11-1-24 YES!: Enhancing Bedside Teaching with Jeffrey Dewey, MD, MHS

Transcript

• 00:00Thank you for joining
• 00:01us. I'm Andres Martin
• 00:03from the Child Study Center
• 00:05and from the Center for
• 00:06Medical Education.
• 00:08And together with Dana Dunn,
• 00:09who, cannot join us today,
• 00:11we,
• 00:13have
• 00:15great fun of putting together
• 00:17this, yes, series,
• 00:19Yale Medical Education
• 00:20educator series.
• 00:22At the very end, we're
• 00:24gonna give you an evaluation
• 00:25form. And, certainly, if there
• 00:26are things you wanna see
• 00:28more of or less of,
• 00:29we are open to feedback.
• 00:31We're,
• 00:32trying to optimize it to
• 00:33everyone's needs.
• 00:36Today is,
• 00:40great to have, Jeff Dewey
• 00:42with us.
• 00:43Jeff wears many, many hats
• 00:45around here.
• 00:46He's,
• 00:47an assistant professor in neurology,
• 00:50and I hear it on
• 00:51good sources that, he may
• 00:53be going
• 00:54in a in a northerly
• 00:56direction in the latter faculty,
• 00:57so stay tuned for that.
• 01:00He,
• 01:01is, the associate program director
• 01:03in the neurology
• 01:04residency, so that's
• 01:06at the GME level. And
• 01:08in the
• 01:09undergraduate level, he directs the
• 01:11neurology clerkship.
• 01:13So he really has all
• 01:14bases covered.
• 01:15He also directs wellness, the
• 01:17neurology residency,
• 01:19and something that I have,
• 01:20personally experienced his expertise in
• 01:23is that Jeff has been
• 01:24kind enough to be,
• 01:26shall we say, a coach's
• 01:27coach
• 01:28in the new program for,
• 01:30coaching for the longitudinal coaching
• 01:32for the medical students.
• 01:34Jeff has met with us,
• 01:36about once a month,
• 01:37and we always learn,
• 01:39something related to
• 01:41to coaching. He really has
• 01:43a lot of expertise in
• 01:44that area.
• 01:45His,
• 01:46other expertise
• 01:47is in neuromuscular,
• 01:50disorders
• 01:51when he's not doing his
• 01:52five other jobs, And we're
• 01:54very happy that he's coming
• 01:55today to remind us of
• 01:57this pre Zoom thing called
• 01:59bedside
• 02:01teaching.
• 02:02So,
• 02:03Jeff, take it away.
• 02:05Thank you.
• 02:07Anything I'll just leave this
• 02:08up while I kinda say
• 02:09my introduction so people can
• 02:10do their,
• 02:11CME information.
• 02:13Thanks for having me. I
• 02:15will say off the bat,
• 02:16there is no
• 02:18setting more intimidating to teach
• 02:19than in front of my
• 02:20colleagues at Yale. Everyone is
• 02:22so accomplished and smart and,
• 02:24you know, you do grand
• 02:25rounds somewhere else and you're
• 02:26out of there, and you
• 02:27do it to the students
• 02:28and you probably, most of
• 02:30the time, know more than
• 02:30they do. But, this is
• 02:32a a different setting. So
• 02:33I'm really honored to be
• 02:34here, and, obviously, you know,
• 02:36few butterflies, but I think
• 02:37we'll have some fun.
• 02:39As far as the,
• 02:41milestones that we're covering today,
• 02:43this is really the core
• 02:44of what we all kinda
• 02:45wanna do, which is teach
• 02:47medicine to trainees. And that
• 02:49could be undergraduate, graduate, you
• 02:51know, residency fellowship,
• 02:53even teaching junior faculty,
• 02:55falls under the spec the
• 02:56scope. So,
• 02:58really at the heart of
• 02:59of why we got into
• 03:00clinical,
• 03:01medical education.
• 03:03I'm gonna use a platform
• 03:04called Mentimeter
• 03:05today.
• 03:07No one's required. I'll actually
• 03:08never know who joined and
• 03:09didn't. It's anonymous. But it's
• 03:11gonna be how we engage,
• 03:12repeatedly throughout the presentation. So
• 03:14if you could,
• 03:16either open up a window
• 03:17on your desktop and enter
• 03:18the website and code or
• 03:19use your phone and grab
• 03:20the QR code.
• 03:22And then we'll this will,
• 03:24it'll it should say if
• 03:25it works that you're waiting
• 03:26on the presenter.
• 03:27And if you're not seeing
• 03:28that, let me know.
• 03:29The instructions will be up
• 03:31periodically throughout the presentation at
• 03:33the top of the screen.
• 03:34So if you can't join
• 03:35or get kicked out or
• 03:36get a call,
• 03:38you can jump back in.
• 03:39But, again, this is anonymous.
• 03:40So the reason I like
• 03:41to do it this way
• 03:41is because then no one
• 03:42feels
• 03:43on the spot sharing their
• 03:44opinions about bedside teaching in
• 03:46this instance. Alright.
• 03:48So I'm gonna leave the
• 03:49instructions at the top, but
• 03:50I just wanna see if
• 03:51it's working.
• 03:52And, also, I wanna give
• 03:53us a little mental palate
• 03:54cleanser.
• 03:55A lot of us just
• 03:56came from busy clinics or
• 03:57other meetings, and I think
• 03:59we can hopefully set aside
• 04:00an hour to just
• 04:02share our joy of teaching.
• 04:03But let me know what
• 04:04gave you joy in the
• 04:05last day or two.
• 04:07And this way, we'll know
• 04:07if your mentee is working
• 04:09through, which is helpful.
• 04:11I will share mine.
• 04:14I enjoyed last night. I
• 04:15got to see some cute
• 04:16costumes. Our neighborhood is very
• 04:18spread out, so I didn't
• 04:19see many.
• 04:20The thing that gave me
• 04:21the most joy in the
• 04:21last forty eight hours was
• 04:22I spent about two hours
• 04:23on Wednesday
• 04:25updating all my AirTags and
• 04:26changing the batteries. And it
• 04:27sounds like a little thing,
• 04:28but I'm a procrastinator.
• 04:30And now that they all
• 04:31work again, it's just joyous.
• 04:32So I see some other
• 04:34fun things, seeing colleague dancing,
• 04:36walking dogs. Great. These are
• 04:37great things.
• 04:38Thank you for sharing. The
• 04:40instructions will remain at the
• 04:41top. Parents coming to visit.
• 04:43Nice.
• 04:44But I wanna turn our
• 04:45heads to why we're here
• 04:46today, and that's to think
• 04:47about
• 04:48teaching learners at the bedside
• 04:50of our patients. So
• 04:52what do you think about
• 04:53this? Is it do the
• 04:54are there positive thoughts, negative
• 04:55thoughts, anxieties,
• 04:57frustrations? What
• 04:59word you know, free association.
• 05:01What comes to your mind?
• 05:12And these won't all be
• 05:13free response too. So if
• 05:14you if you don't love
• 05:15to to type in, it's
• 05:17okay.
• 05:17Insight, relaxing, reflective. Relaxing. That's
• 05:20good. Nostalgia, that's we'll talk
• 05:23about that. Enjoyable fun, high
• 05:25stakes, definitely.
• 05:28Teamwork. Yep. Interactive.
• 05:31These are great.
• 05:34Learners dread. Yeah. I think
• 05:35learners and and some teachers
• 05:37dread it. And we'll talk
• 05:38about why that is and
• 05:39and how to get around
• 05:39it too. Necessary. Yeah. I
• 05:41agree. That's why we're here.
• 05:42You probably all agree to
• 05:43some extent.
• 05:45Great. This is a great
• 05:46work cloud. I'll, I'll save
• 05:47it and share it, next
• 05:48time I do this.
• 05:51I just wanna know who
• 05:51I'm talking to. Are you
• 05:53a I I believe this
• 05:54is open to teaching faculty,
• 05:55so I didn't include other
• 05:56options. But are you a
• 05:57junior,
• 05:58mid career, or a senior
• 05:59faculty?
• 06:05I myself fall in the
• 06:06six to ten year range.
• 06:07So it's,
• 06:09further nerve wracking to see
• 06:10people saying they've been doing
• 06:11this for sixteen years or
• 06:12more,
• 06:13and I'm supposed to tell
• 06:14them something they don't know.
• 06:15But here we are.
• 06:17Alright. So kind of a
• 06:18mix. Cool.
• 06:21Excellent. So I will
• 06:23I will cover the basics.
• 06:24I'll try to cover some
• 06:25of the Nuance things. I
• 06:27really welcome your feedback and
• 06:28your experience. So if you
• 06:29wanna share,
• 06:31just raise your hand, drop
• 06:32a comment in the chat.
• 06:32I may not notice it,
• 06:33but I know Andres is
• 06:34gonna keep an eye on
• 06:35things, and he has free
• 06:36rein to interrupt me anytime.
• 06:39In terms of teaching, where
• 06:40do you spend your time
• 06:41these days? Is it
• 06:43with the patient at the
• 06:44bedside? Is it in the
• 06:45hallway or between you know,
• 06:47while you're walking the patient
• 06:48rooms, the elevator?
• 06:50Or are you spending time
• 06:51sitting around a conference room
• 06:52table or in a workroom?
• 06:54And, you know, I think
• 06:55these are all options for
• 06:56when you're on clinical service.
• 06:58Obviously, we do didactic teaching
• 07:00in other settings.
• 07:01But in terms of case
• 07:02based clinical teaching, where do
• 07:03you spend your time?
• 07:06It's a good mix so
• 07:07far. We got three answers.
• 07:10Quite a spread on
• 07:12how much time people are
• 07:13spending at the bedside in
• 07:14the conference room, and I
• 07:15would imagine those are
• 07:17inversely correlated.
• 07:20Yeah.
• 07:24See how our spreads look.
• 07:25Okay.
• 07:27Cool. So we have a
• 07:28range of of,
• 07:30preferences and experiences. That's the
• 07:32ideal for a conversation like
• 07:33this.
• 07:34So specific to bedside teaching,
• 07:37what would you like to
• 07:38be doing? What do you
• 07:39think is the optimal balance
• 07:41of time spent at the
• 07:42bedside? And then, obviously, I'd
• 07:43like to hear how that
• 07:45shakes out for you in
• 07:46reality. But
• 07:57Yep. Someone has a similar
• 07:58experience to mine. Good.
• 08:07And, again, I'm seeing a
• 08:08range of opinions. Some people
• 08:09would like to spend more
• 08:10than half. Some people would
• 08:11like to spend very little.
• 08:12And I think
• 08:14nothing I'm I'm gonna say
• 08:15today is,
• 08:18a requirement.
• 08:19It is all
• 08:20advice to get you to
• 08:21the bedside more if you
• 08:22think that's where you wanna
• 08:23teach. And I'll spend a
• 08:24little time at the beginning
• 08:26trying to convince you that
• 08:27it's a good place to
• 08:27teach, but I know not
• 08:28everyone will agree with me.
• 08:30And I think the best
• 08:31teachers have stuff in their
• 08:32toolbox for every setting. So
• 08:34let's get into it.
• 08:36Defining terms.
• 08:37What I mean by bedside
• 08:39teaching is teaching
• 08:40clinical science or clinical medicine
• 08:43in the presence of a
• 08:43patient. So that means you're
• 08:45in within the doors of
• 08:46the room in earshots
• 08:48of the patient. They can
• 08:49see you. You can see
• 08:50them, etcetera.
• 08:52I am not counting hallway
• 08:53teaching, doorway teaching, and certainly
• 08:56not workroom or lecture hall
• 08:57teaching.
• 08:58I wanna start with a
• 08:59couple of old school references.
• 09:01So this comes from Sylvius
• 09:03many centuries ago,
• 09:05and he had a pretty
• 09:06clear philosophy on how to
• 09:08teach medicine. So what Silvious
• 09:10said was my method hitherto
• 09:11unknown here and possibly anywhere
• 09:13else is to lead my
• 09:15students by the hand to
• 09:16the practice of medicine,
• 09:17taking them every day to
• 09:18see patients in the public
• 09:20hospital
• 09:21that they may hear the
• 09:22patient's symptoms and see their
• 09:23physical findings. Then I question
• 09:25the students
• 09:27as to what they have
• 09:27noted in the patients
• 09:29and about their thoughts and
• 09:30perceptions regarding the causes of
• 09:31the illnesses and the principles
• 09:33of treatment. And I think
• 09:34this
• 09:35is remarkable considering the time
• 09:37at which it was written.
• 09:38You know, we're this is
• 09:39not too long after the
• 09:40dark ages, and our views
• 09:42of medicine are very different
• 09:43in the seventeenth century. And
• 09:44so it this was Sylvia
• 09:46was ahead of his time
• 09:47in terms of, how to
• 09:49approach and learn about disease,
• 09:51but elsewhere felt the same
• 09:53way. There should be no
• 09:54teaching without a patient for
• 09:55a text and the best
• 09:56teaching
• 09:57is that taught by the
• 09:57patient himself.
• 10:00I agree. That's why we're
• 10:01here.
• 10:02So
• 10:03this is, you know, we
• 10:05we saw some data from
• 10:06this group at the beginning
• 10:07about how much time we
• 10:09spend at the bedside.
• 10:10As a profession of medical
• 10:12educators, we've moved far away
• 10:14from the bedside over
• 10:16a fairly recent period of
• 10:17time. So,
• 10:18survey data from the sixties
• 10:20suggested that seventy five percent
• 10:22of teaching was done with
• 10:23patients, and now it's less
• 10:25than twenty. And there are
• 10:26probably some reasons for that,
• 10:27but I just wanna back
• 10:28that up a little bit.
• 10:29So this is from two
• 10:30thousand and nine, and it's
• 10:31a bit of a complex
• 10:32chart.
• 10:33But what you're seeing is,
• 10:36for medical students and interns,
• 10:38how much time are they
• 10:39spending
• 10:40at the bedside with their
• 10:42their preceptor on rounds? And
• 10:44if you if it's kind
• 10:45of amazing, but it's around
• 10:47the twenty five minute mark,
• 10:48maybe thirty for internal medicine
• 10:49residents. When you think about
• 10:51rounds taking hours,
• 10:53that's not a high percentage
• 10:54and that actually is born
• 10:55out when they break it
• 10:56down by percentage. So draw
• 10:58your attention to these two
• 10:59boxes.
• 11:00Seventy six percent of teaching
• 11:02time with students and interns,
• 11:05is occurring at the bed
• 11:06bedside between zero and twenty
• 11:08five percent of the time.
• 11:09So,
• 11:11couple of percentages there, but
• 11:12the basic lesson is they're
• 11:13not spending a lot of
• 11:15time
• 11:15with attendings in front of
• 11:17patients. They're spending it in
• 11:19work rooms and hallways, probably
• 11:21a lot of it walking
• 11:21around if you're on the
• 11:23neurology consult team, but, very
• 11:25little at the bedside. And,
• 11:26you know, one of my
• 11:27other interests, as Andres mentioned,
• 11:28is physician well-being. And I
• 11:30think if you look at
• 11:31that literature,
• 11:33the relationship between job satisfaction,
• 11:36and meaning in work is
• 11:38directly correlated with the amount
• 11:39of time spent with patients.
• 11:41So if you think about
• 11:41our trainees' well-being,
• 11:43the more time they're at
• 11:44the computer and in the
• 11:45workroom,
• 11:46the higher risk they are
• 11:47for,
• 11:48burnout, lower well-being, etcetera. And
• 11:50that's probably for another talk,
• 11:51but I think this is
• 11:52very relevant on multiple levels.
• 11:55So why why is this
• 11:56happening? What do you think?
• 11:57We'll talk about what the
• 11:58literature shows, but I'm curious
• 12:00about your experience. A lot
• 12:01of you said, yeah. I
• 12:02wanna spend more time at
• 12:03the bedside than I do.
• 12:06Why can't you?
• 12:08And if you're having any
• 12:08technical issues with Menti, feel
• 12:10free to drop things in
• 12:11the chat too.
• 12:12I'll kinda monitor during these
• 12:13questions.
• 12:16Yes. Epic. Absolutely.
• 12:21And the way we access
• 12:22Epic, and I think maybe
• 12:23that's built into your comment,
• 12:24but, it's much easier at
• 12:26a computer than on Haiku,
• 12:28right, or whatever we use
• 12:29for a mobile device. Time
• 12:30crunch, we'll talk about time.
• 12:32I'm gonna make you feel
• 12:33a little better about bedside
• 12:34teaching,
• 12:35same with time constraints. Confidentiality,
• 12:37certainly an issue when there's
• 12:38only a curtain between you
• 12:40and the next patient. And
• 12:41then, of course, technology,
• 12:43time, less comfort with the
• 12:44exam. And I think that
• 12:46that applies to everybody
• 12:49in the room. Right? The
• 12:50but particularly when the learners
• 12:52are less comfortable,
• 12:53it's a bigger ask for
• 12:54them to do it in
• 12:55front of the whole team.
• 12:56And so and teaching it
• 12:58to them may be a
• 12:59bigger task too.
• 13:00Fear of patient criticism on
• 13:01trainees competency, absolutely, and discomfort
• 13:04related privacy. These are all
• 13:05very good reasons, and I
• 13:06can identify with all of
• 13:07them in my experience.
• 13:10Exploitation, voyeurism, yeah, these massive
• 13:12sort of party rooms that
• 13:13we have and some wings
• 13:14of,
• 13:15YNHH certainly at the VA,
• 13:17can be an issue as
• 13:18well.
• 13:20So what's been cited in
• 13:21the literature is a lot
• 13:22of what you said. The
• 13:23workload is higher. We don't
• 13:24have as much time to
• 13:25spend talking about each patient,
• 13:26and the notes for each
• 13:28patient are longer. The, you
• 13:30know, working with Epic takes
• 13:32longer.
• 13:33Patients are often off the
• 13:34floor, at random times a
• 13:35day, including during rounds.
• 13:37I think there's a fear
• 13:38that, it's bad for the
• 13:40patients to be subjected to
• 13:41bedside teaching, and we'll cover
• 13:43that in detail.
• 13:44It's more comfortable to be
• 13:46sitting around a table in
• 13:47a conference room.
• 13:48I heard the VA climate
• 13:49control is not great, but
• 13:50in general,
• 13:52you have good, you know,
• 13:53air conditioning and stuff.
• 13:54And we're spending a lot
• 13:55of time looking at screens.
• 13:56You know, in neurology, we
• 13:57look at MRIs for patients
• 13:59all the time. That's much
• 14:00better done on the big
• 14:01screen on the workroom wall
• 14:03than on an iPad or
• 14:04on a Wow.
• 14:06And so, being kind of
• 14:07tied to the computers has
• 14:09made a huge difference.
• 14:12But why should we push
• 14:12for it? This is my
• 14:14last sort of poll for
• 14:15a little while.
• 14:17Shouldn't we just kinda go
• 14:18with the flow? Isn't this
• 14:19where medicine is heading? Why
• 14:20do we care about being
• 14:21at the bedside?
• 14:25I think this is particularly
• 14:26relevant in the era of
• 14:27telehealth,
• 14:28when we're given even inpatient
• 14:29care sometimes through a screen.
• 14:33Let's see what's in the
• 14:34chat here.
• 14:37Yeah. Billing
• 14:38is a doesn't include H
• 14:39and P anymore. I think
• 14:41it's a very good point
• 14:42for, for E and M.
• 14:43Yeah.
• 14:44And so we're we're kind
• 14:45of volunteering some of that
• 14:47clinical time.
• 14:48It helps us connect with
• 14:49patients. I agree. It reclaims
• 14:51medicine with our own. Absolutely.
• 14:53Us versus other
• 14:55I I don't know who
• 14:56you're reclaiming from in your
• 14:57mind, but I could see
• 14:58us reclaiming from the digital
• 15:00doctors, Google MD,
• 15:02YouTube videos, etcetera.
• 15:05Patients and their experiences are
• 15:06the best teachers. Absolutely. Better
• 15:08cognitive connections, impactful learning. Agree
• 15:10with all of these.
• 15:12The lessons are learned when
• 15:13the patient's included,
• 15:14the best lessons. Yep. And
• 15:16the healing process is a
• 15:17good way to put that.
• 15:18I like that.
• 15:19Cool. I'm gonna keep moving.
• 15:20I know, some of you
• 15:21might be still be typing,
• 15:22but I wanna give us
• 15:23time to talk about everything.
• 15:24So
• 15:25this is my pitch for
• 15:26why you should do this.
• 15:28First of all, hands on
• 15:29learning is irreplaceable for,
• 15:31seeing things, but also from
• 15:32a neurologic perspective, it's irreplaceable
• 15:35for remembering things. So semantic
• 15:37memory is what we're building
• 15:38out of a textbook. You
• 15:40learn a fact. You maybe
• 15:41write it down or make
• 15:42a flashcard.
• 15:43You do some emboss, and
• 15:44you get these thoughts or
• 15:45facts
• 15:46lodged in your head. Right?
• 15:48Upper motor neuron injuries have
• 15:50brisk reflexes
• 15:51when they're chronic.
• 15:52It's good to know. I
• 15:53think when you see a
• 15:55patient,
• 15:56you are now incorporating
• 15:58multiple types of explicit memory.
• 15:59So you have an episode
• 16:00of a does in the
• 16:02illness script and story, and
• 16:04you have a visual image
• 16:05of the patient
• 16:07to lock in with that
• 16:08memory, and that helps you
• 16:09encode it in more places
• 16:10in your brain. It's also
• 16:11an experience that may have
• 16:13a little bit of emotional
• 16:14valence, and that certainly helps
• 16:15lock memories in our brain.
• 16:17So it's much easier to
• 16:18remember
• 16:19an upper motor neuron, brisk
• 16:21reflex when you've seen it
• 16:22than when you've read about
• 16:23it. And I think that
• 16:25is common sense, but it's
• 16:26backed up by neuroscience, and
• 16:27that's important to know.
• 16:29Another advantage, and this kinda
• 16:31came up in our,
• 16:33polls in a minute ago,
• 16:34is that patients actually like
• 16:35it, and there's data to
• 16:36support this. So don't worry
• 16:38about this complex chart. Look
• 16:40at the far right column.
• 16:41And, basically, this is a
• 16:42study where they
• 16:44asked,
• 16:45the team members,
• 16:47about and the patients, excuse
• 16:48me, about the team member's
• 16:50performance on rounds. And they
• 16:52stratified them by whether
• 16:54the presentation was given at
• 16:55the bedside or the patient
• 16:57went to see the team
• 16:58after the, sorry, the team
• 16:59went to see the patient
• 17:00after a conference room presentation.
• 17:03Now none of these adjusted
• 17:04odds ratios were significant. Right?
• 17:06But the trend is undeniable
• 17:08that patients,
• 17:10by and large, thought
• 17:12they learned about their problems
• 17:13better. They understood their treatments
• 17:16and tests.
• 17:17They felt more connected to
• 17:18their physicians,
• 17:19and they felt less worried.
• 17:22And they felt their care
• 17:23was optimal
• 17:24when presentations were done at
• 17:26the bedside.
• 17:27I think that's striking. You
• 17:28know? I mean, how do
• 17:29you argue with that? The
• 17:30patients really appreciate this when
• 17:31it's done well. The second
• 17:33half, we'll talk about how
• 17:34to achieve that,
• 17:35but the the potential is
• 17:37there, undeniably.
• 17:39Another one, and I these
• 17:41are kinda old, so they
• 17:42didn't really focus on,
• 17:44catchy charts back in the
• 17:45day. But,
• 17:46they looked at same study
• 17:48asked the patient's narrative comments.
• 17:50What was your experience like
• 17:52when someone presented your case
• 17:53at the bedside?
• 17:54And a large percentage of
• 17:56them said they weren't upset
• 17:57by it. They wanted physicians
• 17:59to continue it. They understood
• 18:01their illness better.
• 18:03They recognized that teaching trainees
• 18:05was the main focus, but
• 18:07despite that, they still had
• 18:08these other feelings. They didn't
• 18:09feel used as a teaching
• 18:11object or worried about what
• 18:12they heard.
• 18:13There was an issue, with
• 18:15terminology, and we'll talk about
• 18:16that.
• 18:17But very you know, in
• 18:19terms of suggestions,
• 18:20they didn't really have much
• 18:21to say that was negative.
• 18:23A lot of it was
• 18:24maybe they could talk more.
• 18:26Physicians would introduce themselves, and
• 18:27we'll talk about how to
• 18:28do those things. But these
• 18:29are small tweaks. Again, the
• 18:31the experience of being a
• 18:33patient during bedside teaching is
• 18:36generally positive.
• 18:38It's also positive for the
• 18:39learners.
• 18:40So
• 18:41if you survey learners,
• 18:43in the same paper
• 18:45who they asked them about
• 18:47their learning experience
• 18:48after bedside teaching,
• 18:50and the majority said they
• 18:51had more understanding of the
• 18:53patient's problem. They enjoyed it.
• 18:55Some felt anxious.
• 18:56Rarely, there was inappropriate discussion,
• 18:58and we'll talk about how
• 18:59to avoid that.
• 19:02Some were worried about confidentiality,
• 19:03which some of you were
• 19:04as well, but the vast
• 19:06majority would recommend it. They
• 19:07felt it was a positive
• 19:08experience as a learner.
• 19:10So it's really a win
• 19:10win, and I just wanna
• 19:12make that clear upfront.
• 19:13If you wanna get technical,
• 19:15and a lot of us
• 19:15are medical educators and care
• 19:17about this, it also
• 19:19aligns with adult learning theory.
• 19:20So these are the general
• 19:21principles of adult learning theory
• 19:23that we're trying to capitalize
• 19:24on with bedside teaching. So
• 19:26one is that knowledge is
• 19:28continuously revised
• 19:29with
• 19:30the,
• 19:33adjustment of prior experience and
• 19:35knowledge to with current experience.
• 19:37So patients go into the
• 19:39room knowing what they know
• 19:40about reflexes.
• 19:41They test reflexes, and then
• 19:43they come out knowing something
• 19:44different. And either they've added
• 19:46to to their existing repertoire
• 19:47or they've changed something, and
• 19:49the experience is what does
• 19:50that.
• 19:51The better clinical reasoners out
• 19:53there are the ones who've
• 19:54seen the most patients, and
• 19:55so you can contribute to
• 19:56that even in the early
• 19:57stages of learning by broadening
• 19:59their experience examining pathology.
• 20:03Adult learners need to take
• 20:04ownership, and I think ownership
• 20:05is increased when you're face
• 20:07to face with a patient
• 20:08rather than talking about them
• 20:09at a conference room table.
• 20:11And adult learning is social.
• 20:12And so learning how to
• 20:13do a physical exam is
• 20:15actually better with a group,
• 20:17because you learn from each
• 20:17other.
• 20:18And and that also aligns
• 20:20with situated learning,
• 20:21which is a a parallel
• 20:23theory of adult learning that
• 20:24you may or may not
• 20:25have seen. But the brief
• 20:26version is
• 20:28when you start doing something
• 20:29and joining a community of
• 20:31practice like being a physician,
• 20:33you're on the periphery. And
• 20:34we see this physically
• 20:35in rounds. I mean, it's
• 20:37it's it's a little too
• 20:37on the nose sometimes. But
• 20:39the students are really on
• 20:40the outside looking in, and
• 20:42they're learning how to
• 20:44talk, act, behave,
• 20:45walk, dress
• 20:47like physicians. And the way
• 20:48they do that is by
• 20:49interacting with expert physicians. And
• 20:51the more they interact, the
• 20:52more they learn, the more
• 20:53they're supported by experts, the
• 20:55closer they move to the
• 20:56center of the community of
• 20:58practice.
• 20:58And this really is what's
• 21:00happening over medical school and
• 21:02residency.
• 21:03And I I will argue
• 21:04that, you can speed that
• 21:06along
• 21:07by putting them in real
• 21:08life care situations at the
• 21:09bedside as opposed to talking
• 21:11in theory at a table.
• 21:15Last advantage. My last pitch
• 21:17is that you can actually
• 21:18do bedside teaching and be
• 21:20faster than a conference room
• 21:22teacher.
• 21:23So this is a I'll
• 21:25show you the data in
• 21:25a second. But what do
• 21:27you think? Before I show
• 21:28you the data
• 21:29based on what I've already
• 21:30kinda sold you on,
• 21:31where do you feel like
• 21:32you're most efficient in teaching?
• 21:34Is it easier to do
• 21:34it at a Blackboard, or
• 21:35is it easier to do
• 21:36it with a patient? And
• 21:38by easy, I mean, getting
• 21:40important information across quickly.
• 21:42So that's really
• 21:54efficiency. Got it.
• 21:58Yeah. Easier at the bedside,
• 21:59but can slow you down.
• 22:00Absolutely.
• 22:04Yeah. So maybe maybe it's
• 22:06most effective at the bedside,
• 22:07but efficiency is a different
• 22:09story. I think we could
• 22:10all kind of agree with
• 22:11that. I'll give you some
• 22:12tips and tricks to make
• 22:13it more efficient, but I'll
• 22:15show you also some data
• 22:16that
• 22:17proves that I may have
• 22:18a point. So,
• 22:19this was a study done
• 22:20in two thousand and seventeen
• 22:21where they did a, time
• 22:22motion study on,
• 22:24teams rounding. And then they
• 22:26stratified it by
• 22:28what the learners considered were
• 22:29the most effective teachers. So
• 22:31we have most, moderately, and
• 22:33least, three tiers. And what
• 22:34you learn from this is
• 22:36that, first of all, satisfaction
• 22:37is higher
• 22:38with, the most effective teachers.
• 22:40That makes sense.
• 22:42They actually spent less time
• 22:43per patient overall
• 22:45when they were teaching at
• 22:46the bedside, and their rounding
• 22:47time
• 22:48was lower.
• 22:50So the I didn't show
• 22:51you the table, but there
• 22:52is a direct relationship between
• 22:54efficacy
• 22:55and time spent with patients
• 22:56teaching. And so we can
• 22:58really interpret this as
• 22:59intensive bedside teachers, moderate bedside
• 23:02teachers,
• 23:03minimal bedside teachers. And the
• 23:05intensive ones knew what they
• 23:06were doing. They knew how
• 23:07to round faster.
• 23:08They taught more per rounds,
• 23:11more per patient, but spent
• 23:12less time doing it. That's
• 23:13pretty impressive. And so I'll
• 23:15give you some basic frameworks
• 23:16on how to make that
• 23:17happen, but know that it's
• 23:18possible. There is not a
• 23:20guarantee that teaching at the
• 23:21bedside is slow.
• 23:23So we're gonna shift gears.
• 23:25While you fill this out,
• 23:26now would be a good
• 23:27time to ask any questions
• 23:28about the rationale
• 23:29for bedside teaching.
• 23:31Drop them in the chat
• 23:32if you'd like. We will
• 23:33talk about the technique of
• 23:35bedside teaching next.
• 23:38But I'd like to know
• 23:39what you think,
• 23:40makes a good encounter.
• 23:51And the whiteboard be there.
• 23:59Patient input. Yep. We will
• 24:01definitely talk about that.
• 24:09Respect, privacy, engagements,
• 24:11yep, of learners and patient,
• 24:12probably.
• 24:16Inclusive.
• 24:19Absolutely.
• 24:24Yes. This does apply to
• 24:25the outpatient setting.
• 24:26I don't have as much
• 24:27data on outpatient teaching.
• 24:32I would imagine it's similar
• 24:33as someone who teaches a
• 24:34resident clinic,
• 24:35but it does depend on
• 24:36how you budget your time.
• 24:37And we that's probably another
• 24:39talk for another day.
• 24:41Yeah. Focusing on relevant findings,
• 24:45being honest, being caring. Yeah.
• 24:46You know, a lot of
• 24:47it's sort of good intentions,
• 24:48but I think there's also
• 24:49some some frameworks and techniques
• 24:51that can make it better.
• 24:53So,
• 24:54I like to think about
• 24:56any bedside teaching in three
• 24:57phases, and this is the
• 24:58skeleton of the framework I'm
• 25:00gonna fill in for you.
• 25:01So
• 25:02no matter what you're talking
• 25:04about, what type of learning,
• 25:05patient, learner centered,
• 25:07your best thought of you
• 25:08you need to think about
• 25:09it beforehand.
• 25:10There are certain things you
• 25:11can do to make it
• 25:12better, and then I think
• 25:13it's always more effective
• 25:14when you close out the
• 25:16experience
• 25:17generally outside the room. So
• 25:19the preparation and debriefing don't
• 25:20have to happen in front
• 25:21of the patient, and I
• 25:22think they're more effective if
• 25:23they don't. Obviously, the execution
• 25:25is where the rubber meets
• 25:26the road, and we'll talk
• 25:27about that.
• 25:28So there's there's those three
• 25:29phases. And then I think
• 25:31within those phases, there's really
• 25:32two
• 25:34aspects. One is how do
• 25:35you interact with your learners.
• 25:37The other is how do
• 25:38you interact with your patients.
• 25:39And learner interactions are different
• 25:41at the bedside for obvious
• 25:42reasons than they are in
• 25:43the conference room. And, certainly,
• 25:44patient centered interactions only really
• 25:46apply
• 25:47to bedside teaching. So
• 25:49we'll talk about learner centered
• 25:51teaching first.
• 25:53You know, this is a
• 25:54basic dynamic that I think
• 25:55we're all
• 25:56kind
• 25:57of grappling with all the
• 25:58time, which is how do
• 25:59we manage the
• 26:01flow of knowledge between the
• 26:02teacher and the learner in
• 26:04a way that the learner
• 26:04remembers it and can apply
• 26:06it in the future.
• 26:08So this is a a
• 26:09great definition of learner centered
• 26:11teaching. It is a method
• 26:13of teaching in which the
• 26:14students' needs have priority.
• 26:16Teachers are expected to facilitate
• 26:18self directed learning and spent
• 26:19instead of spoon feeding, and
• 26:21it's really the opposite of
• 26:21teacher centered education. And I
• 26:23think if you had to
• 26:23boil this down into
• 26:25a phrase, it would be
• 26:26what the learner needs to
• 26:27know, not what you're comfortable
• 26:29telling them. And so it
• 26:31I didn't see this really
• 26:32in the
• 26:33the initial brainstorms, but there
• 26:35is this concept of thin
• 26:36ice syndrome when teachers are
• 26:38concerned that they're gonna be
• 26:39on thin ice if they
• 26:41don't control the direction of
• 26:42the learning encounter. They're gonna
• 26:44end up having to talk
• 26:44about something that maybe they
• 26:45don't have a chalk talk
• 26:46for or aren't as comfortable
• 26:48with. And I think the
• 26:49odds of that go the
• 26:50stakes of that go way
• 26:51up when you're in front
• 26:52of your patient. And so
• 26:53that to me is a
• 26:54is a big thing to
• 26:55worry about. But you need
• 26:56to be learner centered if
• 26:57you wanna be effective. And
• 26:59the way you do that
• 26:59is you address the needs
• 27:01of the learner, and I
• 27:02put an asterisk there because
• 27:03the biggest the hardest part
• 27:04of this is figuring out
• 27:05what the learner needs to
• 27:06know.
• 27:07It has to be contextual,
• 27:08which doing it with a
• 27:09patient helps, but also timely
• 27:11in their learning trajectory.
• 27:13And it has to facilitate
• 27:14experiential learning, and we'll talk
• 27:15about that in a second.
• 27:17So,
• 27:19I think that slide got
• 27:20doubled up. Yeah. Here's the,
• 27:21here's the experiential learning slide.
• 27:23So you've probably all seen
• 27:25this too. This is like
• 27:25in the canon of medical
• 27:27education,
• 27:28But experiential learning happens through
• 27:31concrete experience and experimentation,
• 27:33and then it's really
• 27:35solidified by observation
• 27:37and drawing conclusions from those
• 27:39observations
• 27:40after the concrete experience.
• 27:42So what bedside teaching does
• 27:44that conference room teaching doesn't
• 27:45do as well
• 27:47is force the learner to
• 27:48experiment and have an experience
• 27:50to draw from that sitting
• 27:51in a chair and thinking
• 27:52does not. And this is
• 27:53where the hands on part
• 27:54is so advantageous.
• 27:56So let's talk about preparation
• 27:57from this learner centered,
• 28:00perspective. So
• 28:01to prepare
• 28:03the learners for bedside teaching,
• 28:04I think you need to
• 28:05establish objectives. And there are
• 28:06many ways you can do
• 28:07this. You can ask them
• 28:08what do you wanna focus
• 28:09on today.
• 28:11You can do a little
• 28:11bit of Socratic,
• 28:14you know, inquisition and figure
• 28:15out what knowledge gaps might
• 28:17they have, that they need
• 28:18to fill out.
• 28:19And one way to do
• 28:21that is with the one
• 28:21minute preceptor.
• 28:23So this is this is
• 28:24an hour in and of
• 28:25itself,
• 28:26but just as a reminder,
• 28:27the one minute preceptor is
• 28:28a quick model for
• 28:30determining knowledge gaps and then
• 28:32filling them in. And you
• 28:33can use this with bedside
• 28:34teaching. So you first get
• 28:36a commitment from the learner.
• 28:38What would you expect to
• 28:39see on I'm sorry. I'm
• 28:40giving all neurology examples. What
• 28:42would you expect to see
• 28:42on the pronator drift exam
• 28:44if this was a stroke?
• 28:46And then the learner tells
• 28:47you what they think, and
• 28:48you kinda probe them. Why
• 28:49do you say that? You
• 28:50know, what makes you answer
• 28:51it the way you did?
• 28:52And then once you find
• 28:53a knowledge gap, you've you
• 28:54hit your target. Right? That's
• 28:56what you need to fill
• 28:56in. So if the learner
• 28:57thinks that, you know, pronator
• 28:59drift is not an upper
• 29:00motor neuron sign or they
• 29:01don't know what it is
• 29:02or they don't know what
• 29:03to look for, there's your
• 29:04teaching goal. And the best
• 29:05way to establish these goals
• 29:07is to figure out by
• 29:08what they know already.
• 29:10Then you teach a general
• 29:11rule, and then you reinforce
• 29:12it and correct mistakes. And
• 29:13that, again, is more for
• 29:15another time. But these first
• 29:17two steps can be really
• 29:18valuable, and you can do
• 29:19them while you're prerounding. You
• 29:20can do them while you're
• 29:21walking to the patient's room.
• 29:22You could even stop outside
• 29:23the room and do them.
• 29:25The the settings are variable.
• 29:27I think it's better to
• 29:27do it outside the room.
• 29:29So you you establish objectives,
• 29:31and then you select the
• 29:32right patient to teach something
• 29:34they need to know. You
• 29:35know, if they need to
• 29:36know about hemiparesis, it may
• 29:38not be great to ask
• 29:39a patient who's not hemiparetic,
• 29:41right, about their their symptoms.
• 29:42So,
• 29:44there's a little bit of
• 29:45give and take and interplay
• 29:46between the patients on your
• 29:47service and the knowledge gaps,
• 29:49but, usually, they're contextually related
• 29:51to the patient.
• 29:52So let's talk about patient
• 29:54selection.
• 29:55You know, you have a
• 29:56pretty big census.
• 29:57Some are very sick. Some
• 29:58are just waiting for discharge.
• 30:02You know, they have various
• 30:03reasons why you may or
• 30:04may not wanna select them.
• 30:05But what comes to mind
• 30:06is important criteria.
• 30:20So, yeah, are they verbal?
• 30:22And it's interesting because in
• 30:23neurology, sometimes the nonverbal,
• 30:26pathologies are important. But I
• 30:28think for
• 30:29non neurologic cases, it much
• 30:31it makes it much easier
• 30:32to learn if the patient
• 30:33can interact. Yeah. Will they
• 30:34cooperate?
• 30:45While you're thinking, it's it's
• 30:46interesting. I didn't put this
• 30:47in my presentation, but there
• 30:48are some good articles on
• 30:49there about ethical
• 30:51patient selection.
• 30:52And,
• 30:54you know, I the thing
• 30:54that made me think of
• 30:55it was there there are
• 30:57some people that argue that,
• 31:00you know, you shouldn't
• 31:02deny the benefit of being
• 31:03included in teaching to any
• 31:05patient based
• 31:07on medical presentation,
• 31:09aggressiveness,
• 31:10personality,
• 31:11language barriers, whatever. And then
• 31:13there are other people that
• 31:13say, well, you have to
• 31:14take some of that into
• 31:15account. And I I don't
• 31:16know. I think about it
• 31:17all the time. I don't
• 31:18know if there's a right
• 31:18answer, but I think it's
• 31:19important to think about when
• 31:20you're picking a patient or
• 31:21not, why do you think
• 31:23they're appropriate.
• 31:24Patient anxiety is important.
• 31:26Willingness.
• 31:27Yeah. These are important things.
• 31:28We'll talk about some more.
• 31:30One other thing I like
• 31:31to think about when I'm
• 31:32selecting a patient is, you
• 31:34know, am I
• 31:36if I'm uncomfortable with them,
• 31:37why is that? And I
• 31:38think that varies based on
• 31:39the severity of their illness.
• 31:41So,
• 31:42how comfortable are you
• 31:44in selecting a patient in
• 31:46these different scenarios? So one
• 31:47is just overall. Do you
• 31:48feel like you're pretty good
• 31:49at selecting bedside teaching patients?
• 31:52And then when a patient
• 31:53has an unusual finding, does
• 31:54that make it more or
• 31:55less comfortable to teach with
• 31:56them?
• 31:58And then I think these
• 31:59other ones are really relevant
• 32:00too. A patient with a
• 32:01terminal prognosis or diagnosis who
• 32:03knows it,
• 32:04and and you need to
• 32:05talk about it with them.
• 32:06And then a patient who
• 32:07isn't aware, doesn't have insight,
• 32:09either they're encephalopathic
• 32:10or in a coma.
• 32:12So how comfortable are you
• 32:13teaching each of these settings?
• 32:26Interesting. I give this, I
• 32:27give a similar talk to
• 32:28the residents
• 32:30every year in July,
• 32:32and, it pretty much slopes,
• 32:35from high to low as
• 32:36you go down the list.
• 32:37A lot of them feel
• 32:38very uncomfortable teaching
• 32:39a patient who can't interact,
• 32:41which is really important in
• 32:42neurology at least. And then
• 32:44over they feel a little
• 32:45bit better if they're awake
• 32:46and have an exam finding.
• 32:47So you got you all
• 32:48are a little more comfortable,
• 32:50across the board, at least
• 32:52to the moderate level, which
• 32:53is good to know.
• 32:56So this is, one of
• 32:57those papers I kinda referenced
• 32:59earlier, and these are the
• 33:00things I think you should
• 33:01at least think about when
• 33:02you're selecting a patient for
• 33:03teaching. You can't always satisfy
• 33:05all of them, but
• 33:06one we've covered so far
• 33:07is do they fit what
• 33:08the learner needs to know,
• 33:09and I think that's, a
• 33:10bare minimum.
• 33:12But then also,
• 33:13what's the patient's personality like?
• 33:16What are their what's their
• 33:17understanding, and how sick are
• 33:18they? Are you putting the
• 33:20team at risk, if they
• 33:21have a communicable disease? You
• 33:23know, teaching at the COVID
• 33:24bedside
• 33:25in twenty twenty was not
• 33:26happening for good reason.
• 33:29Does the patient understand what's
• 33:30going on enough to participate
• 33:32in teaching?
• 33:33And then what's your relationship
• 33:34with them? If it's your
• 33:35first time meeting them, maybe
• 33:37it's not the day to
• 33:37bring your students by to
• 33:38practice auscultation. Right?
• 33:41And then structural stuff too.
• 33:44How often are you calling
• 33:45on one particular patient with
• 33:46an interesting finding? If you're
• 33:47teaching on them every day,
• 33:48they're gonna get sick of
• 33:49it.
• 33:50How big is your census?
• 33:52Can you reach the patient?
• 33:53And then, you know, are
• 33:54there are there medical legal
• 33:55considerations,
• 33:57that may come into play?
• 33:59One important one I think
• 34:00that you don't always think
• 34:01about it first is if
• 34:02there is a potential
• 34:04medical legal situation, any learner
• 34:06you draw into the case
• 34:07can get subpoenaed and have
• 34:09to testify. So,
• 34:10I've had learners stay out
• 34:12of certain cases, when they're
• 34:13they're legally gray, And I
• 34:15think that's important to consider
• 34:16too.
• 34:19So you've picked your patient,
• 34:20you've found your learning goals,
• 34:23and you've you're at the
• 34:24room. And now it's time
• 34:25to execute. And this is
• 34:27probably the most nerve wracking
• 34:28part. So So we'll talk
• 34:29about a couple of ways
• 34:30to do this well.
• 34:32And, again, we're still thinking
• 34:33about the teacher learner. We'll
• 34:34talk about the patient learner
• 34:36in a moment. So
• 34:38good learner centered teaching, is
• 34:40adapted to learning needs, allows
• 34:41time for questions,
• 34:42and give some feedback in
• 34:44real time. There's a I
• 34:45think there's
• 34:46a distinct feedback session that
• 34:48happens later.
• 34:49But particularly at the bedside,
• 34:50if someone's using improper technique,
• 34:52you don't wanna let that
• 34:53go. Right? You wanna catch
• 34:54it in the moment and
• 34:55correct them and use that
• 34:57as your teaching opportunity,
• 34:58a, so they don't force
• 34:59bad habits, but b, so
• 35:00it's relevant
• 35:01and vivid in their memory.
• 35:04And then you debrief.
• 35:05So you you go outside
• 35:07the room and you say,
• 35:08what did we wanna learn?
• 35:09What did we learn? Here's
• 35:11what I saw you do
• 35:11well. Here's what you should
• 35:13do differently next time. What
• 35:14did you get out of
• 35:15this?
• 35:16And part of that reflection
• 35:17is also
• 35:18the the learner's emotional experience
• 35:21of being put on the
• 35:22spot and what they may
• 35:23have seen or talked about
• 35:24with the patient in that
• 35:25discussion.
• 35:26Because, again, the stakes feel
• 35:27higher when your entire team
• 35:29is watching you.
• 35:30A lot of this is
• 35:31pretty intuitive to you as
• 35:33good teachers. You know how
• 35:34to do learner centered teaching.
• 35:36You know how to execute
• 35:37it. You know how to
• 35:38give feedback.
• 35:39I think the part that
• 35:40makes bedside teaching hard is
• 35:42that it also has to
• 35:43be patient centered. So you're
• 35:44you're really managing a much
• 35:46more complex dynamic
• 35:48at the bedside than you
• 35:49are at the conference room
• 35:50table. And so that's what
• 35:51I wanna spend the rest
• 35:52of our time thinking about.
• 35:55So now it's instead of
• 35:56one dynamic, you have three.
• 35:57Right? You have to manage
• 35:58your teaching of the learner.
• 35:59You have to manage your
• 36:01relationship with the patient. And
• 36:02probably most challenging,
• 36:04you are overseeing
• 36:06the learner patient interaction.
• 36:08And I think what scares
• 36:08the heck out of me
• 36:09teaching at the bedside is
• 36:11what's gonna come out of
• 36:12the learner's mouth. Right? You
• 36:13never really know. And so
• 36:15that, I think adds a
• 36:16lot of,
• 36:17perceived risk to this situation,
• 36:19but we'll talk about some
• 36:20ways to do it.
• 36:21So just like learner centered
• 36:23teaching,
• 36:24patient centered teaching focuses on
• 36:26someone else's needs, but this
• 36:27time it's the patients. What
• 36:28do they need to get
• 36:29out of this interaction?
• 36:30Do they need to understand
• 36:31their diagnosis better?
• 36:33Do they just need to
• 36:34give you an update on
• 36:35how their last twenty four
• 36:36hours went? What do they
• 36:37need?
• 36:38It should actively include the
• 36:39patient, and I think this
• 36:40is what the real masters
• 36:42do is bring the patient
• 36:43into the team. We'll talk
• 36:45about ways to do that.
• 36:46And then the patient should
• 36:47leave knowing more than when
• 36:48you walked in. I don't
• 36:50think the learners are the
• 36:50only ones who can grow
• 36:52in terms of their understanding
• 36:54and insight from a a
• 36:55bedside teaching encounter.
• 36:57So before you go in,
• 37:00we talked about which patients
• 37:01to pick a little bit
• 37:02and how to fill learning
• 37:03gaps.
• 37:06You wanna establish objectives that
• 37:08also take into account the
• 37:09needs of the patient. So
• 37:10if the learner wants to
• 37:11learn
• 37:12about informed consent and the
• 37:14patient has an LP, that's
• 37:15a a perfect patient to
• 37:16choose. Right? They can you
• 37:17can kill two birds with
• 37:18one stone.
• 37:20One important question that always
• 37:22comes up and you don't
• 37:23really think about it too
• 37:24much, but it's relevant is
• 37:25do you need to get
• 37:26informed consent from the patient
• 37:29to teach
• 37:30in their bedside encounter, if
• 37:32that makes sense?
• 37:33So I'm just curious. What
• 37:34do you all think? Do
• 37:35you need to say,
• 37:37you know, does it need
• 37:38to be formal, informal? Does
• 37:40it apply to every patient?
• 37:42I don't think it needs
• 37:43to be written. That seems
• 37:44a little excessive. But even
• 37:45a verbal consent, should you
• 37:46be getting that from everyone?
• 37:49And it could be as
• 37:49simple as, hey. I'm gonna
• 37:50bring in a group to
• 37:51teach on you.
• 37:52Not on you, but you
• 37:53know what I mean. Bring
• 37:54in a group to teach
• 37:55about your disease,
• 37:57or your treatment. Are you
• 37:58okay with that?
• 38:05So we have one for
• 38:06sometimes.
• 38:07Let's see. Sometimes we'll chat
• 38:09here too.
• 38:10Yes. Verbal. Okay. Someone for
• 38:13verbal consent. Bill, you have
• 38:15your hand up.
• 38:17Yeah. Thanks, Jeff. When you
• 38:19say should, do you mean
• 38:20should
• 38:21sort of ethically,
• 38:23should pedagogically,
• 38:24or should legally?
• 38:26I think ethically. I I
• 38:27don't think legally it's required,
• 38:29but I think ethically
• 38:31is what I'm getting at
• 38:32here. Got it.
• 38:38Thanks.
• 38:43Yeah. We could probably have
• 38:44an interesting,
• 38:45you know,
• 38:46twenty minute discussion on this
• 38:48for the rest of the
• 38:48time, but, I think it's
• 38:50it's just worth noting that
• 38:51we're a little bit split.
• 38:52And that
• 38:54that tracks with when I've
• 38:56given a similar talk before,
• 38:58that not everybody agrees that
• 38:59every patient needs to be
• 39:00consented, but some feel pretty
• 39:01strongly they do.
• 39:04So,
• 39:05there's a little bit of
• 39:06guidance on this.
• 39:08For those of you who
• 39:09thinking of a patient you
• 39:10should consent, what do you
• 39:11tell them? You know, it's
• 39:12obvious for
• 39:13lumbar punctures. There are risks
• 39:15of post LP headache, bleeding
• 39:16infection,
• 39:18rarely nerve damage. The benefits
• 39:20are diagnosis and or treatment.
• 39:23That conversation is a little
• 39:24murkier with teaching. So what
• 39:26do you think you need
• 39:26to bring up?
• 39:33Patients yeah. So this is
• 39:34an important point that I
• 39:35see in the chat.
• 39:37It should be implied
• 39:38that patients, because they're at
• 39:40a teaching institution, are going
• 39:41to be involved in teaching.
• 39:46I'm not saying whether I
• 39:47agree or disagree, but I've
• 39:48had people say, well,
• 39:50not every patient chose to
• 39:51come to you. Right? That's
• 39:52just where the ambulance brought
• 39:53them. And if it was
• 39:55an elective admission, sure. But,
• 39:57can we really say that?
• 39:59And is that fair to
• 39:59our patients who live down
• 40:00the street from the hospital
• 40:01but don't wanna be part
• 40:03of teaching?
• 40:04So I I'm not saying
• 40:05you're right or wrong. I'm
• 40:06saying I don't think there
• 40:07is a right or wrong
• 40:07answer, and there's multiple ways
• 40:09to consider this.
• 40:10And and perhaps it's not
• 40:11as clear to everyone what
• 40:13you would need to say.
• 40:13So let's let's go into
• 40:15what I've seen in the
• 40:16literature.
• 40:18Just like any consent, you
• 40:20need to at least have
• 40:21a couple of things. And,
• 40:22again, this can be accomplished
• 40:23in one sentence,
• 40:24but you should have you
• 40:25should ask for yes or
• 40:26no.
• 40:27The patient should be aware
• 40:28that they have the choice,
• 40:29and they should be aware
• 40:30that anything that's talked about
• 40:32in the teaching session is
• 40:33equally as confidential
• 40:35as if you weren't there,
• 40:36with the team, if you
• 40:37were just there by yourself.
• 40:38So this could be as
• 40:39simple as, you know, hey,
• 40:41mister Smith. I'm I got
• 40:43the team outside the door.
• 40:45If it's okay with you,
• 40:46I'd like to bring everyone
• 40:47in, talk a little bit
• 40:48about your disease,
• 40:50and, maybe they can learn
• 40:51some things for the next
• 40:52time they see someone like
• 40:53you. Just so you know,
• 40:55this is just gonna stay
• 40:56in the room. And if
• 40:57you say no, it's not
• 40:58gonna affect your care. Are
• 40:59you okay with that?
• 41:01Takes ten seconds, but I
• 41:02think it's really effective. So
• 41:04I've started doing this on
• 41:05almost every patient. Now if
• 41:07if you've seen the same
• 41:08patient five days in a
• 41:09row on rounds and they
• 41:10know what's coming, maybe you
• 41:12don't have to do it.
• 41:13But for the first time,
• 41:14you know, their first morning
• 41:15in the hospital, I think
• 41:16it makes a huge difference.
• 41:17Agree or disagree? To Bill's
• 41:18point, I don't think it's
• 41:20gonna be a legal issue.
• 41:21I think it's really
• 41:22a a personal comfort issue.
• 41:24So once you've consented,
• 41:26you it's time it's time
• 41:28to teach. And there's some
• 41:29really good ways to involve
• 41:30the patient effectively
• 41:32in your teaching.
• 41:33So one is to be
• 41:35explicit about
• 41:37their feelings, their needs, their
• 41:38preferences,
• 41:39about their
• 41:40approach to their illness, their
• 41:42understanding of what happened to
• 41:43them,
• 41:44what they need from the
• 41:45team. And so you can
• 41:46ask them that explicitly
• 41:47even before you put the
• 41:48learner on the spot.
• 41:50Mister Smith, what do you
• 41:51wanna get out of this
• 41:52discussion?
• 41:53You should involve the patient
• 41:55throughout,
• 41:55and we'll talk about some
• 41:56ways to do that specifically,
• 41:58but I think it
• 42:00it's something we all intuitively
• 42:01agree with. But then when
• 42:02it comes time to teach,
• 42:03you sometimes forget that the
• 42:05patient is hearing everything and
• 42:07if you're not involved in
• 42:08them, they will feel it.
• 42:10I think it's effective to
• 42:11let the patient know,
• 42:14things in their
• 42:15at their understanding level of
• 42:17medicine. So if you're gonna
• 42:18teach about reflexes,
• 42:20talk shop with the residents
• 42:21of the students, but then
• 42:23say, hey. I just just
• 42:24so you know, I'm just
• 42:25telling them that after you
• 42:26had that stroke, your reflex
• 42:28has changed, and that's how
• 42:28we would detect it.
• 42:30You let the patient chip
• 42:31in with questions. And then
• 42:32if you're really have some
• 42:33time,
• 42:34and the patient is, you
• 42:36know, willing to be involved,
• 42:37you can have them feedback.
• 42:39Did that hurt? How did
• 42:40it feel
• 42:41when
• 42:42so and so doctor so
• 42:43and so talked to you
• 42:44that way? Things like that,
• 42:45and get their experience. And
• 42:46I think that's really valuable
• 42:47for the learners.
• 42:50This is a really good
• 42:51study. And if you wanna
• 42:52read an interesting ethnography study,
• 42:54this one is great. So
• 42:55they they looked at videos
• 42:57of
• 42:58teaching encounters at the bedside
• 43:00and,
• 43:01categorized behaviors
• 43:02both by the team,
• 43:04in particular, but then also,
• 43:06as they related to the
• 43:07patient's experience.
• 43:08And they really came down
• 43:09to two types of encounters.
• 43:11And I think we know
• 43:12which one is better, but,
• 43:13again, I don't think it's
• 43:14quite so easy in the
• 43:15moment.
• 43:16So one type would be
• 43:17the patient as body as
• 43:19they called it. The discussions
• 43:20about the patient
• 43:22make them feel excluded in
• 43:23some way. You know, they're
• 43:24separate. They're at the foot
• 43:25of the bed.
• 43:26They're in low tones of
• 43:27voice. They're not looking at
• 43:29the patients,
• 43:30and they use medical jargon
• 43:31that the patient can understand.
• 43:33And if you look at
• 43:34from an overhead view, there's
• 43:36a physical distance between the
• 43:37team and the patient. You
• 43:38know, again, maybe they're at
• 43:39the foot of the bed
• 43:40or they have some of
• 43:41the team members have their
• 43:42back turned.
• 43:43These are easy things to
• 43:44do when you're talking about
• 43:45complex subjects, and you don't
• 43:47want to alarm the patient
• 43:48by saying the word,
• 43:50you know, myopathy or with
• 43:52something they haven't heard yet.
• 43:53But it makes them feel
• 43:55bad, and that's what the
• 43:56study showed. The opposite would
• 43:57be the patient embodied approach.
• 43:59So the patients are invited
• 44:01to contribute like we talked
• 44:02about. You can use jargon,
• 44:03but explain it. Avoid it
• 44:05when possible. But if you
• 44:06have to say it, say
• 44:07this is what I mean
• 44:07by that word.
• 44:09And then you you surround
• 44:10the patient. Their head is
• 44:11part of the circle of
• 44:12bodies around the bed, and
• 44:14you stand on their good
• 44:15side if they're deaf or,
• 44:17have hearing loss or have
• 44:18neglect or something. So you
• 44:19really take into account the
• 44:20fact that they need to
• 44:21be hyper aware
• 44:23that you believe they're part
• 44:24of the team. And the
• 44:26better encounters where the patients
• 44:27felt better afterward were these
• 44:29patient embodied ones. And, again,
• 44:30it's common sense. Right? But
• 44:31I think it's really hard
• 44:32to remember in practice.
• 44:34So you've done your teaching.
• 44:36You've answered the patient questions.
• 44:37They feel better. The learners
• 44:38feel better, and you step
• 44:40out of the room.
• 44:41I think a patient centered
• 44:42debriefing is much like a
• 44:44learner centered debriefing,
• 44:45but you talk about the
• 44:46patient experience. How did it
• 44:48feel
• 44:49giving the patient that news
• 44:50or
• 44:51doing that exam that can
• 44:53sometimes be kind of awkward
• 44:54positioning wise?
• 44:56Were you how do you
• 44:57feel about having to pinch
• 44:58them because they can't
• 44:59speak to tell you if
• 45:00they feel pain? You know,
• 45:01these things are tough for
• 45:02learners, and I think it's
• 45:04important to think about what
• 45:05the patient experienced
• 45:07as well as what the
• 45:07learner experienced. And then you
• 45:09reflect. Anything else that came
• 45:11to your mind, anything that
• 45:12bothered you or you wanna
• 45:13talk about.
• 45:15So this whole thing can
• 45:16be done very quickly
• 45:17if you,
• 45:19employ these techniques.
• 45:21And, again, you're really managing
• 45:22three dynamics at the same
• 45:24time.
• 45:25Two with patient centered principles
• 45:26and one with learner centered
• 45:28principles.
• 45:29So this this table is
• 45:30a summary of everything we
• 45:31just said.
• 45:32It's out there in the
• 45:33world. I wrote a review
• 45:34on this a couple years
• 45:35ago, and I think it's
• 45:36been cited, like, three times.
• 45:37So,
• 45:38clearly, it broke the Internet.
• 45:39But, if you wanna find
• 45:41it, it's in seminars and
• 45:42neurology, and we can probably
• 45:43make these slides available too.
• 45:45I keep this little, on
• 45:47a card in my pocket
• 45:48when I'm on service,
• 45:49and I I know it
• 45:50pretty well by now. But
• 45:51if I'm if I really
• 45:52wanna do teaching,
• 45:54well, I just look at
• 45:55it and say, hey. Did
• 45:55I do all these things?
• 45:56So if you're trying to
• 45:58build a habit, I think
• 45:59it's a good good reference
• 46:00card to have.
• 46:02Practically,
• 46:03do I teach on every
• 46:04patient when I'm on service?
• 46:05No. I think
• 46:07my goal when I'm on
• 46:08service is for each learner
• 46:10to get one good
• 46:12bedside teaching encounter on on
• 46:14each rounds.
• 46:15So if it's a big
• 46:15team, that could be six
• 46:17or seven patients.
• 46:18But if you do it
• 46:19quick, you know what you're
• 46:20doing, and you say, hey.
• 46:22You don't do it twice.
• 46:23Right? You don't teach about
• 46:24it at the at the
• 46:25conference room table and then
• 46:26at the bedside.
• 46:27You you save it for
• 46:28the bedside.
• 46:30You could do it in
• 46:30the same amount of time
• 46:31using the techniques that we
• 46:32talked about.
• 46:33Other things that are easy
• 46:35to do but also easy
• 46:36to forget,
• 46:37introduce yourselves to the patient,
• 46:39especially if there's new team
• 46:40members. Introduce everyone on the
• 46:42team, not just yourself.
• 46:43Let the patient interrupt.
• 46:45You model professionalism for the
• 46:47team and the way you
• 46:48talk to the patient, and
• 46:49that is bedside teaching
• 46:51automatically.
• 46:53I like to give the
• 46:54team homework. That's part that's
• 46:55part of those, one minute
• 46:57preceptor snaps models
• 46:58where you you have the
• 47:00the learner
• 47:01take something out of the
• 47:02encounter and learn about themselves
• 47:04later. And if you wanna
• 47:05help them do that, you
• 47:06can email them resources. You
• 47:08know, I have a scanned
• 47:09version of a neurologic exam
• 47:10book, and I'll send them
• 47:11a couple relevant pages
• 47:13related to what they learned
• 47:14on service. These adds a
• 47:15time, but I think they
• 47:17really drive the experience home.
• 47:19And this this quote always
• 47:21stands out to me,
• 47:23and I think it summarizes
• 47:24everything we said. Unless everyone,
• 47:26patient included,
• 47:28feels better after the bedside
• 47:29rounds, those rounds were not
• 47:31successful.
• 47:32So you're really there for
• 47:33everyone, not just one learner
• 47:35at a time.
• 47:37So I have some I
• 47:38have some practice scenarios we
• 47:40could talk about, but I
• 47:40also according to our schedule,
• 47:42I wanna allow time for
• 47:43questions at twelve fifty, and
• 47:44it's twelve forty nine. So,
• 47:47I would love your feedback
• 47:49on this if you have
• 47:50a few moments, but I'd
• 47:51also like to open the
• 47:51floor
• 47:52to any questions, criticisms, disagreements,
• 47:55things you wanna talk about.
• 48:05I
• 48:07see some things in the
• 48:08chat here.
• 48:11Bias, the the code.
• 48:13Yeah. So major HIPAA violation
• 48:15in a shared patient room.
• 48:16This always comes up.
• 48:19And I see something about,
• 48:20pediatric patients too. So we'll
• 48:22cover both of those.
• 48:24The HIPAA violation question is
• 48:26very interesting.
• 48:28In my mind,
• 48:31there's no difference between talking
• 48:33to a patient
• 48:34in a double room with
• 48:35a curtain and teaching with
• 48:36a patient in a double
• 48:37room with a curtain.
• 48:39In either conversation, you may
• 48:40have to talk about sensitive
• 48:41things. I think it's really
• 48:43useful as part of that
• 48:44consent process
• 48:46to say, hey. I know
• 48:46we're in a shared room.
• 48:47Is there anything you don't
• 48:48wanna talk about right now?
• 48:50And you can do that
• 48:51even if you're not teaching.
• 48:52Right? I think you can
• 48:52just acknowledge the lack of
• 48:54privacy.
• 48:55I've always been curious about
• 48:56how legally it's okay to
• 48:58have those conversations in a
• 48:59shared room, but on the
• 49:00other hand, they have to
• 49:01be had, and that's the
• 49:02only place you can do
• 49:03them. So,
• 49:04that may be a a
• 49:05question for the lawyers too,
• 49:07but I think you can
• 49:08get around it the same
• 49:09way as you would with
• 49:10any sensitive conversation.
• 49:12Yeah. Plug for pediatric patients
• 49:14who may not always have
• 49:16parents, guardians at all time
• 49:17to get consent.
• 49:19Richie, can can you elaborate
• 49:20a little bit? Is that
• 49:21a, a plug for,
• 49:23consenting talking to the parents
• 49:25first, or is that a
• 49:26Yeah. Yeah. Sorry. I I
• 49:27own a Milton clinic and
• 49:28have bad reception.
• 49:30So I didn't know if
• 49:31you're alluded to it before.
• 49:32But I was just, like,
• 49:33when we were talking about
• 49:34consent, that's very different when
• 49:35it's an adult patient you
• 49:36can ask directly versus infants
• 49:38who are just in the
• 49:39room.
• 49:39And usually, you know, it
• 49:41it's not uncommon that parents
• 49:43will leave to take care
• 49:44of other kids, and that's
• 49:45when their team might even
• 49:47be, you know that might
• 49:48be co coincide very well
• 49:50with the time that the
• 49:51team has for teaching.
• 49:52Mhmm. So I was just
• 49:53kind of saying how do
• 49:54we go about in terms
• 49:55of, like, when we're talking
• 49:56about consent,
• 49:57how to approach that situation.
• 50:00Yeah. So
• 50:02I get in a similar
• 50:03this is not the same,
• 50:04but in a similar situation
• 50:05in, like, the neuro ICU
• 50:06when a a patient is
• 50:08either sedated or or comatose
• 50:10and there's no family around.
• 50:12And I
• 50:14it's really important that learners
• 50:15learn how to interact with
• 50:17infants and with comatose patients.
• 50:19So what I try to
• 50:20do is split the difference.
• 50:22If I can't
• 50:23reach anybody for consent or
• 50:24I've never talked to them
• 50:25before and I don't really
• 50:26know what's going on, I
• 50:28keep it to a minimum.
• 50:29But if the Babinski sign
• 50:31needs to be checked regardless
• 50:33and I feel confident that
• 50:34a learner can do it
• 50:35with my feedback, I let
• 50:36them do it instead of
• 50:36me do it, and I
• 50:37observe.
• 50:38And so I think there
• 50:39are are some compromises you
• 50:41can make that don't add
• 50:42any burden to the patient
• 50:43that they can't consent to,
• 50:45but still accomplish the goal
• 50:46of teaching and practice. Because
• 50:48this is a whole another
• 50:49ethics conversation, but there are
• 50:51some people who say you
• 50:52should never teach on a
• 50:53patient who's in a coma.
• 50:55And I disagree with that.
• 50:55I think that does a
• 50:56disservice to future patients
• 50:58in comas.
• 50:59So,
• 51:00there there is a gray
• 51:01area, though. I agree.
• 51:03I see another comment here.
• 51:05Yeah. Have you tried using
• 51:06the bridge software during bedside
• 51:08teaching? I have not. One
• 51:10of my colleagues uses it
• 51:11in our outpatient resident clinic,
• 51:13and it's pretty good. It
• 51:15gets a little
• 51:16confused when there's a long
• 51:17back and forth,
• 51:19about a
• 51:20a patient, and I don't
• 51:21know the extent to which
• 51:22he uses it in the
• 51:23exam room,
• 51:24during teaching. So that that
• 51:25remains to be seen.
• 51:27Have you had any experience,
• 51:28Joe?
• 51:31I've also used it for
• 51:33about the last six months
• 51:34in clinic.
• 51:36I haven't used it in,
• 51:37excuse me, the,
• 51:39inpatient setting, but I have
• 51:40heard some colleagues have been
• 51:42using it with success.
• 51:45And I just like, listening
• 51:46to your talk and thinking
• 51:47about
• 51:48bedside teaching,
• 51:50if the Abridge software was
• 51:52running throughout the patient encounter,
• 51:54essentially,
• 51:55you know, your note would
• 51:56be
• 51:58near nearly done by the
• 51:59time you were finished rounding.
• 52:01So Yeah. No. I think
• 52:02it's a really good point.
• 52:03And it you know, we're
• 52:04we don't get to round
• 52:05with a wow on, like,
• 52:06the consult service, but I
• 52:07I can you use a
• 52:08phone to do the same
• 52:09thing?
• 52:10Yes. That software is on
• 52:12your phone. Okay. Yeah. I
• 52:13need to get set up
• 52:14with it. Obviously, I have
• 52:15a I have a live
• 52:15scribe in the outpatient setting,
• 52:17but,
• 52:17I think it I'll be
• 52:18curious. I think we can
• 52:19learn more in the next
• 52:20six to twelve months about
• 52:21how to do that. And
• 52:22then if I get invited
• 52:23back next year, I'll add
• 52:24it into my presentation.
• 52:26Thank you. Yeah. Thank you.
• 52:29Other, Bill, you had your
• 52:30hand up, I think.
• 52:32I just the only
• 52:34you know, when we started
• 52:36and,
• 52:38one of the main reasons
• 52:40that you've that that people
• 52:41said, and I think
• 52:43the research agreed
• 52:44that we see less bedside
• 52:46teaching is this notion of,
• 52:48you know, discomfort.
• 52:49And you along the way,
• 52:51mentioned,
• 52:52you
• 52:53know, your own your own
• 52:54trepidation
• 52:55around
• 52:56you don't know what students
• 52:58are gonna say.
• 53:00And I just thought given
• 53:01that it it it might
• 53:03be useful to talk a
• 53:04little bit about what do
• 53:06you do
• 53:08when
• 53:09you know, that there are
• 53:11things you can do if
• 53:12you're in a bedside teaching
• 53:13situation,
• 53:14and it doesn't
• 53:15it's not going well. Something
• 53:17happens.
• 53:19Any thoughts?
• 53:20So let me
• 53:22let me fast forward to
• 53:23one of my scenarios
• 53:25here.
• 53:27This to me is the
• 53:28worst case one of the
• 53:29worst case scenarios. Right? So
• 53:30you're
• 53:31you're rounding about on a
• 53:32patient. You've you've done some
• 53:34reflex teaching at the bedside,
• 53:36and you're you're feeling good,
• 53:38and you say, so what
• 53:38do you think could be
• 53:39causing this?
• 53:40And the the learner says
• 53:42peripheral neuropathy,
• 53:43cancer, ALS, and the patient
• 53:46hears it and freaks out.
• 53:47And this has happened to
• 53:48me.
• 53:51I think it well, I
• 53:52don't know.
• 53:54Anyone have any thoughts? I'll
• 53:55share mine at the end
• 53:56because I don't wanna bias
• 53:57anybody.
• 54:12I know we all hate
• 54:12awkward silences, so I'll I'll
• 54:14just talk.
• 54:15And you can put it
• 54:16in the chat too. I
• 54:17think at that point, you
• 54:18just need to
• 54:19acknowledge the elephant in the
• 54:20room and say, let's pause.
• 54:22You know, we've we've done
• 54:23a lot of talking about
• 54:24things.
• 54:26You know, to the patient,
• 54:27I just wanna be clear
• 54:29this, so and so
• 54:31is a learner. And it's
• 54:33important that our learners think
• 54:34about these diseases.
• 54:36And then you kinda break
• 54:37the fourth wall, and you
• 54:38and you have to give
• 54:39some information. Right? Of course,
• 54:41we would consider ALS in
• 54:42the differential for weak legs,
• 54:43but in your case, I
• 54:45don't think it's likely for
• 54:46these reasons.
• 54:47And you just have to
• 54:48kind of
• 54:49stop teaching
• 54:51and clean up the mess
• 54:52a little bit.
• 54:53And I I think the
• 54:54where it goes wrong is
• 54:55when people are afraid to
• 54:57acknowledge
• 54:58that something
• 54:59was said in error or
• 55:01that there was something in
• 55:02that unintentionally
• 55:03accept upset the patient and
• 55:05just kind of move on.
• 55:07And we see that same
• 55:08behavior in inappropriate comments to
• 55:10learners or by learners from
• 55:11patients. If you don't address
• 55:12it in the moment and
• 55:13then debrief it afterward,
• 55:15everyone feels worse. You'll feel
• 55:17much better if you just
• 55:18acknowledge that we're a teaching
• 55:19hospital. People are learning. I
• 55:21want my learners to think
• 55:22about ALS, but I don't
• 55:23want you to think you
• 55:24have ALS. And I think
• 55:25there's a big distinction there.
• 55:27There was something in the
• 55:28chat, I think, too. Let
• 55:29me see.
• 55:31Emphasize the differential. Yeah. So
• 55:33I think that's where you
• 55:34just you remove the veil
• 55:35of teaching. You get rid
• 55:36of the Socratic method, and
• 55:38you just say what needs
• 55:39to be said both in
• 55:40acknowledging
• 55:41what happened and also the
• 55:43real the facts of the
• 55:43situation.
• 55:44Do you have any thoughts,
• 55:45Bill, as you as you
• 55:46hear me say that? Just
• 55:47I think you kinda just
• 55:49said it at the end.
• 55:49You know, the place where
• 55:53you you acknowledge
• 55:55that the patient is crying.
• 55:56You you talk to the
• 55:57patient Yeah. That they're crying.
• 55:59Clearly, something has scared them.
• 56:02Right? And say that.
• 56:04Let them say, I get
• 56:05afraid when I hear ALS.
• 56:08You just said cancer.
• 56:11You know, just let them
• 56:12say it and acknowledge
• 56:14and,
• 56:16the the scariness of it.
• 56:17And then
• 56:18and, yeah, just that that
• 56:20is a starting place, I
• 56:21think.
• 56:22Yeah.
• 56:23And if I if I
• 56:24was involved in this scenario,
• 56:25I think I would do
• 56:26a double debrief. You know,
• 56:27I would I would make
• 56:28sure to debrief with the
• 56:29learner outside the room, maybe
• 56:31even again later. And then
• 56:32I would drop back to
• 56:33the patient's room in the
• 56:34afternoon and say, hey. I
• 56:35just wanna acknowledge what happened
• 56:36this morning. How are you
• 56:37feeling? Is Is there anything
• 56:38else you wanna talk about?
• 56:40These these are not
• 56:42medical errors. Right? These are
• 56:43just conversational mistakes, and I
• 56:45think
• 56:46you you can clean them
• 56:47up, right, if you just
• 56:48acknowledge what happened.
• 56:50Okay. I'm gonna show the
• 56:52last slide here, and then
• 56:54we will call it a
• 56:55day.
• 56:56Upcoming events. So, you know,
• 56:58these these happen every couple
• 56:59of weeks. Looks like Friday,
• 57:00November fifteenth,
• 57:02we have our very own
• 57:03Andres,
• 57:04presenting
• 57:05on, leading engaging workshops and
• 57:07then, more to come.
• 57:09I'm happy to stick around
• 57:10and chat. Please drop any
• 57:11questions in the chat, but
• 57:13thank you all for coming
• 57:13and staying, and hope you
• 57:15learn something new. I'm always
• 57:16happy to talk more and
• 57:18strategize with you if you
• 57:19wanna employ any of these
• 57:20things.
• 57:22Thanks, Jeff. Thanks, everybody. Thank
• 57:24you, Jeff. Thank you. That
• 57:25was great.
• 57:26Thank you. That was great.
• 57:27Appreciate it. Thanks for coming.