3/15 YES!: Trainee Performance Improvement: Where We Are and Where We’re Going

March 15, 2024

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00:00Afternoon, everyone.
00:03Good afternoon everyone,
00:05and welcome to the next to next to
00:08last installment of the ES series.
00:10Yeah, Y'all Medical Education educator
00:13series that I've had the wonderful
00:16privilege of planning together with
00:18Ina Dunn who's here and colleagues
00:20at the Center for Medical Education.
00:25Yeah, I'll let we we were fighting
00:27over who would introduce our esteemed
00:30speaker today and and I lost.
00:32So Dana wants. So she want to produce
00:34our speaker and just to tell you
00:36before that that our last two sessions
00:39that will be coming up the first
00:41one will be on getting chalk box.
00:45How to do that by Jeremy Knoller
00:47from urology.
00:48And then we're gonna have
00:50Shali Gupta talking about
00:55what is the word that I'm up to
00:57standard training. Yeah. We'll
00:58have more information about
00:59that at the end. Thanks
01:00for that. And that will that will
01:03wrap up a year of the yes series.
01:05So. So you can put the next one.
01:06And Dana you want to
01:08introduce the person. Yes.
01:10It's my pleasure to introduce The Lawn
01:12with Jay Sekara who is a a colleague
01:15in the Center for Medical Education.
01:17He's an associate there and has many
01:22roles including the the director of
01:25clinical performance improvement.
01:27I want to make sure I've got say that
01:30correctly performance improvement
01:32and also as a course director for
01:35the longitudinal interprofessional
01:38longitudinal clinical experience.
01:41But does spend a lot of time on thinking
01:43about clinical reasoning has been a
01:46leader and naturally and internationally
01:48writing and and speaking about how to
01:51teach and assess clinical reasoning.
01:54So we're really excited
01:55to hear from you today.
01:56Dylan take it. Add
01:58one thing to his biography.
02:02I I you some of you may know that
02:05four of the students failed the C
02:08Oski this year and by a lot and
02:11within a couple of months Dylan
02:14worked with all four of them and they
02:17all passed with very high scores.
02:23Yeah we're very we're
02:24very excited about that.
02:25We found out that news on on Monday.
02:27Thanks Michael for setting
02:28that up and Edwards.
02:30So yeah I I thanks all for coming out as
02:32well on this at least if you're in New Haven.
02:35Lovely Friday afternoon.
02:37I will be talking today about a
02:40trainee performance improvement,
02:43maybe a new term for some of y'all
02:46where we are and where we're going.
02:48I do want to take a note that it's
02:50also actually match day here and it
02:53literally happened outside and you know,
02:55I think the idea of performance
02:57improvement that we're framing
02:58it to have a growth mind.
02:59So we'll talk about that a little bit later.
03:02It has maybe some negative connotation,
03:05but this is the goal, right?
03:06The goal is to be outside my
03:08office right now watching our
03:10learners really thrive and get
03:12to the places they want to go as
03:14clinicians and healthcare providers.
03:16So I just also before we get started,
03:19I want to make sure that everybody gets
03:21credit for coming out to this session.
03:23So make sure to text to your
03:26Yale CME phone number,
03:28that 9435 number
03:3338948 again, to get credit for that.
03:35And I'm sure we'll put that in the
03:36chat as well, as Linda has done.
03:38I have a couple disclosures.
03:41I consult for the National Board
03:42of Medical Examiners and Glass
03:44Health on clinical reasoning,
03:45assessment and artificial intelligence work,
03:48and let's get started.
03:49So here are our goals,
03:50our road map objectives
03:52for the session today.
03:54We're gonna describe the current state of
03:56performance improvement in medical education.
03:58We're gonna identify different
04:00types of struggling learners and
04:02we're gonna explore effective
04:03processes for identifying them and
04:05creating plans for them as well.
04:07So what is performance improvement
04:09or commonly a more reference
04:11remediation as a term.
04:13So there are many ways of defining it.
04:15Y'all have something in your heads as well,
04:17but from Doctor Calais out of NYUI
04:20believe she defined it as facilitating
04:22a correction for trainees who started
04:25out on the journey towards becoming
04:28an excellent health professional
04:29but have moved off course, right.
04:32So a goal of becoming a clinician,
04:34but they just quite haven't gotten
04:36there yet or they're headed in a
04:38little bit of a wrong direction.
04:39So some examples of struggling learners,
04:41these are some numbers you can
04:43take it across professions,
04:44but at least medical students
04:46from some papers listed below,
04:48we've seen it documented at
04:50least as self reported.
04:5215% of third year medical students
04:54struggle during their clerkships,
04:5611% struggle and 4th year.
04:57I guess that kind of depends on how
04:59much clinical time they have to,
05:01amongst other requirements, residents.
05:04We've see up to almost 20% of
05:07residents have significant areas
05:08of difficulty along competencies.
05:111520 to 20% of Jimmy trainees
05:13need some form of remediation
05:16and residents self identify.
05:17However performance issues
05:19only 5 to 6% of the time.
05:21I will say that second stat
05:23looks a little bit high for me,
05:24at least for my knowledge
05:26of the residency programs,
05:27but could be defined a little bit
05:29differently at what that threshold is.
05:31So for the 25 of us on the call,
05:35our large group activity,
05:35I'd like to kind of warm ups up
05:37and get the conversation started.
05:39I have my chat open,
05:40so definitely feel free to throw
05:42any thoughts in there about this
05:45exercise or unmute yourself.
05:47But I wanted to ask you,
05:48what are some adjectives or examples you
05:51might use to describe a struggling learner?
06:06All right, Andres, why don't
06:08you pick us off? I see Roberts
06:10says disengaged in there, right.
06:13Yeah. And I'll continue with
06:15another one. Yeah. There
06:17you go. There you go.
06:20So, yeah, some great terms in there.
06:22I think, you know,
06:23KD has just like a reference standard.
06:25Sometimes that's helpful as a gestalt,
06:26like not where we'd expect them
06:28to be here for their peers.
06:30Sometimes, like Claudia mentions,
06:31it's just a just a feeling.
06:33I think there's value in that too,
06:34like why isn't this happening
06:36the way they should?
06:37You can almost like
06:39introspectively think about that.
06:41John mentions anxious.
06:42We talk about maybe not the greatest insight.
06:46And so there are a lot of things
06:48that we can do to describe.
06:49And here are just some more terms,
06:51many of which you describe as well
06:53that Doctor Cole had mentioned
06:55and it's a really Seminole text
06:58around remediation and a lot more
07:01when it comes to insight as well.
07:04So y'all clearly know it when you see it,
07:07when it comes to identifying
07:09struggling learners.
07:09And now our conversations can be
07:12across different frames, right?
07:13I mentioned it could be introspective,
07:15how you feel.
07:16It could be around more general parameters
07:18from their knowledge to their outputs,
07:21their performance,
07:21what are they showing you,
07:23how they reflect on their performance,
07:25right, Which aren't always concordant
07:28what their production is and
07:30hopefully it never gets to this point.
07:31But that's a reference more to patient
07:35care outcomes, the competencies,
07:36right from an A/C, GME framework,
07:39what we're kind of like growing to at
07:41least at the UME level as well, right.
07:43We measure them along these and
07:44make sure they're progressing.
07:46Some might have different
07:47frameworks like the reporter,
07:49interpreter, manager,
07:49educator framework,
07:50some a little bit more gestalt.
07:52Along those lines we have entrustable
07:55professional activities as ways to assess
07:58learners again more holistically for tasks.
08:00And then,
08:01you know,
08:01we can think about them moving from
08:03novice to expert when realistically
08:05we hopefully our learners can at
08:07least be competent to some degree,
08:09like the competencies mentioned before.
08:11So lots of frameworks to thinking
08:13about our learners and identifying
08:15how they're struggling.
08:16But again, we know when we see it,
08:19but I think it does matter about that
08:22struggle and at what point we identify
08:25learners as needing more support,
08:27right?
08:27Do they actually need to
08:29fail before that happens?
08:31Are they just below average before
08:33we do something about the change
08:35their trajectory in some way?
08:37Could there be risk factors of sorts?
08:39Could it just be how they feel?
08:40Or maybe it just we do this for everybody?
08:42Maybe we're regularly evaluating
08:44our learners regardless of what
08:46their evaluation is to make
08:48sure that they're progressing.
08:49I think another way to do this and you know,
08:51we were talking John Andres
08:53and I were talking about this.
08:55Sometimes you can think about
08:57the amount of feedback you have
08:58to give your learner as well.
09:00So for example, in a perfect world,
09:03our learners can reflect on what they
09:06did and improve from that, right?
09:08So this is kind of what Dana's
09:10trying to
09:10really foster in the coaching program, right?
09:13And so you don't really need to do
09:14much talking with your learners.
09:16You just ask them, hey, like how'd that go?
09:17What do you need to work on?
09:19And that's honestly probably a high
09:21performing learning, especially if
09:23they have to do that every time.
09:25Then they're just we give ad hoc tips, right?
09:27Like oh, work on this,
09:28work on this, right.
09:29Like we do that for everybody.
09:31That's why our learn,
09:32our students and trainees are there.
09:34They need to get some sort of feedback.
09:37This is 1 level.
09:38That's a little bit deeper,
09:40but you know it doesn't necessarily mean
09:42a learner needs to go into more formal
09:45performance improvement is frameworks,
09:48schemas. We approach situations.
09:50We're really talking about adaptive
09:53expertise, the master adaptive learner.
09:55And we want our learners to be able to
09:58be put in different situations and still
10:00be able to provide the clinical reasoning,
10:02patient care tasks that they need to.
10:05While having frameworks
10:06for that can be helpful,
10:07some learners might not be able to
10:09connect those dots quite as well.
10:10If you have to model for a learner like, OK,
10:13so actually this is how you need to do it.
10:16And show them how you present,
10:18show them all the time what
10:20they're doing in the OR,
10:22then that might suggest that a
10:23learner needs a little bit more help.
10:25And then there's to the point that a script,
10:27you really need to walk them through exactly
10:29what they need to do to do on their own.
10:32If they're unable to do it by the script,
10:35or even despite giving that
10:37they're still struggling,
10:38then it suggests that our
10:40learners might be in a tough spot.
10:41So there are different points at which,
10:43at least in my experience,
10:45it can be helpful to refer to some
10:47sort of performance improvement.
10:49If you're at the stage where a learner
10:51just constantly needs frameworks
10:52all the time for everything,
10:54they can't put that together
10:55themselves themselves.
10:56That might be a point that they
10:58need a little bit more support if
11:00they really need to have things
11:01shown to them all the time.
11:02And I'll do this with like high
11:04performing learners as well,
11:05sometimes to get just a little bit
11:07more nuance and what they're doing
11:09and to demonstrate that for them.
11:11But if you need to show them
11:12how to do everything,
11:13then that's a suggestion that
11:15they might potentially need more.
11:18And if they need,
11:19if they're at the point where
11:21they need scripts honestly at all,
11:23that suggests that they really should be
11:25in some sort of extra support program.
11:28So I just want to give a framework
11:30because often times we see learners,
11:32we give them feedback and we can't.
11:34It's not necessarily normalized as
11:36far as like when is this point that
11:38I need to talk to a program director,
11:40talk to a course director about that.
11:44So in the large group,
11:46I also wanted to maybe go through
11:49a bit of a case and again,
11:51we already got the ball rolling
11:53on audience participation.
11:54So continue to throw comments into that chat.
11:59But the task that we're going
12:00through now is we're going to hear
12:02a case about a struggling learn.
12:03I've I've tried to make it general enough ume
12:06to gme procedural to general types of fields,
12:09although I admit I'm an internist, so
12:11ideas will generally be structured that way.
12:15We'll brainstorm about referral practices.
12:17I've hinted at some We'll discuss an
12:20initial intake or our introduction
12:22when you first meet your learner,
12:24and we'll talk about how you
12:27create a learning plan for them.
12:29So let's talk about Alex.
12:31Alex is an intern referred by their
12:34program director for remediation.
12:37So on their first rotation,
12:39it's a Ward's rotation neuro psych medicine.
12:43They get comments like this.
12:46It's a hard worker.
12:47Alex stays late most days of the week.
12:49Presentations can be disorganized sometimes.
12:52Miskey information notes are often
12:54copied forward with old information
12:57and they're starting to not respond to
13:00nursing concerns in a timely fashion.
13:02You can kind of see how this evaluation is
13:05like starting to plummet as it goes on,
13:07but you know still some good
13:09stuff there with at least like
13:11favourable connotations Block 2,
13:12we're in clinic now whichever profession
13:15specialty that we want to choose and
13:17Alex is showing a positive attitude.
13:19Clearly Alex cares about their patients,
13:23but missing some history with
13:24some limited management plans,
13:26those notes are not getting closed on time.
13:28Attendings are gonna have to prompt
13:30them multiple times for that.
13:32And they're being behind on
13:34in basket tasks too,
13:35which can really build up in the
13:38outpatient setting. Block 3.
13:40Now they get to the intensive care unit.
13:43They seem quite overwhelmed.
13:45They disappear on rounds.
13:47I think I saw that actually
13:48in one of the comments.
13:50They, like, literally aren't there.
13:52A learner might be notes are signed
13:55in the evening or not at all,
13:57and they didn't really know
13:59their patience well.
13:59But, you know,
14:00it's always tough You
14:01get something like this.
14:02Well, you know,
14:02you want to give the benefit of the doubt.
14:04They missed several days.
14:05And so maybe there's something that,
14:08like a qualifier that would
14:09be a reason why that happened.
14:11That would be understandable.
14:12But they got into an argument with the
14:15consultant, something she's like, wait, what?
14:17Like, why?
14:17Why did that happen?
14:18Just odd behaviors that might be
14:22suggestive of something else I And
14:25then So my question to y'all is what
14:29more information would you want to
14:31know about this learner, right.
14:33So we're thinking about when we
14:36might refer Alex for extra support.
14:38Reach out to a supervisor beyond you
14:41and yourself as an educator on that service.
14:44What do you want to know?
14:52All right, Dana,
14:53I know the comments are coming,
14:54so I'm going to lead off with you.
14:56After we mentioned Claudia was asking
14:58about is there something going on
15:01in their personal life that could
15:03be having an impact, LES, Like,
15:05how do they think they're doing?
15:07This is a great one to really
15:09get at that insight.
15:10How's he doing outside of the
15:13rotations, right.
15:13Like, maybe not personal life.
15:15Maybe there might be something else
15:17going on that might be affecting
15:19them too and do you have anything
15:21else that comes to mind when like
15:23just things that you want to
15:24know about a learner that that
15:25have been telltale signs for you.
15:27I
15:30mean people are getting into the
15:32lot of the background issues.
15:34I mean asking some of
15:35those open-ended question,
15:36you get some of the insight that they
15:38have into how that they're they're doing.
15:40And sometimes it can be lack of
15:42insight versus some of the specific
15:43domains you're going to go over.
15:45But like making sure that they've
15:47covered those other 7DS of
15:49distraction and drugs and depression
15:51and the like are are are great.
15:54The people are thinking about those.
15:56Yeah,
15:56that's great. Dana and I also will
15:59point to Michael as well asking
16:02about direct observation, right.
16:04Like especially at the GME level,
16:07right when so many things are happening
16:09all the time tasks need to get done,
16:10you can't observe everything.
16:12What actually happened was anybody there?
16:15Do we need to like observe ourselves?
16:18So a lot of data that we still need
16:21from Alex as well, but it seems
16:24like Alex might need some support.
16:25I'd be interested to hear
16:26from the audience though.
16:27At which block do you think we
16:30should start talking about?
16:31So if you saw which of these
16:33evals would you say at what point,
16:36assuming they came back in a reasonable hour?
16:39I don't know if we have any
16:40program directors on the call,
16:41but like let's say you get an e-mail,
16:43I don't know,
16:44two weeks later would be like dreamy.
16:47What when would you start discussions about
16:49some sort of performance improvement plan?
16:52You can just throw that into the chat.
16:54I want to wait until we get
16:56at least 7 numbers in there.
16:59So 123 or not yet.
17:05When should we ask if Alex
17:08needs some more support? Yep.
17:12So Ken makes a good point.
17:13Like, you know,
17:14first month is always difficult.
17:15Transitions outside the
17:17hospital are hard enough,
17:19let alone inside the hospital.
17:21What else?
17:24Claudia is on it at least by three.
17:27And you know,
17:28I think it's always good to just ask
17:31be asking how our learners are doing.
17:33And you know,
17:34Kate mentions like early on like you know,
17:36maybe it's not like that like severe,
17:39but if there's something
17:39low hanging fruit, right,
17:41like a disorganization that
17:42can be like helpful to move
17:45their work along in the future.
17:48I think that's a a good point too.
17:52Any reason why?
17:53So I can't mentions one but
17:55what about like reasons why
17:57not necessarily doing that what
17:59kind of like makes you want to
18:01hold off Because I I do think
18:03there are legitimate reasons
18:04why we don't reach out for more
18:06support sooner for our learners.
18:16I know too many people here so we're
18:17going to start warm approaching people.
18:19Michael what's been your experience
18:21like what what is the reason why
18:23like you feel like learners don't
18:25necessarily like get referred early on.
18:27It might be from like the faculty end.
18:29It might be from the learning end.
18:30But as the head of the CSA committee,
18:32what do you find?
18:34I mean, some sometimes
18:37the students or the supervisors
18:39are concerned about this
18:41forward flow of information.
18:43And and as you know,
18:46as helpful as it could be,
18:47there's a fear that it would
18:51bias subsequent observers.
18:53And that's often a unfortunate barrier.
18:58It's a double edged sword, right?
18:59The educational hand off.
19:02There's always concerns about just how
19:04this will impact the trainee themselves.
19:07Could just could they be probably
19:08just going through like a thing
19:10during this period of time?
19:12Either the setting is tough for
19:13them or they're going through
19:14something that they outside the
19:16hospital that was able to be remedied
19:19quickly and they're doing fine,
19:21but then bringing attention.
19:22This could like start making them feel worse.
19:26In the perfect learning environment.
19:28It wouldn't be an issue.
19:31And so exactly so.
19:33Sandra mentioned the same thing,
19:36Feeling, fear, being judged too early.
19:39Robert was mentioning not wanting their
19:41supervisors to think badly about them.
19:43Future letters of recommendation.
19:45This is a tricky thing as well,
19:47especially once we get to certain stages.
19:50There's a performative aspect too.
19:51And a lot of times our learners,
19:53you know, are scared to show they
19:56don't know until it's too late.
19:58And so there's a certain, like,
19:59almost like hiding that can happen,
20:01which makes it even harder as a factor,
20:04I'll just say for any of y'all when
20:06you're thinking about your success team.
20:08There are a lot of people involved,
20:11so it's not just one person making the call.
20:14We're often triangulating this together,
20:16both in our assessment and in
20:17our support for our learner.
20:19But here at Yale,
20:21here are some examples of resources and
20:24you can probably find some analogy in where
20:27what your institution's programs processes.
20:29So around the EO medical students,
20:32we have their course directors there.
20:34And within those,
20:35the faculty who might be
20:36working more closely with them.
20:37For us,
20:38we have a pretty broad student
20:41affairs program with myself being
20:43part of our academic support team
20:45with Andrea our learning specialist.
20:48There's also other leadership students here,
20:51like Angela was mentioning,
20:52they're high performers,
20:53they're doing really neat stuff.
20:55And sometimes you'll have MDPHDS,
20:58MB, A program directors,
20:59other leadership who has staked
21:01them and wants to help as well.
21:04The coaching program that we have another
21:07layer that we're adding into what we do here.
21:10We also have our Dice program.
21:13Students individually might have mentors
21:15that they work with at different levels,
21:17clinical research,
21:18education.
21:18It's also important to note
21:20that we have other services is
21:22a nice part of being at Yale.
21:24We have accessibility services for
21:26learners who have some sort of learning
21:29disability or they're they need to
21:31be diagnosed if we realize that the
21:34learner might be struggling a lot.
21:36And of course,
21:37outside of the clinic, the hospital,
21:40the classroom setting,
21:42the healthcare providers,
21:43family and friends will also play
21:45a really important role in helping
21:47our students with their journey.
21:49This is not quite as beautiful,
21:51Dana,
21:52as your figure as far as the different
21:55parts of the learning triage go.
21:57But at least when it comes to
22:00the learners that we have,
22:01there are a number of ways
22:03that they can get to us in the
22:05performance improvement program.
22:07So students, they work with their faculty,
22:10they get feedback there.
22:12The faculty can also feed forward
22:14flow to the coaches and the
22:16potential of Dean's advisors.
22:17If there are struggles,
22:19usually it's at the faculty
22:21should be able by policy to meet
22:23with the learners at first,
22:25if they're struggling,
22:26give them feedback and then talk to
22:29the course directors so students
22:31aren't surprised when that happens.
22:33And then if a learner for whatever
22:35reason is struggling basic
22:36science clinical courses,
22:37then they can move on to
22:38the coaches or the
22:39advisors here about that as well.
22:41Now where we get involved is
22:43almost exclusively through
22:44the advisors or the course.
22:46Directors will mention to the advisors
22:48will talk to us if a learner really
22:51needs a lot of support outside their
22:55regular educational support teams.
22:57And that's when they referred
22:58them to us for an assessment,
23:00a learning plan and a reassessment as well.
23:04I'll pause for just a second to
23:06catch up on my chat and make sure
23:09I'm reading John's question. Well,
23:20you know, John, you make a good
23:22point about, you know, at what,
23:24like how much are we honestly
23:27allowed to know as educators, right.
23:29If it's something that's
23:31going on outside their life,
23:34it might be really personal, right?
23:36And you know, I think on the
23:38one hand you want to respect the
23:41private and everybody deserves
23:42to have their privacy respected.
23:44But when we're working in clinical settings,
23:46right, like these are highest stakes, right?
23:49And you know,
23:49especially if you get to the GME level
23:52and they're affecting patient care, right.
23:54I think that's worth noting.
23:56And so I think you can it's part
24:01of the and we can talk about the
24:03learning more about the learner
24:05in that introductory stage usually
24:07identify like more just the outputs
24:09like this learner is not where they
24:10need to be right now to the point that
24:13they can't safely care for patients,
24:14they can't meet whatever major
24:17tasks that they have a step exam
24:20an oski that they have.
24:22And so then I think, you know,
24:24it's more of an open-ended discussion
24:26with the learners about, hey,
24:28what do you think could be going on?
24:30I personally tell my learners,
24:33especially because I'm in this unique
24:36role where it's not something that
24:38necessarily goes on any transcripts
24:40or anything that anybody work with us,
24:42work with me.
24:43But I tell my learners, hey,
24:44help me, help you.
24:46Like if there's any way I
24:48can advocate for you,
24:49if there's things that
24:49are affecting your life,
24:50I can't say that I'll solve it, but we are.
24:53We've all been through these things
24:55before and it certainly wouldn't be like
24:58without beyond the realm of like normal,
25:01regular for those things too.
25:02So and then I just encourage them to share.
25:05And I'll say, John, you never know
25:06exactly what goes on in people's life.
25:08But I feel like at least the big things I've
25:12gotten surprised maybe like 5% of the time,
25:1610% of the time where
25:18something will come up later.
25:19And I'll say,
25:20hey,
25:20like why didn't you let me know that,
25:22you know that that would have
25:24been really helpful for me to
25:25help talk out with you as well.
25:27Does that answer your question, John?
25:30Yes, thanks. Very thorough, Sir.
25:33Thanks. It's such a balance.
25:35So when I'm talking about my
25:39initial evaluation process,
25:39John, this is a great segue.
25:41I first think about what is
25:43happening and this is if it's
25:45like a progressive process,
25:47right, Like a resident still
25:48on like their rotations, right.
25:50Maybe a student like finishes at the end.
25:52So it's what happened.
25:54But I try my best to triangulate.
25:57What are the things that are bringing,
26:00what is the situation around
26:03these this bad feedback,
26:05these evaluations that are so far
26:07this like performance that isn't
26:09that is less than expected at that
26:11time the situation then I think
26:14about extrinsic factors, external.
26:16So what is going on around the
26:18learn like many of you mentioned,
26:20right,
26:20like family crises that could be happening,
26:23financial insecurity,
26:24These are just some of the
26:27things that have come back up
26:29in my working with learners.
26:31Then I think about what are
26:33more intrinsic aspects of the
26:34learner themselves and there are
26:36different ways you can split this,
26:38categorize these.
26:39I think a big category broadly is
26:41health that we think of that everybody
26:44has mentioned physical health,
26:45mental health,
26:47other aspects to you know where I'm
26:50becoming more familiar and still
26:51hoping to learn more about learning
26:53disabilities that come up and are
26:55being diagnosed earlier and earlier.
26:57But we're doing that as well even
26:58at the medical school level.
26:59So I want to de stigmatize that a
27:01bit and saying our learners are
27:03incredible and they can get to Yale
27:06Medical School and these highest
27:08level of residency programs without
27:10even having something diagnosed
27:12or having been diagnosed and
27:14getting interventions for that.
27:16I think 1 common thing we think
27:18about is whether it's like
27:21personality characteristics,
27:22personal characteristics around organization,
27:25communication, these come up all the time.
27:27Communication you more see in
27:28things like professionalism,
27:30organization and outputs like
27:32efficiency that aren't quite
27:34happening the way they should.
27:35The insight one is again something
27:38that is intrinsic to the learner.
27:41It's really tough to build
27:43that reflective process,
27:45but can a learner identify
27:47where they're struggling?
27:48Because I've had learners who
27:49have all the other three aspects
27:52that I'm mentioning here.
27:54OK.
27:54But the insight actually is what
27:56makes it even harder for them to
27:59progress as opposed to some of those
28:01other factors that we were talking about.
28:04So then I think about what do we need to do,
28:07right.
28:08So what are our new outputs
28:09that we need to come up with?
28:11You can go back to the competencies,
28:13whatever skills,
28:13you can break them down in different ways.
28:15For example,
28:15if you want to say like you know,
28:17within patient care, history,
28:19physical exam, clinical reasoning,
28:21documentation, whatever this is.
28:23But what do I need to help grow the learner,
28:25right.
28:25So again,
28:26we try and figure out what happened,
28:28what has been happening,
28:30extrinsic factors,
28:31intrinsic factors and then
28:32what where do we need to
28:35get them to. Does anybody have
28:37questions around that kind of how I
28:40think about learners and this isn't
28:42particularly novel or anything.
28:43There are shades of this in everything we do
28:46in order to, you know,
28:48for you to figure out which competency
28:51or sub competency it would.
28:53Do you find yourself performing,
28:56for lack of a better word,
28:58some sort of diagnostic tests.
29:01Yeah, that's a great segue. Yes.
29:03In in multiple different formats, Michael,
29:05because we're going to have to get data.
29:07So I try and triangulate a lot of this
29:09information and this actually isn't like
29:11a perfect timeline of how things go.
29:13I try and do as much of
29:15my homework previously.
29:16So finding out what their previous
29:19records are, talking to some
29:21of the people they worked with,
29:23you know, obviously their advisors,
29:25their coaches,
29:25but honestly even course directors.
29:27What were you hearing?
29:29And maybe even sometimes the faculty,
29:32the initial point person, the attending,
29:33who was on service with them,
29:35who reached out to the course director,
29:36the small group leader who reach out
29:38to the course director to get as high
29:41fidelity information as possible.
29:42Because you lose your learners in those
29:44early conversations if they feel like
29:46you don't know what they're talking about.
29:48And if you aren't,
29:50if you're inaccurate in some ways you
29:52almost have to be 150% correct just
29:54to make like a 10% change of sorts.
29:58So Michael, we're going to get to
30:00that learning plan a little bit,
30:00but I just wanted to provide some of
30:03this information on Alex, our learner,
30:04so we can think about them more.
30:06So we have our struggling learner, Alex,
30:08we find across like talking to them,
30:11talking to their, their team,
30:14their success team.
30:15We find that they have seemingly
30:17a good support system,
30:18at least that they're close
30:20with their family.
30:21However, things have been bumpier lately.
30:24The move has been tough.
30:25They live across the country
30:27or father has been ill,
30:29which can certainly play a role.
30:30This happens very commonly with
30:33learners for mental health.
30:34There might not be a formal diagnosis,
30:37but she they or they perceive he or the she,
30:41or they perceive themselves
30:42as having no formal diagnosis,
30:45but report feeling anxious and
30:47stressed about the new rotations,
30:49saying that they drink occasionally
30:51but no clear substance use disorder.
30:54I will say the latter is really
30:57hard to tease out.
30:58I honestly like have never like
31:01formally like diagnosed that or
31:02had a learner tell tell me that.
31:05So that could be like a blind
31:06spot in what I do.
31:07I mean I understand why that they
31:09wouldn't share those with me,
31:10but I'll just say that keep a closer
31:13eye on that because you might not get
31:15direct information from the learner
31:17or outside sources for study skills.
31:20Alex likes podcast and question banks and
31:22does try to read about their patients.
31:25Sometimes it can also be helpful
31:27to ask Alex exactly what they mean
31:30by reading about their patients.
31:32So then we come up with an individual
31:35learning plan, individualized learning plan,
31:36different ways of putting it,
31:37Ieps as well which have their own
31:40like connotation from like the
31:42secondary elementary schools.
31:43But I will say this,
31:45every individual learning,
31:46individualized learning plan starts
31:48with the learner you have to have
31:50buy and they have to be
31:51on board otherwise it just
31:52isn't going to be as effective.
31:54And so when we think about these,
31:56we want to make sure they have ownership,
31:58their self direction and that we have
32:00plans for both short term and long
32:03term learning so that it's sustainable
32:05once they're done their work with you.
32:08So you know my initial,
32:09my different types of meetings
32:11as we think about sessions,
32:12so you know some will usually
32:14be an introduction.
32:16I'll admit I do fairly long
32:18introductions with my students
32:20anywhere from 45 to 90 minutes if
32:23we're really getting into the details,
32:26covering everything honestly first from
32:29who they are as a person who matters to them.
32:32One question that I ask is,
32:34do you have people who you can
32:36tell at least 90% of your life to?
32:38Because it's interesting how fragmented
32:40the different worlds can be for learners.
32:42They have friends who talk about
32:44their personal stuff.
32:44They have their medical school people.
32:46Then I get observations and Mike,
32:48I'll talk about that a little bit more.
32:50Obviously we'll assess during that
32:51time for our more primary data.
32:53We'll give feedback,
32:54talk about directed learning
32:55and we'll do follow up.
32:57There are shades of all of these
32:59great tools out there from the R2C2
33:02really building on relationship,
33:04making sure we're having SMART goals, right.
33:07So being specific, measurable to realistic.
33:10When we give feedback,
33:11we want to try and be as consistent
33:13in how we do as possible, right.
33:15So they're ready their goals
33:17before you go in.
33:19Then you ask them that,
33:20you're asking them how it went.
33:21You're making sure they're retaining
33:23that information for take home to for,
33:26you know, doing it in the future.
33:29You want to make sure as much as
33:31you can that you're trying to
33:32help them build self regulation
33:34with that reflective practice.
33:36So a lot of these are threaded and
33:37I don't think there's any single
33:39particular model or paradigm that works.
33:42But we just have been doing medical
33:43education for a while and all of them,
33:45all of those and works are helpful.
33:47Dana.
33:48Yeah,
33:49I just didn't know if any of the
33:51listeners might have this question.
33:53But back when you were talking
33:55about asking the questions about
33:58mental health or physical that there
34:00may be a difference with what like
34:02program directors and faculty can ask
34:04about that as opposed to Someone Like
34:07You or who's separate from the program.
34:08Do you want us to say,
34:10yeah, that's such a good point Dana,
34:12I I feel like I and I mean I need it,
34:17but like it's a very
34:20different level of knowledge.
34:21And honestly like volition I have with
34:24students the willingness that their
34:25share they're able to share because
34:27they know like I'm like a closed
34:29source like when I talk to example.
34:32So I, myself and Andrew,
34:34we work together,
34:34we have like because we like share
34:36pretty much all of our learners together.
34:39We have like our own like closed off
34:42like way of like talk about learners,
34:45but we don't actually share everything
34:47honestly even with the advisors like
34:49they help us with extra information.
34:51But you know sometimes it'll be like,
34:53hey we'll like there's like
34:54some like health thing going on.
34:56There's social and it's very reasonable
34:58for us to take this amount of time.
35:00And I think you know,
35:01at what stage more to your question is
35:04someone able to ask those like questions.
35:07I think for just the primary
35:09faculty attending,
35:10I think it's OK just to show an interest
35:12like, hey, like how's it going?
35:14Like I noticed that you were
35:16late to this session, right?
35:17I probably would get to like that
35:19level of detail most unless a learner
35:21like really shares everything and
35:22then you have to ask permission like,
35:24hey, like you know,
35:25you might want to reach out to someone.
35:27Would you want me to advocate for you?
35:29Similarly,
35:30once you get to more leadership roles,
35:32course directors,
35:33advisors then like learners often
35:36are more willing actually to share.
35:39And I think it's fair to ask
35:41a little bit more.
35:42I think once you get to,
35:43at least for us, I don't know,
35:44of course,
35:45directors are really exploring as much
35:48along those like personal details as much.
35:51So probably similar to what
35:53I described for attendings.
35:54But I think honestly when it
35:55gets to like the advisor,
35:56maybe even the coach level,
35:58because I know that's more of a
36:00longitudinal relationship where
36:02they're not really being judged
36:03or or graded by them.
36:05I think that's when you start getting
36:07to the point where like it's fair to
36:09ask a little bit more detailed questions.
36:11Does that answer your question,
36:12Dana?
36:14Yeah. I just know that there's
36:16some tension around, you know,
36:17program directors not being able to
36:18say what are your medical problems,
36:20You know, unless, you know they are,
36:22they're volunteered. You know,
36:23as opposed to like saying, you know,
36:25if you think a medical problem or a
36:26mental health issue could be getting
36:27in the way of your performance,
36:29you know, here it's the resources. Yeah.
36:31No, I think that's fair.
36:33I mean, I I don't quite know,
36:34especially because when you
36:35say program director, right,
36:36Like that's at the GME level
36:38that I'm not operating at.
36:39And so there might be honestly,
36:40like legal reasons for that.
36:42So make sure like, you get those
36:44details down if you're in leadership.
36:45But I think for most people just asking like,
36:47hey, how you're doing like initially
36:49can open up a lot of dialogue.
36:52So what are the resources that I like,
36:55have at my disposal And
36:57that a lot of services,
36:59a lot of like different programs could
37:01have and as well As for analogy 1.
37:03So speaking about the
37:05learner health resources,
37:06I know we have a lot of mental
37:09health resources as well.
37:10I think it can be important,
37:11especially if you're at leadership to
37:12know how to get your learners to whatever
37:15they need including accessibility services,
37:17including if there are financial
37:19struggles which could be playing a role,
37:22clinical skills.
37:23So you know,
37:25I think so we have Andrea as
37:27Andrea as our learning specialist.
37:30We have the ability to use standardized
37:33patients within our program which are
37:36really helpful for objective assessments.
37:38There are different knowledge
37:39resources for example that we have.
37:41So we have like an ambos database
37:43or you could say up to date or
37:44dynamite or whatever you want to use.
37:46So knowledge building resources there.
37:48We have a wonderful library that has many,
37:50many more,
37:51not just just for professionalism,
37:54but we do like think about the
37:56importance of like reflection as a tool.
37:59I will say professionalism
38:00can be really tricky.
38:01Insight can be really tricky and I haven't
38:04done a lot of like narrative work the way Dr.
38:07Kalai suggests,
38:08but it has been done and
38:10talked about in the literature.
38:12We have a theatre coach.
38:13Actually we we don't use them a ton.
38:16But in certain situations where
38:18learners are really struggling,
38:20there's just like such such a big
38:22disconnect between what they know and
38:24what they can do in some settings
38:26versus the actual clinical setting.
38:28It can be helpful.
38:29Sometimes we have referred learners to
38:32our Yale School of Drama for coaches
38:35who can help them with prevent how
38:38they present themselves and other
38:41aspects of using their voice and
38:43really making sure they can get out
38:45what they know and what they can show.
38:47Systems based practice.
38:49That gets an organization honestly like
38:51learning how to organize your in basket,
38:54how to organize your day,
38:56how to organize your e-mail,
38:58how to set up a schedule,
39:00working them through their
39:02actual tasks that they'll do,
39:04how they call consults,
39:05how they look through the chart.
39:07I've had students ask me to work on all
39:09of these with them for both clinical skills,
39:12which is my background,
39:14but also on things like test taking too.
39:18So we talked about those
39:20different forms of feedback.
39:21But Michael,
39:21I know I've put a pin in it
39:23for a while. But now just
39:25talking about observations,
39:26you can triangulate as much
39:28information as you want,
39:29but you really need high quality
39:32observations and feedback,
39:33especially to really get your
39:35learner on the same page with you.
39:37Because if things are second
39:39hand and you can't speak very
39:41in a detailed fashion about it,
39:43it's just going to be tough to get by in.
39:45So I start off with some sort
39:48of low fidelity scenarios.
39:49So I'll have my initial introduction
39:51and then I may have just a zoom call
39:54of sorts to have conversations.
39:55I might like play if it's clinical skills,
39:58I might just have some sort of a
40:00play the role of an SP and just have
40:03them practice asking questions.
40:05If they're strong with their
40:06clinical reasoning,
40:07I might just give them chief
40:08concerns and talk about them.
40:10If we're talking about like test planning,
40:12test prep, I may ask them,
40:14you know exactly what their
40:16plan is for studying.
40:17Just getting an idea of what
40:19they would do on their own in
40:21a quick and easy fashion.
40:23Then I try and move them towards
40:25more forms of higher fidelity
40:27situation based off of what we do
40:29in our lower fidelity situations.
40:31Then I figure out if we need like an
40:33intermediate step like simulation
40:34or if we can really take our show on
40:37the roller and get them into like
40:39the high fidelity real setting for example,
40:42like taking them onto the awards with me,
40:45Michael,
40:45I I'm not sure if you have a hand up.
40:47It looks like you might have been
40:48raising your hand. No, no, OK, sorry.
40:51I just want to make sure include everybody.
40:54Again, like if you have any comments,
40:56thoughts, questions,
40:57please feel free to throw them in the chat.
41:00So as we're going for feedback
41:02if I'm being honest.
41:03So what do are the most things
41:05working with learners who come to me,
41:07they have reached that level.
41:10I start off with frameworks of sorts.
41:12So for example Michael,
41:15I had mentioned that you know we
41:18we had those students who were
41:20working on those Oskis for.
41:21And I will say no,
41:22we we we do go through this whole like chain.
41:25We go through like the self reflection.
41:27I'll do some low fidelity exercise and
41:29then I might give them tips here or there,
41:32see how they incorporate those tips as well.
41:35But for most learners who work with me,
41:38they need some sort of framework and
41:41that works across all the different
41:43those different competencies,
41:44not just patient care and clinical skills,
41:47but for professionalism as well.
41:50For knowledge more specifically.
41:51I honestly believe like you can
41:53make frameworks.
41:54I I take analogy from the clinical
41:56reasoning literature that I'm immersed in.
41:58But you know,
41:58I think that works across any skill.
42:01Sometimes I'll have to model,
42:02sometimes I'll have to do scripts.
42:04But I will say,
42:05while I use all of these on occasion,
42:07my goal is to move the learners more
42:10and more to the left of those, right.
42:13That's why I have the
42:14arrows going that direction.
42:15If your learner is staying on the right side,
42:18they really need things modeled.
42:20They need scripts,
42:21but they can't do it on their own.
42:23They can't replicate it or they'll
42:24replicate it and they you come back
42:26to it and they still are struggling.
42:28That's when I think you really need to
42:30consider some of those other aspects
42:32We talked about outside or even
42:34intrinsic to the learners, like, hey,
42:36are we sure there's nothing going on?
42:37Is there not a mental health
42:41process going on?
42:42Is there not some sort of maybe even learning
42:45disability that might be affecting them?
42:46So just to give some reference,
42:48like those are the points where we
42:50actually start like potentially referring
42:52out to some of those services as well.
42:54It can be like completely private.
42:56We have therapists, cognitive psychologists,
42:58I just will just refer to initially
42:59just hey like just take a meeting.
43:01This is like helpful for like you know,
43:03could be helpful for anybody,
43:03at least at therapy level,
43:05could be a one off,
43:06but at least just talk to them.
43:08And then accessibility services,
43:10well, nothing might come from that
43:13but at least it's worth a shot.
43:14And I think learners,
43:15when they realize that they are
43:17really struggling to move forward,
43:19they're more open to it in my experience.
43:24So as we move on,
43:26we get to outcomes.
43:27Outcomes is one of the hardest parts
43:30of the performance improvement process.
43:32We get more evaluations again
43:34with significant lag time.
43:36So you know you play this game
43:38then of like you you don't want to
43:40like tell necessarily the faculty
43:41who are working on this learner,
43:43but maybe like following up with
43:44them afterwards and see what happened
43:46as quickly as possible,
43:47just because you'd want to make
43:49sure that they get like a fair
43:51and honest evaluation.
43:53Direct observations for example.
43:54Like you know students often
43:56have to just repeat stuff,
43:58knowledge assessments.
43:59And I mentioned some examples of
44:01why it's challenging.
44:03One, the lagging evaluations, One,
44:05it just it takes a lot of time to improve.
44:10And you know, I think we don't
44:12necessarily see changes right away.
44:14Sometimes,
44:15you know,
44:15you might get some progression and
44:18then maybe less so or or falling
44:20back into all habits and maybe
44:21that's just like a tougher setting,
44:23right?
44:24Like maybe they really did well on one
44:26rotation because they have that knowledge,
44:28they have that skill set or
44:30maybe they were just working in
44:31like a learning environment that
44:33they felt really comfortable in
44:34that they could thrive in.
44:36So the data is just so messy.
44:38In addition to them taking
44:41time to improve on their own,
44:43some more challenges that we think
44:45of the lack of early information
44:47we described the like a double
44:49edged sword of forward feeding,
44:51educational hand off attitudinal.
44:53So the insight that I mentioned
44:57motivation can come up.
44:59I have seen it come up,
45:00it doesn't come up all the time
45:03or that often to be honest.
45:04A bigger thing I honestly
45:06see is just like shame.
45:07There was a great JAMA paper
45:09on shame a few years ago.
45:11Academic medicine has said some
45:13perspective pieces and actually
45:14some qualitative studies on this.
45:16This is a big aspect of what we do.
45:18I saw in the comments earlier talking
45:20about the high performers, right?
45:22And we're in this world of
45:23so much positive feedback.
45:25And you know, we can say terms
45:27like growth mindset all the time,
45:28but that's honestly just not how
45:30the way all of us are, even myself,
45:32you know, for resources.
45:34So this is a big thing.
45:36I, you know, I'll give this talk,
45:38I'll show like all my slides of our
45:41success team, all these resources,
45:42particularly a drama coach
45:44can always get some like,
45:45eyebrows raised.
45:46But this is tough in different settings.
45:50And you know the the,
45:52the biggest one I think that you
45:54would hope for is at least time,
45:56time to do those observations
45:57in a consistent fashion.
45:59That's something I've really tried
46:01to do myself is trying and to bring
46:05learners on service with me to get
46:07reps with them virtually with SPS.
46:10But that's just not always realistic.
46:12Sometimes you have to get the faculty
46:14to do so, and that can be tough.
46:15Sometimes your faculty who are
46:17working with learners need to be,
46:18like, trained up.
46:19Another reason why it's great
46:20to be a faculty.
46:21Coming out to these Yes series.
46:23And then just the types of
46:25assessments can be tricky too.
46:26There just often aren't many ways
46:28for us to do that and following up,
46:32they're often unclear parameters
46:34for outcomes,
46:35right Like,
46:35so it's been a while since I've sat
46:38in on clinical competency meeting,
46:40but I know right,
46:41like you're moving your learners along.
46:42Like at what point is like
46:44the point of no return?
46:45Like we need to extend
46:48this learner's training.
46:49At what point have we
46:50seen enough information?
46:51How much do we value this versus that data?
46:53So it can be tricky to figure out when
46:55you've had enough data to say you,
46:57you can decide on that outcome.
47:00Stakeholders can be tricky to
47:01identify and collaborate with.
47:03So there are a lot of challenges
47:05obviously in performance improvement.
47:06But you know,
47:08hopefully there are some like tools
47:10and strategies that that we can
47:13share with each other that you know,
47:15it might be like suggesting as well.
47:16I think you know as a whole in
47:20medical education we are lowering our
47:22threshold and we're destigmatizing
47:24more about how we frame just
47:27improvement which is important.
47:29And you know, as I,
47:30as we think about moving forward,
47:32I think just the name can be tricky
47:35sometimes there are formal there,
47:37there are times when you formally
47:39need to use these words.
47:41But it's been a long time since
47:43I was called
47:43director of remediation.
47:45I was hired into that role in January
47:472021 and I only had four students who
47:49I was working with because they had.
47:52They were only at that point where
47:55something really bad had happened.
47:57And now and since then January 2021,
47:59I'm getting close to,
48:00I've worked with 200 learners
48:03and many of them have been self
48:05referring themselves so to speak.
48:07I mean, I think there's a value in that,
48:09right, As if we move more towards just
48:11coaching and performance improvement
48:12and getting a more support system
48:15like Dana Adena's coaching program.
48:17So it's not just me and we can
48:19catch learners earlier on in
48:21the process or support them.
48:22So they don't necessarily need
48:23to get to me at any point.
48:25So I think transitioning that as
48:27much as we can is certainly of value.
48:31So what about qualities of
48:34successful programs.
48:35So as much as you can try and be
48:37learner centre, early identification,
48:39having data when you can is helpful, right.
48:43And so for example,
48:45we're going to start moving more towards
48:47like within our educational portfolio,
48:49those evaluations that are going
48:51to be coming up and they're going
48:53to be coached and reviewed as well.
48:55The resources.
48:56I think this is really tough
48:57at the GME level,
48:59particularly with smaller programs.
49:00But I do think there are benefits
49:03and maybe there's role in the future
49:05for a broader coaching program.
49:08I usually give this talk with Andrew Parsons,
49:11one of my frequent collaborators
49:12who's out of Virginia,
49:14and he has a GME role of broader coaching
49:18for everybody and all specialties
49:21can refer learners, so to speak,
49:23into those types of programs.
49:26And so anything else you can do there
49:29making sure those things outside the
49:31hospital are being supported like
49:33Wellness finances when possible as well.
49:36Those bring together like really
49:39strong successful support programs.
49:42And I think that kind of touches on
49:44what I consider the biggest future
49:46direction for performance improvement.
49:48Just trying our best to really move
49:51that forward having a lower threshold
49:54for having learners reach out,
49:56maybe having more standardized
49:58coaching and feedback with more
50:00longitudinal objective learners
50:01instead of relying at least at the
50:04GME level on just their in time
50:06evaluators I think and then just
50:08giving more robust support for the
50:11educators that are needed do that.
50:13Michael,
50:14I'm just thinking, you know,
50:17maybe with the coaching program,
50:20struggling learners will be
50:22detected earlier and and a a
50:25plan could be put in the place
50:28and maybe they never reach you.
50:32Yeah, you know, I think it's interesting.
50:33We were at the retreat and Dana was
50:36asking us earlier just about like how the
50:39coaching program has affected referrals.
50:40And we quite haven't like gotten to that
50:43stage simply because the coaches haven't been
50:45around long enough to really like compare.
50:47But it'll be really interesting
50:49to see next year because you could
50:51argue both ends are a success, right?
50:53Like if we get more referrals,
50:55that could be a success, right?
50:56And also if we got less referrals
50:58like that could also be a success.
51:00As you know,
51:01our coaches get more familiar with a
51:03lot of these like slick new study tools
51:06that are learners are using now. Or
51:08maybe you see the most extreme cases,
51:11right. And and maybe it's just like
51:12honestly like that, Michael, right?
51:14Like the acuity, so to speak,
51:16like there are less extreme cases,
51:18right, Because once a learner has
51:20gotten that far, it is really tough.
51:22It's really tough to pull them out
51:24without extending their training time,
51:29so open to questions and answers.
51:31I do want to make sure I leave
51:34this evaluation up there for
51:35any but for all of Y'all,
51:37we appreciate your feedback
51:39here with the Yes series,
51:40but I'm here for any other questions
51:42and thoughts that Y'all might have.
51:50Can can I just make a plug?
51:52Also that and just this is not
51:55that all of the people on the call
51:57today could come to all the yeses,
51:58but this also I think another
52:00characteristics for success is that
52:02all of this is built on hopefully
52:04that you've articulated your goals
52:06like so maybe learners aren't able
52:08to perform because they don't know,
52:09they can't guess what you want maybe
52:11like in the clinical realm for example.
52:13So thinking about being effective
52:15in setting your goals and we'd have
52:18sessions about then when you when
52:20you've that those have not been met
52:23how effective has your feedback been
52:25because a lot of times you know maybe
52:28people struggle because we remain
52:29unclear and we remain like not giving
52:32them feedback and then they struggle
52:33and then we are in a worse position.
52:35So ideally this is all kind of built on
52:39these found this foundational skills.
52:43So just want to put put that in there.
52:47Definitely agree.
52:52I don't know if you did you have
52:53any resources on another slide
52:55or anything before any people go
52:56away till everybody I did and I'll
52:58go away and you, you can honestly
53:00I feel like I need Linda's
53:02permission because poor Linda has
53:03not been getting any people filling
53:05out like my session evaluations.
53:07And I think it's 'cause I'm not
53:09lingering long enough on this slide,
53:10but I'm happy to like open up
53:12to other resources as far as we
53:14do 60 seconds typically.
53:16So I think I was perfect.
53:18Oh, and yes, Pete,
53:21we have some upcoming talks. Dana,
53:23if you want to mention and then I can
53:26put the resources on the last slide.
53:29Yeah, the Med Ed discussion group on
53:31nutrition with Nate Wood coming up.
53:34And then we have a session on chalk talks
53:36for this Yes series with Jeremy Mueller.
53:39There's the QR code if you want to register.
53:40Thanks, Dylan. You can go on.
53:43All right. And so thank you so much
53:46for being at today's Yes series
53:48where we talked about training
53:50performance improvement, We talked
53:52about the current state of education.
53:54We talked about the future as
53:56well and how to identify learners,
53:58what stages of feedback,
54:00what stages of struggle, so to speak,
54:03and also what might be like
54:05holistic approaches to helping
54:07them meet their goals eventually.
54:09So some resources here and thank you so
54:12much for coming out again to this Yes series.
54:17Thanks, Nilan. Yeah.
54:19And any questions anybody has while
54:21you're downloading his references,
54:30you have clapping hands.
54:32I'll take it. I
54:45don't know if you guys like, you know,
54:47looking at it more aesthetically
54:49pleasing picture everybody.
54:51I think I'm going to go,
54:51there's some people out here,
54:53Dana, I think I'm going to say
54:56congratulations to some of the.
54:57Yeah, go check it out. All right.
55:00We'll, we'll catch up the the line.
55:01And thank you very much.
55:02And thanks everybody for joining. All
55:03right. Bye all. Thank you.