3/15 YES!: Trainee Performance Improvement: Where We Are and Where We’re Going
March 15, 2024ID11478
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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.