Are you brave enough to feed back when you see poor behaviour? I wish I was—because feedback can lead to improvement, whereas silence allows the poor behaviour to continue.

I’ve been thinking about feedback after talking to some medical students, but let me begin with my own failures. I go regularly with my mother on hospital visits, and my role as an observer allows me to see many things that could be done better. I always think about feeding back, and as I sit waiting I even compose what I might say. I start by saying, “We are very grateful for what you are doing for my mother, but would you mind if I suggested a few ways in which you might improve your service?”

But I don’t say it. I’m fearful that they will label me a “nutter.” I’m even worried that my mother’s care might be compromised in some way.

I thought of this as one student described being on a firm where the consultant never spoke to her and where it wasn’t clear when she was supposed to be there and what she was supposed to do. It was a miserable educational experience. I asked the student whether she’d fed back to the consultant, and of course she hadn’t.

We reflected on how bold she would have to have been to do so. It would have been seen as extraordinary, a student booking an appointment with the consultant, and beginning to say “I hope you won’t mind this. Indeed, I hope you will find it helpful, but I’d like to tell you what it feels like to be a student on your firm and suggest ways in which you might improve.” Perhaps, the consultant would have been grateful, but neither the student nor I could imagine the student being so bold.

She did feed back to the medical school but was left with the feeling that it wouldn’t do anything—probably because the staff too were fearful of feeding back. We discussed how she might have said: “Can you tell me what you will do about what I have told you? And will you mind if I come to see you in a month’s time to find out what you have done and how effective it’s been?” That again, we agreed, would be a bold step. Would the medical school write “difficult” on her records, or would she be regarded as a star student? It’s not inconceivable to me that it could be the latter.

Another student had been to a practice where the GP called her “love” for eight weeks, never seemed to learn her name, and couldn’t explain anything he did. The GPs all seemed to dislike each other, and the student had had the entire practice team moan at her about each other. Could she have asked the GP to use her name? She might have, but she didn’t—and she couldn’t ask for better teaching because the GP was clearly incapable of it. She did feedback to the medical school, but she was told how hard it was to find GPs who were willing to take students.

It isn’t easy to feed back when you are a student as you are at the bottom of the hierarchy, too often tolerated rather than celebrated. But nor is it easy to feed back when you’re an ex-editor of the BMJ with nothing to lose.

Richard Smith was the editor of the BMJ until 2004.