But a critical approach is also relevant to everyday communication, where again it allows one to challenge errors or misunderstandings, or voice an alternative opinion. It is certainly healthier to speak ones mind than suffer in silence or to voice a concern rather than bear a grudge. Conversely it is better to be corrected through reasoned criticism than to continue in ignorance. 

Despite its obvious value, in medical practice and education criticism is usually seen as a negative activity. So much so that the word itself can only be used if somehow qualified, as in, for instance ‘constructive’ criticism, or its delivery softened by offering it as from a ‘critical friend’ or delivered as part of a ‘praise sandwich’. Criticism is seen as so dangerous and hurtful by some educationalists that teachers and senior clinicians are advised to think long and hard before criticising juniors/students. Moreover, it is taboo for students or young doctors to criticise their seniors, possibly because of the fear of recrimination. But while criticism may not always be welcome, the alternative (silence), is the greater wrong when, for instance  it leaves the perpetrator assuming there is agreement, or that his/her audience necessarily concurs. In those environments where criticism is prohibited and where only the view of the most senior speaker (say a consultant or professor) is allowed to prevail, conversation or any other form of social intercourse, becomes irrelevant.

While being critical and receiving criticism are now core parts of me, there are three particular events in my history that will have shaped my approach. When I was thirteen I corrected my headmaster. I was a (very) late developer and after a disastrous performance in the 11+ exam managed in two years to climb from the bottom to the top stream of my grammar school. For this the headmaster promised me a prize. However, when prize-giving day came this was forgotten, and encouraged by my parents I went to see the headmaster to confront him. After knocking gingerly at his door, and being summoned into what seemed an enormous office, I carefully told him how he had gone back on his word. To his credit he apologised and in time I received a (treasured but now very dog-eared) dictionary embossed with the school crest.

The next event occurred when I was a medical student. One morning on a ward round the consultant bullied a female colleague to such an extent that she burst into tears and ran off down the ward. I stepped forward,  told him that while a minute ago I had been a student I was now talking to him ‘man-to-man’, and said that his behaviour towards a woman student had been totally unacceptable and that he should never again treat a woman student in that way. He apologised, we continued, his manner changed, and two years later I was offered (and accepted) the job of being his house officer.

The third event was when I received criticism. I was a senior house officer and had just started working with the Drug and Therapeutics Bulletin as an article editor.  The review comments I received about my first article were very damming – the article was unclear, badly structured, grammatically poor, inconsistent with house style, and overall so flawed that it was unpublishable. I was devastated and would have given up were it not for the intervention of Andrew Herxheimer, the then editor. He pointed out that I was taking the criticism personally, as though the article was an extension of my body, a belief that had no basis in reality and was clearly counter-productive. In science, once thoughts or ideas are spoken or expressed they become public property, and are the legitimate subject for criticism. As an author it was essential to concentrate on the article rather than on oneself and it was certainly inappropriate to defend ones work at an emotional level. Adopting this notion in my professional work (much much more difficult in one’s own private life!) of the dispassionate relationship has proved invaluable, and through it my relationships with work colleagues have been much the stronger.

As a critic there are some key rules I try to follow. First, before being critical I check that I am in a forum where criticism is part (either assumed or agreed) of the dynamic, as for instance – in discussion in a committee; when acting as an advisor, consultant or a referee; in a teaching environment; in a debate; when invited to comment on an article or presentation etc. When actually criticising I try to ensure that the comments I make are clear, unambiguous, reasoned, reasonable (fair), dispassionate, unthreatening, not personal, not devious, and are given in such a way that the recipient has an opportunity to respond. In fora at which I am repeatedly amongst the same people (colleagues) I strive to ensure that any criticism is directed according to the issues at hand and not the person involved. Moreover, whatever the outcome of the intervention, I try hard that it does not alter my professional relationship with the person criticised.      

As a recipient (at least in the work environment) I welcome criticism and assume it is serious, and made in the spirit of genuine interest rather than with any cynical intent. I do not feel ‘put upon’ or threatened by such criticism and try to answer it fully treating the question posed at its face value (I do not seek a hidden agenda). 

Criticism is a valuable commodity and doctors and students should be made aware of the critical process, be versed in its use, and trained how to be critical and, of course, how to receive criticism. Problems arise when one is surrounded by people who can’t or won’t speak their mind and so are unwilling to be critical. If sycophancy is a killer, which I believe it is, then criticism is a lifeline.       

Joe Collier is emeritus professor of medicines policy at St George’s, University of London