11-3: YES!: Enhancing Bedside Teaching

November 03, 2023

ID10939

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00:00Yes is a
00:02yes is a year long series that gives
00:05us the opportunity to meet at this
00:07time on Friday is twice a month,
00:09this time on Fridays.
00:11So we welcome your ongoing
00:13attendance at the series.
00:15Doctor Andres Martin from Psychiatry
00:17in the Child Study Center and
00:19Doctor Dana Dunn from Internal
00:21Medicine are Co directors of YES.
00:23So I'd like to invite Doctor Martin
00:26now to let us know what we'll
00:28be doing today and to introduce
00:30today's presenter, Andreas.
00:33Thanks, John.
00:34Well, we're all in for a treat today and I
00:39won't take much time telling you about Jeff,
00:43but I'll share one or two things.
00:45As you can see, he is a neurologist.
00:47He's an associate professor in
00:49the Department of Neurology,
00:51Neurology assistant, associate.
00:52He should be a assistant.
00:56He's assistant. But you heard it here first.
00:58You heard it here first.
00:59He will be an associate
01:01sometime soon I'm I'm sure.
01:03And he is associate training director
01:07for the residency and it's interesting
01:09that he's a director of Wellness.
01:11I I say that because as you get to know
01:14Jeff and the time that I've met him
01:16you will see what a Zen master he is.
01:18He's a really incredibly calm and
01:23calming presence and and everything
01:25that he does in teaching and and
01:28so when I asked him what area of
01:29neurology he is dedicated to I thought
01:31it was going to be I don't know like
01:34some brain waves about calmness.
01:35No. He is an electromuscular Dr.
01:38Doctor so for a living he inserts needles
01:42into people pleasant experience but he
01:44is an expert at that and general neurology.
01:48So today Jeff is going to be telling us about
01:52the what I think could be in some places,
01:56the lost art of bedside teaching.
01:57But it is far from lost and with with
02:01teachers and educators like like Jeff it,
02:04it will not be lost.
02:05So let's learn about that bedside teaching.
02:07Jeff,
02:09thank you. Thank you all for having me.
02:11I don't usually get to join at this time.
02:12So I'm excited to to be part
02:15of the series and to attend
02:16today in my speaker role.
02:18I'll switch the next slide.
02:19Here's all the CME information
02:21you need to know.
02:23The code and the number are also in the chat,
02:26so don't feel like you have
02:27to frantically put that down.
02:32So we asked you ahead of time.
02:34You may have seemed to come with a
02:36mobile device, and this is going
02:38to be an interactive session.
02:39I hope to listen,
02:41maybe not as much as I speak,
02:43but at least a fair proportion of
02:45the time to what you have to say.
02:47And I've found that I know you all learned
02:49about Mentimeter at the last session.
02:51I found it's a really useful
02:52platform for teaching and we're
02:53going to use it together today.
02:55So the instructions will be
02:56at the top of every slide.
02:58If for any reason you get logged out,
03:00you'll also notice in the in the on
03:02your screen some slides will give you
03:03an opportunity to give a thumbs up.
03:05Some slides will give you an
03:07opportunity to ask a question.
03:08So if you have a question,
03:10just click on the question button and
03:11I'll be monitoring the bottom of the screen.
03:13Other ways to ask questions are
03:15to raise your hand in zoom or
03:16to drop them in the chat.
03:20So let's see if we got logged in.
03:21Please share with us a recent moment of joy,
03:25something that brought you joy.
03:26While we're waiting, I'll just share.
03:28We entered my dog in a Halloween costume
03:30contest last weekend at a local brewery.
03:33Anyone. Top prize?
03:34So that was my moment of joy that
03:36we dressed him up as serious black.
03:38He's a big black dog.
03:39And for those of you who know
03:40the Harry Potter series,
03:41that was his sort of alter ego.
03:43That character was a dog.
03:44So I see people who did some baking,
03:47some reorganizing,
03:48spending some time with family.
03:50Yeah.
03:52And and dogs. All right.
03:56This is good.
03:58I always get joy just reading these.
04:00I I hope you all do as well.
04:02And I'm happy to see that you're
04:04able to log in and use Ventimeter.
04:05So keep your phone handy.
04:08We are going to, I'm going to hit
04:10you with questions throughout this.
04:12Some will be free response.
04:13Some will be just polls,
04:15and you'll it'll give you a little
04:17taste of how I use mentimeter in
04:19an instructional level as well,
04:20although I can't say I've ever
04:21incorporated it at the bedside.
04:23So thank you for sharing
04:24these moments of joy.
04:26Please share what thoughts or
04:27feelings come to mind when you
04:29think about bedside teaching.
04:31These can be emotions.
04:32These can be key points
04:35about good bedside teaching.
04:37These can be personal experiences.
04:38But what do you think about,
04:44especially if someone told you,
04:45hey, today you have to go and you
04:47have to teach at the bedside,
04:48what does that make you feel?
04:51Well thank you for sharing a
04:52moment to join the chat too.
04:53I see that excitement, curiosity,
04:59fun, happy, valuable.
05:00I agree it's very valuable.
05:03There isn't.
05:04There is a performance elements
05:05that side teaching for sure,
05:07involving the patient,
05:08great 19th century sad emoji
05:14lost art. Yeah, you know,
05:16I agree with a lot of these points.
05:20Keep your senses peeled.
05:22Absolutely. Be curious.
05:25Awkward. It can certainly be awkward.
05:27I think with good with practice
05:29and good good practices,
05:30we can make it less awkward.
05:32Wish it was more common. I agree.
05:35Thank you for sharing that.
05:38Just so I know who I'm talking to.
05:39How long have you been in your
05:40role as a teaching faculty here?
05:41And it doesn't have to be here at Yale.
05:50It can be on any institution you're
05:52around. But where do we stand? We've
05:56got some junior teachers,
05:58some master teachers, some people
06:00who are perhaps younger masters.
06:05Interesting. We're missing the six to
06:0710 year demographic, but that's OK.
06:08So I think no matter how long
06:10you've been teaching for,
06:11you've probably done, oh,
06:13there we go. Good.
06:14You've done some bedside teaching.
06:16Some of you may make it central
06:18to your practice.
06:18Some of you may dabble and my
06:21hope is that you'll no matter what
06:22amount you do after this talk,
06:24you'll do a little more and you'll feel
06:26a little more comfortable doing it.
06:28So what percentage of teaching and
06:30learning is done in the presence
06:32of a patient in your practice?
06:33As a teacher and this,
06:35I want to know both in the ideal
06:37setting but also in reality,
06:38you know,
06:38with with the constraints of
06:40teaching at the bedside involved,
06:42where do you end up.
07:00This is fairly typical of what I
07:02see when I ask people this question.
07:03We all want to do more and I
07:07think that's very telling.
07:09Some of you would like to
07:10do it all of the time,
07:11some of you get to do it most of the time,
07:12which is pretty cool.
07:15Not all of us are are in that position.
07:17And again, I want to move you more toward
07:19your ideal by the end of this talk.
07:23One last question for now.
07:25Where do you teach?
07:49Yeah, so this is already approaching.
07:51Again, what I typically see when I have
07:54these conversations with teachers is
07:56the majority of teaching goes on as
08:00far away from the patient as possible,
08:01right in a conference room at a table,
08:04probably with a white board or a
08:05computer involved. And that's OK.
08:07And I'm not saying that's bad teaching.
08:09I think that could be very good teaching,
08:11but of course that's not our focus today.
08:13I always am interested in how much teaching
08:16goes on in the hallway sort of in that
08:18in that liminal space between the the
08:21conference room and the patient's bedside.
08:23And then of course we end up doing
08:25probably the least amount at the bedside.
08:27And there are many reasons for that
08:29which we're going to talk about.
08:31So let's let's define what
08:32we're talking about today.
08:33So my definition of bedside
08:37teaching is clinical teaching in
08:38the presence of a patient.
08:40So that can be teaching the exam,
08:42that can be teaching history,
08:46taking skills,
08:48presentation skills,
08:49rounding with the patient in in in front
08:51of the team and doing some teaching.
08:53In that setting it can be a total one
08:55off teaching session where you grab
08:57some students who are pre clinical and
08:59take them to the bedside to teach.
09:02So there are many ways to teach
09:03at the bedside,
09:03but really it's that presence of the patient
09:06that defines what we're talking about today.
09:08So bedside teaching has been around
09:10since really the the 17th century
09:13and and at least at least that long,
09:15probably not much longer,
09:17right,
09:17Probably since in the history of medicine
09:19there's always been bedside teaching,
09:20but this is a quote from Sylvia.
09:22So my method,
09:23hitherto unknown here and
09:25possibly anywhere else,
09:26is to lead my students by the
09:27hand to the practice of medicine,
09:29taking them every day to see
09:31patients in the public hospital.
09:33But they may hear the patient's symptoms
09:35and see their physical findings.
09:37And then I question the students
09:39as to what they have noted in the
09:41patients and about their thoughts
09:43and perceptions regarding the
09:44illnesses and principles of treatment.
09:46I couldn't put bedside teaching any better,
09:48right?
09:48Taking the students to the practice
09:51of medicine,
09:51to the bedside where they can
09:53learn from the patients.
09:55And of course we'd be remiss if
09:56we didn't find a no slick quote.
09:58There should be no teaching without
09:59a patient for a text.
10:01And the best teaching is that
10:02taught by the patient himself.
10:04So I find these quotes inspiring.
10:05They remind me how important
10:08bedside teaching is.
10:10I hope they do the same for you.
10:12Bedside teaching is not what it used to be.
10:14So if you look at the literature,
10:17back in the 60s we were teaching at least
10:20reportedly 75% of the time at the bedside,
10:23and now we're teaching perhaps less
10:26than 20% of the time at the bedside.
10:27And that kind of resonates with the
10:30data that you all gave me a moment ago
10:31as to where you spend most
10:33of your time teaching.
10:34So why is that? Well, let's,
10:37let's look at some more data first.
10:38So this is a busy table.
10:41I'm going to show you what's
10:42important in a second.
10:43But basically what this study did was it,
10:46it surveyed medical students and
10:48internal medicine residents and
10:49it asked them how much of your
10:51time is spent at the bedside
10:53during rounds with the attending?
10:55And then how many,
10:56what percentage of cases are
10:57you presenting at the bedside,
10:59So actually presenting the history,
11:01the differential diagnosis,
11:02the thought process and the clinical
11:05reasoning in front of the patient.
11:06And the,
11:07the real standout point here is first of all,
11:10if you look at the top numbers,
11:13somewhere between 1/4 and 1/3 of time
11:15is spent at the bedside on rounds.
11:18It's kind of crazy when you think about it.
11:20But in terms of case presentations,
11:23the vast majority are presenting 25%
11:27or less of their cases at the bedside,
11:29meaning most cases are being presented,
11:31thought through,
11:32discussed in a conference room
11:33or in a hallway.
11:53So why, why do you think that is
11:57much data the time it takes?
11:59We'll talk about time in a little bit.
12:02Yeah. COVID has absolutely
12:03changed how we round and teach
12:06the reliance on the EMRI.
12:07Agree confidentiality is an issue,
12:09especially in crowded rooms, right,
12:11with two or more patients in a room,
12:14busy schedules.
12:17Let's see. There's a lot of answers here.
12:18Time. Afraid of patients and needing
12:20the computer to enter orders.
12:22That comes up a lot.
12:23I think this is an important one.
12:25Afraid. Afraid of saying something
12:26that upsets the patient,
12:27and it may be related to also needing
12:31to make joint decisions and it may be
12:35information overload for the patient if
12:37you present everything in front of them.
12:39Resistance for patients and families,
12:41shared rooms, patient privacy.
12:42We have a lot more info on the patients now,
12:45Absolutely.
12:45So we we know more than we ever did
12:48before in terms of data to process and
12:51visiting visiting hours have changed.
12:52So presenting with family there versus
12:54without is always, always an issue.
12:56Great.
12:59So you all covered what
13:01the literature tells us.
13:02Our workload has increased,
13:04patients are off the floor more we
13:07we do worry about burdening patients.
13:09This is a legitimate fear that's
13:10cited in a lot of bedside literature,
13:12Bedside teaching literature.
13:14The conference room is more comfortable.
13:16I didn't see that come up,
13:17but I hear that often it's much
13:19nicer to sit around a table
13:21than to stand around a bed.
13:23And we do use the computer a ton.
13:26And even I think mobile,
13:27mobile based Epic or things like it have
13:30not pulled us away from the computer.
13:32Perhaps as much as we would like.
13:34Imaging needs big screens to review.
13:36You know,
13:37there's lots of data that needs big screens,
13:50but why should we?
13:51Then we've talked about why not.
13:53Why do you think it's so important?
13:55You all came here for a reason to
13:57discuss and think about this topic.
14:01The exam matters. You know, as a
14:03neurologist, I couldn't agree more.
14:08Helps us patients know we were
14:09thinking hard about them.
14:10Yeah. And there there actually
14:11is data to support that.
14:12It engages the patients.
14:15The patients are at the core of what we do.
14:17It's our our primary value.
14:19So we should express that improves
14:22patient and medical team relationships.
14:24Absolutely.
14:24Patients can correct what we've got wrong.
14:28Very important.
14:28You know we a lot of times we present off
14:31a note that was written the night before
14:33by a different person who's not there.
14:35Data can get lost in the game
14:38of telephone that we play.
14:39There's a human connection aspect.
14:40Absolutely.
14:41Patients can feel involved and informed.
14:45I couldn't agree with any of these more,
14:51right? So again,
14:53you all are are hitting right on the nose.
14:56So if you look at the literature to
14:59support why we should teach at the bedside,
15:02hands on learning is irreplaceable.
15:04You know, especially when we teach the exam,
15:08you can only do so much on SIM models,
15:11on each other, on even standardized patients.
15:14Really seeing pathology upfront is crucial.
15:19Patients appreciate it and
15:20there's data to support this.
15:21So if you this is an even busier table and
15:23I'll show you what's important in a second.
15:25But the this study was done
15:27in 97 and they asked patients
15:30about presenting at the bedside,
15:31How do you feel about it?
15:33What is, what aspects of it
15:36come across well to you?
15:37And they asked them about
15:39explanation of problems,
15:40explanation of tests and medications,
15:43whether or not the team treated
15:45them with respect and introduced
15:46themselves and what was their overall
15:48experience of rounds were round,
15:49satisfying, Were rounds worrisome?
15:52Was care ideal?
15:54And if you look at the adjusted odds ratios,
15:57unfortunately none of
15:59these reached significance.
16:00But there was the clear trend
16:02toward the odds of patients
16:05getting better explanations,
16:07having a better interpersonal experience,
16:09and overall enjoying the rounds more if
16:12their case was presented in front of them.
16:15So this is not even necessarily teaching,
16:17but I think it is because we teach
16:19when we learn from presentations.
16:21But discussing patient care in front
16:24of the patient is a good thing.
16:26That's what I get out of this study.
16:29This was another table from the same
16:31study where they asked patients
16:34about their perceptions of bedside
16:36presentation and bedside teaching,
16:38and the majority percentage said
16:40it was not upsetting to them.
16:43The the majority said they should
16:45continue teaching at the bedside.
16:47A minor majority said it helped
16:50them understand their illness and
16:52they gave us some points of caution
16:54about using too much terminology
16:56and about focusing on trainees
16:58as opposed to the patient.
17:00So they gave some suggestions as well,
17:01which had various levels of support.
17:04But things like patients should be
17:06encouraged to say more during rounds.
17:08Everyone should introduce themselves.
17:10I think that's the best practice.
17:12Fewer,
17:12fewer physicians perhaps should be present,
17:15although not very many said that and there
17:18were a few other sort of minor points.
17:19But again,
17:20I think this reinforces the point that
17:22patients don't get upset when you
17:24talk about them in front of them and
17:26in many cases they can appreciate it.
17:30Learners definitely
17:31appreciate bedside teaching.
17:33So this study looked at just asks
17:37learners a different study from
17:39the same year what did you think
17:42about being taught at the bedside
17:43And they felt that it increased
17:45their understanding of the problem.
17:46They enjoyed it.
17:48It didn't necessarily make them
17:50anxious if it was done well.
17:53The minority only the minority of
17:56cases discussions were inappropriate.
17:58There could have been maybe
17:59better pre briefing and we'll talk
18:01about how to do that effectively,
18:03but most of them thought it didn't
18:06reach confidentiality and they we
18:08didn't get into getting it into,
18:09you know, room setups.
18:10How many of these were in private rooms
18:12and would you recommend it to others?
18:15The majority said yes,
18:16so learners love it,
18:17but why not do more of it?
18:20It's also consistent with what
18:21we know about how adults learn.
18:23And I know there's not one
18:25definite adult learning theory,
18:26but there are a few out there that
18:28agree well with bedside teaching.
18:30So this is from a lot of literatures
18:33from 1997 on bedside teaching,
18:35it must have been a themed issue,
18:38this journal.
18:40But there are a few principles
18:42of adult learning that I think
18:43we need to accept in order to
18:45be good bedside teachers.
18:46So the first is that knowledge is
18:48continuously revised by applying
18:50experience to prior knowledge and
18:52it's really getting that experience
18:54that we're doing as bedside teachers.
18:56Expert clinical reasoning is based
18:58on a repertoire of experience.
18:59And again,
19:00we're building that by teaching
19:01at the bedside.
19:02Adult learners must have ownership
19:04in the learning activity and I
19:06think putting them on the spot at
19:08the bedside really does that well.
19:10And adult learning is a social activity.
19:11It's best done in groups and bedside
19:13teaching is done in a small group setting.
19:15So these are principles to accept
19:17and I'd be curious maybe if
19:19we have time at the end if you
19:21disagreed with any of these.
19:24There's also the theory of situated learning,
19:26and this is one of my favourites as far as
19:30potentially valid theories of adult learning.
19:32But the idea of situated learning,
19:34for those who don't know it,
19:35is that learners start at the periphery
19:38of the the context of their learning.
19:41And so in medicine they started the
19:43periphery of the practice of medicine,
19:45and as they interact with
19:46experts who support them,
19:48they move toward the center of their context.
19:52Until they don't,
19:53they themselves become experts and
19:55begin to support other novice learners.
19:57And so this is done through activities,
19:59through artifacts,
20:00through identities,
20:01and through relationships and I think the
20:03activities and relationships aspects.
20:05Of situated learning are really,
20:07really where bedside teaching
20:10is extremely powerful.
20:11We're building relationships with patients,
20:13we're building relationships with each
20:15other and we're doing activities that
20:17are central to the practice of medicine,
20:19examining patients,
20:20clinical reasoning and educating
20:22the patients themselves.
20:27So let's talk about efficiency for a minute.
20:29Because the time came up, we've talked
20:32about reasons why bedside teaching is tough
20:38and why did it do it. And one of
20:40the reasons you mentioned was time.
20:42Where is the most efficient place
20:44in your experience to teach?
20:52And I'm talking about educational
20:53bang for your buck here.
20:57OK, So we got a fair mix.
21:04Yeah. And this is consistent with
21:08my discussions with teachers and
21:10my experience helping people learn
21:11how to teach at the bedside.
21:15I I find understanding that we
21:16ranked hallway the highest.
21:17I think there's something to be
21:18said for that when you're out
21:20of the presence of the patient,
21:21but still in that patient care context,
21:24perhaps you get a lot of,
21:25a lot of bang for your buck.
21:27But I'm going to argue from the next
21:29moment here that bedside teaching
21:31is not necessarily inefficient.
21:32And when done well,
21:33it can even be more efficient than
21:35teaching in the conference room.
21:37So this was a
21:40study of effective teachers and
21:41they did a time in motion study.
21:44And so they looked at the
21:46most effective teachers,
21:47the medium effective teachers,
21:49and the least effective teachers.
21:50And they they looked at how they
21:52spent their time on rounds and how
21:55many teaching activities they did.
21:56So it won't surprise you
21:58to see that for instance,
21:59the most effective teachers did the
22:01most number of teaching activities
22:03on rounds by by a large handful,
22:06maybe not significant, but there's a trend.
22:08What I think is really interesting
22:10in this slide is the number of the
22:12amount of time that the effective
22:14teachers spent on rounding versus
22:16the least effective teachers.
22:18So it there was a clear divide where
22:20these most highly effective teachers
22:22actually were the most efficient on rounds.
22:26And yet, if you look down to lines below,
22:29they did the most number of
22:31teaching activities for patients.
22:33So I think the question we have to
22:34ask ourselves is what are these,
22:35what are these teachers doing right,
22:37where they can teach more and
22:39spend less time doing?
22:40And I think a lot of that has to do
22:42with where they did their teaching,
22:43which was at the bedside.
22:46So let's talk about how to
22:47do bedside teaching.
22:48Well,
22:48that's where we're going to spend
22:50the next half hour of our time.
22:52So I want to hear from you first,
22:53what are the characteristics of a good
22:55teaching encounter at the bedside?
23:24Everybody participates. Yeah.
23:28It's succinct. It's directed,
23:30It's collaborative, focused,
23:33motivated by curiosity and
23:34active in its teaching,
23:36allowing time for questions.
23:42Yeah, the patient needs well, I don't know.
23:45As someone who teaches on patients in comas,
23:47do they need to be awake?
23:50Depends. It depends.
23:53But I like all these points.
23:54I think these are great points
23:55and I appreciate you sharing them.
23:56I'm going to make,
23:58I'm going to spend my time for the next 25
24:01minutes really focusing on two big ideas,
24:04and we'll talk about the
24:06details of those ideas.
24:07But all of the things that you're
24:09saying here and continue to say are
24:11relevant to good bedside teaching,
24:12we'll talk about ways to do some of them.
24:14For instance,
24:15how to include the patient,
24:16how to get everyone to participate.
24:18I like the phrase zone of proximal
24:21developments.
24:21I think that's a really important concept.
24:25But the big ideas are this effective.
24:28Bedside teaching really has three phases
24:30and if you do all of these phases,
24:32you're almost guaranteed to succeed.
24:34So the first is preparation,
24:35the 2nd is execution,
24:36and the third is debriefing.
24:37And I'm going to use this three-step
24:39model as I talk about the next point,
24:42which is that good bedside
24:44teaching encounters are both
24:46learner and patient centered.
24:48And you have to do both in
24:50order to really be effective.
24:51And all we're going to talk about the
24:53rest of the time is how to do that.
24:55So let's talk about learner
24:57centered teaching for a second.
24:59The big dynamic we probably spend a lot
25:00of time thinking about as teachers is
25:02how are we interacting with our learners?
25:04How are they interacting with us?
25:06How are we monitoring their learning and
25:08ensuring that it's actually happening?
25:10How are we encouraging retention?
25:12You know this is the essence
25:14of teaching right?
25:15Is is this teacher run a relationship
25:19learner centered teaching.
25:20The best definition I've seen is
25:22this a method of teaching in which
25:24the students needs have priority.
25:26Teachers are expected to facilitate
25:28self-directed learning instead instead
25:30of supplying spoon fed information.
25:32And this is the opposite of
25:34teacher centered education.
25:35The simpler way to put it would be
25:36teaching what the learner needs to teach,
25:38not what you want to teach.
25:39And those do not always overlap.
25:41In fact, often they don't and
25:43that's what makes learner centered
25:45teaching so challenging.
25:47But again, the key points are this.
25:48It addresses the learner's needs,
25:50which some of you said in that word cloud.
25:52It's contextual and timely,
25:53which all of you said and it
25:56facilitates experiential learning.
25:58So learning through practice and experience.
26:00And you may or may not be familiar
26:02with the experiential learning cycle,
26:04but what we're really doing is providing
26:07this, these two top items here.
26:10So learning,
26:11experiential learning begins
26:13with concrete experience,
26:14moves into reflective observation.
26:18And this is what we're doing
26:19when we teach at the bedside.
26:20We're giving students or learners hands
26:22on experience and then encouraging
26:24them and helping them reflect.
26:26And that's where debriefing is
26:28so important on what they did
26:30and what they learned.
26:31And then we give them time
26:32and we allow them to form,
26:34abstract these concepts from what they
26:36learned and experiment with those concepts
26:38in their future interactions with patients.
26:41So again,
26:41we're moderating these first
26:43two steps if we do it right.
26:45So let's talk about the preparation phase.
26:48I think the two keys to preparing
26:51in a learner centered manner are
26:53selecting appropriate patients
26:54for learning and then establishing
26:56learning objectives based on
26:57what the learners need to know.
27:01So let's talk about patient
27:03selection for a minute.
27:04How important or how comfortable are you
27:07teaching in these these settings overall,
27:12when there's an unusual exam
27:13finding which may or may not be
27:16serious but is worth multiple
27:17learners seeing or experiencing?
27:20When the patient has a serious
27:22terminal diagnosis or prognosis
27:23and is cognitively intact.
27:24In other words, the conversation
27:26could get difficult in the moment.
27:28And then what about teaching
27:30on patients who aren't awake,
27:32who are encephalopathic for instance,
27:34or even in the coma?
27:56wow, you all are are feeling
27:57pretty comfortable. That's good.
27:58You should be teaching this instead of me.
28:02You know, it's it's an interesting
28:04phenomenon that I've seen as I
28:06asked this question of many groups,
28:07encephalopathic and comatose always wins.
28:10And I wonder when we talk about moderating
28:15the patient learner interaction,
28:16I wonder if that has something to do with it.
28:19But I'm glad to see that most of you are
28:21fairly comfortable because if you're if
28:23you're uncomfortable you need more practice.
28:25But also that's probably the biggest
28:27barrier to doing it is getting
28:29over that personal discomfort and
28:31some of you are and that's OK.
28:33Our goal is to make you more comfortable.
28:37So thinking about those groups of
28:39patients and other patients perhaps
28:41that you've taught on recently or not
28:44taught on recently for for a reason,
28:47What characteristics should
28:48we think about when we select
28:49patients for bedside teaching,
29:09appropriate mood?
29:09Yep, the patient agrees to it.
29:11We're going to talk
29:12about consent in a bit.
29:16Awakeness again, I think the patient being,
29:19I think what you may be referring
29:20to is if the patient is asleep,
29:22don't wake them up if you don't have to.
29:26But there's also the spectrum of
29:29AWAKEN ALERT versus encephalopathic,
29:31stuporous or comatose.
29:33What is their health literacy appropriate?
29:35Yeah. Can you prepare them ahead of time?
29:38I think that's always good if you can,
29:39avoiding usually agitated patients,
29:41which you're going to run into for sure
29:44agreeable to having a learner join them.
29:47The learner's interest in the topic.
29:49Yeah, so that's part of learner
29:51centered teaching is, you know,
29:53do the learners want to learn about
29:54what you're going to teach them?
29:56Hopefully as a motivated adult learners,
29:58there they do.
29:59But that's not always the case.
30:01Religious and cultural beliefs
30:03regarding groups and teaching,
30:06considering the family's thoughts
30:07and teaching the presence of
30:08a family is a whole another.
30:09It's probably an hour onto itself.
30:13A good physical exam.
30:14I'm not intrusive to other parts.
30:15Yep. Engage ability,
30:17all all great things to think of.
30:19If you go to the literature on this,
30:20there's not much,
30:22and I think some of that's because
30:24this is maybe considered common sense,
30:25but I think there's an art to
30:27picking the right patient one.
30:31Oops.
30:32One the table that I found that I
30:35thought was helpful is this one.
30:37And these are things you can think about,
30:39some of which you've already mentioned
30:41in terms of how to pick the best
30:42patient from bedside teaching.
30:43So does it fit the lessons topic?
30:48Makes sense Language and verbal skills.
30:51One thing to consider is,
30:53is a non-english speaking patient
30:55a barrier to bedside teaching?
30:57Yes,
30:57but should we deprive those patients
30:59of the benefits of bedside teaching?
31:01I would argue no.
31:03And so if an appropriate
31:04interpreter can be found,
31:05including patients who are non-english
31:07speaking is very important.
31:09Their state of health right?
31:11Are they tenuous?
31:13Are they in step down unit and quite sick?
31:16Are they in an ICU?
31:17And how much teaching is appropriate
31:19on a patient who's critically,
31:20I'll for instance,
31:22interactions down on personality,
31:24the dangers of infection?
31:25Speaking of COVID,
31:27is it appropriate to bring a large group
31:29into a patient on contact precautions,
31:32their own insight into the disease?
31:34And I think bedside teaching is
31:35a chance to develop that insight.
31:37But thinking about where they're
31:39starting is really important and what's
31:40your relationship with that patient?
31:42If they're angry at the team,
31:43probably not a great day.
31:44Ask them if they're OK with being taught
31:46or taught on or included in teaching.
31:49And then there's some
31:50structural factors to consider.
31:51How many patients do you have to round on,
31:54and how many?
31:55How many of those are?
31:56Can you really logistically teach on?
32:00Maybe don't teach on the same
32:02patient every day.
32:02Frequency of participation.
32:04What's the lesson schedule?
32:05Can you contact the patient?
32:07Are they on the floor?
32:08And then of course,
32:08any legal aspects always need
32:10to be considered as well.
32:11So these are things to think about.
32:13But the ideal patient is somebody
32:16who ideally can participate.
32:17Unless you're trying to teach,
32:20the comatose exam is agreeable
32:23to participate.
32:24Again,
32:25I I think language should be thought about
32:27very carefully and then has something
32:30that's worthy of of being taught,
32:33right?
32:33And that could be an exam finding.
32:34That could be modeling the
32:36patient doctor interaction in
32:37a difficult conversation,
32:39That could be modeling patient education,
32:43or it could be practicing
32:45clinical reasoning and explaining
32:46thought processes to the patient.
32:47So it doesn't have to be the physical exam,
32:50but something that's relevant to
32:50what the learners need to know.
32:52I'm not going to get too much into the
32:55second point of preparation because that's
32:57determining learner objectives is really
33:01hours of lecture all unto themselves.
33:05But I just want to talk about how to execute.
33:08So we'll go on to the next phase.
33:11How do you execute a good
33:13bedside teaching encounter?
33:13I think it starts in the doorway.
33:15And so I think reviewing the
33:17learning objectives that you may
33:18have developed earlier in the day,
33:20for instance on table rounds,
33:22reviewing those objectives right before
33:24you go in to see the patient is important.
33:26Adapting the teaching to the learning needs,
33:28being learner centered,
33:30allowing for questions in the moment is key.
33:32So not not shying away from questions.
33:36I think this can be really nerve
33:38wracking as a bedside teacher
33:40because you don't know what you're
33:42going to get asked and you can be.
33:43There's a lot of thin ice phenomenon
33:45where you're going to be afraid to
33:47be put on the spot for something
33:48you may not know the answer to.
33:50But I think that's a chance to model
33:51how you find the answers to things
33:53and how you go back and and tell the
33:54patient what you want them to know
33:56and then give real time feedback.
33:58So don't don't necessarily wait
34:00until you're outside the room.
34:01I think there's a lot of value in
34:04giving feedback in front of the patient.
34:06There are many models and ways to do this,
34:09but one that I'm I'm very fond of
34:10is called the One minute Preceptor.
34:12You've probably seen it before.
34:13I'm not going to belabor it here,
34:16but it's a way to teach in a minute or less,
34:18maybe 2 minutes. One minute's a little.
34:20A little optimistic perhaps,
34:22but and you can do this in phases too.
34:24You can do some of this in pre rounds,
34:26some of this at the best side and
34:27some of this in the hallway.
34:28But get a commitment from the learner.
34:31So figure out,
34:33ask them to put their money down
34:35on something.
34:35What do you what do you think
34:36is going on here?
34:37What do you think is the cause?
34:39What is your treatment of choice?
34:40What diagnostic tests are next?
34:43Something that asks them to make
34:45a commitment and then ask them why
34:46probe for supporting evidence?
34:47Why do you think that?
34:49Why is this the best treatment?
34:50Or why would you do this as your next test?
34:53This then tells you what you need to teach.
34:55So if you do this either in front
34:57of the patient or right before you
34:59go to see them, now you know.
35:00This is how I'm going to teach to
35:02the learner's needs and not to my
35:04own comfort level,
35:05and then teach them something
35:07widely applicable.
35:08Here's how I do the reflex
35:10exam in somebody in bed.
35:11Here is how I check a wound
35:14to make sure it's truly clean,
35:16dry and intact. Whatever.
35:19Reinforce what the learner did well.
35:21So make sure that and you can do this
35:22at the bedside or in the hallway,
35:23but make sure they understand what
35:25what their strengths are and then
35:27give them some corrective feedback.
35:28What do you need to do better?
35:30So if you do this well, it's quick.
35:32And I think the best teachers are doing this,
35:35perhaps without even knowing
35:36they're doing it.
35:37And in fact that's how this
35:38model was developed,
35:39is they they observed excellent teachers
35:41and then did an ethnographic study and
35:44pulled out the behaviors they had in common.
35:47So good teachers are already doing this.
35:48You may already be doing this and
35:50feel free to implement it as a way to
35:52execute learner centered teaching.
35:53And then you want to debrief.
35:57So review the learning objectives,
35:59Provide some additional feedback,
36:00especially feedback you don't want
36:02to give in front of the patient.
36:04You know,
36:05things that are a little either
36:06maybe a little harsh or could
36:08embarrass the learner that you
36:10want to give in person without the
36:11rest of the team there and then
36:14allow for some time for reflection.
36:16Remember that abstract conceptualization
36:17and reflection are part of that
36:20experiential learning cycle.
36:21So ask them what did you learn from this?
36:23What are you going to take
36:25away for future encounters?
36:26What do you want to do differently
36:28the next time and and really guide
36:30some of that reflection in real time.
36:32So again,
36:33this doesn't have to be done
36:34in front of the patient,
36:35but it doesn't have to be done in
36:36order to do an effective learner
36:39centered teaching encounter.
36:41But remember,
36:43the bedside teaching encounters are
36:44both learner and patient centered.
36:46So we're going to,
36:46we're going to move on to talk about
36:48how to do patient centered encounters.
36:53And really what's happening now is
36:55we're introducing A complication
36:57to that initial dynamic.
36:58So instead of just a teacher and a learner,
37:00it's now as the teacher.
37:02You're moderating the
37:03teacher learner interaction.
37:05You're moderating your
37:06interaction with the patient,
37:07and you're also moderating the
37:09learner's interaction with the patient.
37:11So this is quite challenging you you
37:13just went from 1 interaction to three,
37:16but it still has three phases and
37:18good patient centered teaching,
37:20similar to learner centered teaching
37:22addresses the patient's needs,
37:24actively includes the patient,
37:26and facilitates patient education.
37:28So a lot of the same principles apply,
37:31you just need to moderate.
37:33You need to juggle multiple
37:35interactions at once.
37:36So how do you prepare in
37:38a patient centered way?
37:39So I think selecting patients
37:41based on the risk and benefits to
37:43them and ethical considerations.
37:45So risk benefits.
37:46A funny thing to think about
37:47when it comes to teaching,
37:49but it's a reality, right?
37:51There is a risk to being
37:53included in education.
37:54You may be uncomfortable,
37:56You may feel embarrassed.
37:58You may have confidential information
38:00discussed in front of a group.
38:02Your neighbor may overhear
38:03what's going on in the room.
38:05There's a lot to think about there,
38:07but there's a lot of benefit too.
38:09You will understand your condition better.
38:11You will know what your team is thinking.
38:12You will have benefited future
38:14patients because of the learners that
38:17you're teaching and then the ethical
38:19considerations that we discussed before.
38:21So pick the right patient,
38:24establish objectives based on
38:25what the patient needs from you.
38:27Do they need more education on
38:29the nature of their condition?
38:31Do they need to be included in a
38:33more active way in the discussion
38:35of their treatment plan?
38:37What can you do as a teacher
38:38to model these things and also
38:40accomplish what the patient needs?
38:41And then I would add a third
38:43element to this preparation,
38:44which is get consent from the patient.
38:47So I put a question mark there
38:49because I think this is an
38:50interesting question to think about
38:52at an academic Learning Center.
38:54So I want to know what you think.
38:56Should we be consenting patients
38:58explicitly for bedside teaching?
38:59And we'll talk about what the
39:00consent includes in a minute.
39:01But at least asking one question,
39:05do you want to be included
39:11or not?
39:14OK, so we're pretty evenly split
39:17here between always and sometimes.
39:20That, again, is pretty consistent
39:22with what I've seen in the past.
39:23Some people say, well,
39:26you're at an academic center,
39:27so it's implied that there's
39:29going to be teaching involved.
39:30And you don't necessarily
39:31need to ask every patient.
39:33Some people say the patient
39:34didn't get to choose to be
39:36admitted to an academic center.
39:37We may have just been the closest
39:39center to them and they would have
39:41preferred to be at a private hospital
39:42and want to be treated that way.
39:43So you always need to find out are
39:45they OK with being taught on Both
39:47points are valid and I'm not gonna
39:49make a case today for either one,
39:51but I'm gonna talk about how
39:53you consent to patients,
39:54if you want to consent them,
39:55if you feel that it's important.
39:57So what do you think you should
39:58include in that conversation?
40:23If they're up for it, What topic?
40:26Yeah. When they have questions,
40:28a quick description of what
40:29they should expect. Absolutely.
40:32Is it OK to talk just to learners?
40:34Yeah, More of an ascent.
40:36A brief expectation of what to expect.
40:38Rules of engagement.
40:39I like that phrase.
40:41Anything they want to avoid?
40:42Absolutely. Letting them know
40:44that others may be joining you.
40:46Giving a patient the scope of the visit,
40:47Informing them how many people will be there,
40:50anything they want to cover. Yeah.
40:51So what do you want to talk about?
40:53What don't you want to talk about?
40:54Assuring them that it's
40:56safe structure and timing.
40:58These are all excellent points,
41:00and I think you can cover most of
41:02these in a couple of sentences.
41:03So we're not talking about
41:05informed consent for surgery here,
41:06but we we are talking about
41:09some aspect of consent.
41:10Again, when you go to the literature on this,
41:12there's not a lot,
41:13but the literature suggests at
41:15least including three things.
41:17So one is, do they consent?
41:18Are they OK with that?
41:19Are they up for it? Can we do it now?
41:21Are they too tired?
41:23Whatever #2 is this choice,
41:25letting them know you can
41:26say yes or you can say no,
41:28and neither choice is going to affect
41:30your care in an appreciable way.
41:32We're going to care for you the same
41:33regardless of whether we do some teaching.
41:35And then the third is that even
41:37though there's a group here,
41:38you're and we may discuss you
41:41as a patient on post rounds.
41:43We're not going to spread
41:45your information to others.
41:46This is not going to go,
41:48you know,
41:49in somebody's Twitter account or whatever.
41:51So assert patients of that is really
41:53key and getting their consent and
41:54letting them know they have choice.
41:56If you include those three things and
41:58you can do that in one or two sentences,
42:00that's an adequate consent or
42:02something like this, The risk is low.
42:04The benefit is moderate to high
42:07and it's fairly straightforward.
42:10So you've consented the patient,
42:12you've selected them,
42:13you've established learning goals.
42:14They know what's coming.
42:17What do you actually do
42:18when you're at the bedside?
42:19So I think before you go in,
42:21just like you had a doorway review
42:23of the expectations you need to
42:25have or the learning objectives,
42:27you need to have a doorway
42:28review of expectations.
42:29What do we think the patient needs from this?
42:31And what did they tell
42:32us they want from this?
42:33And that includes what they wanted
42:35and what they wanted to avoid.
42:37When you get in there,
42:38make sure you involve the patient.
42:40We're going to talk about some
42:41ways to do that in a second.
42:43Also make sure as a way of involving
42:45them that you summarize what's
42:46going on so that they understand it.
42:48Translate jargon into patient
42:52centered language.
42:54Allow for the patients to ask
42:55you questions just like you
42:57allow for the learners to ask you
42:58questions and get feedback from
43:00the patient for the learner.
43:01What what did you like about the way
43:04this person examined you or what do you
43:07know now that you didn't know before?
43:09And so getting getting that feedback
43:11from the patient is really invaluable.
43:13That's probably the thing we get the
43:15least is effective patient feedback
43:18on what we're doing as clinicians.
43:21So seize that opportunity.
43:24This is a really interesting
43:26study that was done.
43:27It was an ethnographic study
43:29and it was done on teams that
43:31were teaching at the bedside.
43:32When they looked at videos of these
43:34teams and study their behaviors
43:36and what they found was that they
43:39really fit into two categories.
43:41So one was called patient as body
43:43and this is where the patient was
43:45used essentially as a teaching prop.
43:47So the patient was discussed in a
43:49separate way in a way that made
43:51them feel perhaps excluded from the
43:53conversation or didn't acknowledge them.
43:55Medical jargon was used and the
43:57patient was non verbally excluded.
43:59In other words,
44:00the team was clustered at the
44:02foot of the bed.
44:03They sometimes even blocked the patients
44:04out or had their backs to the patients,
44:06and they were discussing them
44:08as if they weren't there.
44:09The patient and body group,
44:10on the other hand,
44:12was many of the opposite behaviors.
44:14So they invited the patient to contribute.
44:16They asked them to tell part of their story.
44:18They asked them if the story was correct.
44:20They asked them to explain or describe
44:23their experience being examined.
44:24They avoided or at least explained,
44:28medical jargon and terminology,
44:29and they included the patient non verbally.
44:31They surrounded the bedside.
44:33They formed almost a circle with the
44:35patient at the head of the circle,
44:37and so the patient felt as if
44:39they were part of the encounter.
44:41Obviously,
44:41you know which one is more effective.
44:43I think that is not the point of the study.
44:44But the point is it's really
44:48easy to drift toward patient as
44:50body when you're busy,
44:51when things are complicated,
44:53when the diagnosis is difficult or you
44:57feel awkward or anxious about teaching.
45:00So really paying attention to your behaviors,
45:03setting someone up to monitor these
45:05behaviors and remind the team to include
45:08the patient can be really effective.
45:10And that can be a role that
45:11you give to the learners,
45:12which then has the extra benefit
45:14of teaching them how to be good
45:17bedside teachers when they step
45:18into those shoes down the line.
45:21So once you've executed good bedside
45:23teaching in a patient centered way,
45:25then you want to debrief it.
45:27So discuss the learner reactions
45:28to the patient experience.
45:30And again,
45:31this can be done outside of the room,
45:33but what what do you think
45:35the patient got out of that?
45:36Did they seem uncomfortable at any point?
45:38What could we do better to
45:39embody them instead of as body,
45:43things like that and then
45:45reflect on what you learned?
45:47Again, reflection is key,
45:48so you have to allow time and guidance
45:51and space for that reflection in
45:53order for them to solidify and
45:55create these abstract concepts
45:57and encourage and incorporate
45:58them into future activities.
46:02So again, this is the dynamic
46:03that you're moderating.
46:04It's a teacher learner,
46:06patient triad.
46:07It's both patient centered.
46:09It's learner centered.
46:11You're watching all these
46:12things happen at once, right?
46:13And This is why I think bedside teaching
46:15is so challenging and so intimidating,
46:17but also so beautiful
46:18when it comes off well.
46:22So we'll drop this hand out in the chat now,
46:24but I I made you a quick little
46:27reference card for how to do
46:30effective bedside teaching.
46:32And if you can really pay attention to
46:34these steps and this is everything that we
46:37just talked about in sort of a table format.
46:39So be both learner centered,
46:42follow the three steps and you're going
46:44to find yourself being a much more
46:46effective bedside teacher and also
46:48feeling more comfortable doing it.
46:51And really we're moving toward
46:53that ideal where you're spending,
46:55you know, more than half of your
46:57time teaching in front of a patient.
47:00Now you still have to round,
47:01you still have to do all these things,
47:02but I think you can really incorporate
47:04it more if you're efficient
47:06and effective with it.
47:08Some additional best practices
47:09that may seem obvious,
47:10but I just want to kind of cover,
47:13introduce the team,
47:15introduce yourselves, explain your roles.
47:18You know, I'm a medical student,
47:19I'm the attending physician.
47:20What does attending physician mean?
47:22Things like that are really
47:24important for the patients.
47:25Let them interrupt.
47:26Let them stop you.
47:28Let learners interrupt too and ask questions.
47:31Be a model for how to interact with patients.
47:34Sometimes that's the bedside
47:36teaching is we're not going to
47:38all examine the patient today,
47:40but I'm going to model how to.
47:42Well, first of all, you can be practical.
47:44I'm going to model how to drape the patient.
47:45I'm going to model how I listen to the four
47:48or five points for cardiac auscultation.
47:52Or you can model behaviors so you
47:55can model humanistic behaviors.
47:57I want to show you how I disclose a
48:00difficult diagnosis or I want to show
48:02you how I educate a family and a patient
48:05at the same time when one is much more
48:09you know up to speed on the diagnosis.
48:12Give your learners homework.
48:14You don't have to teach everything.
48:16And remember we said at the beginning
48:18self-directed learning is part
48:20of learner centered teaching.
48:21So really saying you know we
48:23learned this today.
48:24If you want to learn more,
48:25go check out this chapter in Bates physical
48:29examination or go check out this study.
48:32It was landmark trial on
48:34optic thyritis treatments.
48:36Pick your pick your poison and then you
48:38can follow up later with resources as well.
48:40So one thing I like to do this is not
48:42really related to bedside teaching
48:43but is start an e-mail chain at the
48:46beginning of a rotation with everyone
48:47on the team and so then you have access
48:50to giving them some resources later on,
48:52you know here.
48:53Hey guys,
48:53here's the chapter from my
48:55favorite book on this topic.
48:57Check it out.
48:58And so you can really teach them how to
49:00become self-directed learners in that way.
49:04I'll close with a quote and then
49:06I'll leave some time for questions.
49:07Unless everyone, patient included,
49:09feels better after the bedside rounds.
49:11Those rounds were not successful.
49:13So we all want to feel good about what
49:15we're doing as bedside teachers and make
49:17sure the patient feels good for them.
49:19So I'll allow some time for questions.
49:21I have two closing slides.
49:24This is one we would love to hear
49:27what you thought about this session,
49:29what you think about the curriculum
49:30as a whole and any feedback.
49:32So feel free to scan.
49:33The QR code is also in the chat,
49:36as is the link.
49:39Any questions
49:44or comments or stories, whatever.
49:52I have a question, Jeff. Yeah. Is it
49:54ever OK for students to be
49:57using personal devices like,
49:58you know like a phone to look up
50:01something about the condition
50:02in in the front of in front of
50:05the patient or do you do you
50:07steer students away from that?
50:10I think it's inevitable.
50:12I'm, I'm not a fan of it,
50:14but I also think that especially with AI,
50:18there's no way around it.
50:19So I I do think we have to explain
50:20to the patient what we're doing.
50:21You know, there's these signs
50:23at the bedside that say we may
50:25be on our phones and whatever,
50:26but I don't think that's the same thing.
50:27I think you need if you see it happening,
50:29you need to call it out in a way
50:31that explains why it's happening.
50:33So you know, just so you know,
50:35X here is is looking up the generic
50:37dosing of your medication so
50:38that they can learn it from it.
50:40But I I don't prohibit it, you know,
50:43probably because I want to do it myself.
50:45Sometimes when I need to look up a
50:48dosing or remind myself of of something,
50:56if I may, there's something very
51:00interesting I learned in discussion with
51:02a medical anthropologist years ago,
51:04which is that he felt 2 defining
51:08characteristics of medical
51:09caregivers were shame and fear,
51:12and caregivers go to great extents to avoid
51:16any situation that might provoke that.
51:21But what's also interesting is,
51:25you know, for example,
51:26not knowing what to answer and you
51:28touched on that in your presentation,
51:30you know, not having a pad answer
51:32for everything that's asked.
51:35But what I've discovered
51:37in teaching and also directly work
51:41with patients is that it's a no lose.
51:44If you tell your patient, gosh,
51:46that's a great question and you know
51:49something we're going to get the best
51:51and most up to date answer for that.
51:53You know, patients will often comment
51:55and say wow, that's a good doctor.
51:58He admits if he doesn't know and
52:01he looks it up that you know.
52:04So I just wanted to share that in in case
52:08it encourages other people, you know,
52:10to recognize it's really a no lose,
52:12it's a win win no matter
52:15where the chips fall.
52:18Yeah. Thank you.
52:19I I couldn't agree more.
52:21And I think as we talk about modeling,
52:24what an opportunity to model
52:26how to be a physician in the
52:28time of information overload,
52:30you're not going to know every answer.
52:31And so modeling how to go look for
52:33it and it reassure your patient that
52:35you're going to find it is really key.
52:44I see a comment in the chat, advice for
52:46a teaching session that didn't go well,
52:48that someone unexpectedly upset the patient.
52:50Of course of all apologize.
52:51Would you avoid teaching with them
52:53in the future? So it's funny.
52:55I created scenarios in case we finished
52:57early to talk about One was digital devices,
53:00and we've covered that.
53:00This was one of the other ones.
53:02What happens when you unexpectedly upset
53:05a patient during a teaching encounter?
53:07And there I can imagine many ways
53:09where that could happen, right?
53:11So if you're teaching the exam and
53:13something uncomfortable happens,
53:15you hurt them or cause pain.
53:18If you are disclosing A diagnosis that you
53:21thought they knew about and they didn't,
53:23we're discussing it in an offhand way or
53:25you just say something that rubs them
53:27the wrong way and they get upset about it.
53:29I I agree.
53:30I think you of course have
53:31to apologize in the moment.
53:33I think you need to debrief that with
53:35the learners after the experience
53:37and say what happened here,
53:39you know first of all normalize it.
53:40This is going to happen even
53:42in non teaching encounters.
53:43You're going to,
53:44you're going to upset patients by accident.
53:47And so normalizing that,
53:49modeling,
53:49reviewing the behavior that you modeled on,
53:52how to re establish the relationship
53:55with the patient in the room and
53:57then getting their feelings about it.
54:00Some students may be upset,
54:01some may feel that it was, you know,
54:04totally justified, the patient's reaction,
54:05obviously feel it was unjustified,
54:07etcetera.
54:07But as creditors put in the chat,
54:09modeling humility in the face of
54:12all those reactions I think is key.
54:14And would I avoid teaching with them?
54:16I don't think I would,
54:17but I think I would definitely be a little
54:20more explicit than my consent the next time,
54:23you know, hey, we're back.
54:25I know last time didn't go well,
54:27but I think it'd be really
54:29important for us to do this.
54:30Would you be OK with it?
54:32I think that's appropriate.
54:33I don't think you need to avoid it.
54:35If you feel more comfortable avoiding
54:37it or the patient says no more,
54:38then you're done.
54:40But at least asking is really important.
54:54While we're in the last
54:54couple of minutes here,
54:55I'm just going to switch to the last slide,
54:57which is a schedule of upcoming
55:00events because I know people are
55:02going to drop off to get the places.
55:03So the next event is Thursday,
55:06November 17th and then you'll see
55:08there's another one scheduled for Friday,
55:10December 1st.
55:12And you can see all of the,
55:15you can register and see all the
55:17information at the QR code on the right.
55:22Any last thoughts or comments?
55:24I really appreciate all of you participating.
55:26I got to say, you know,
55:28I'm by no means the master of this.
55:31And so I think the hive mind is really the
55:34way to go as we develop best practices.
55:36So thank you for for humoring me.
55:40Or if you're a Marvel fan. The UNI brain.
55:43The UNI brain. I love it.
55:51All right, well,
55:52maybe we'll wrap it there then.
55:54Thank you, everybody.
55:55Thanks for being here.
55:56Thanks for coming to the sessions.
55:58Thanks so much. Yeah.