9-22-23 YES!: Learning Climate

September 25, 2023

ID10740

To CiteDCA Citation Guide

00:00The slides, right. So
00:03yes, I'll run the sides. OK,
00:06With Vinny and Chada and everyone,
00:07I'm going to record it because there
00:09are some people who wanted. OK.
00:12OK. That sounds great.
00:13Sounds good. OK. So welcome, everyone.
00:17Thanks for your time and taking the time
00:19out to to attend this session today.
00:21Like Shona had indicated,
00:22there's a great opportunity for us to
00:26constantly modify this talk to try to reach,
00:29you know, outstanding educators
00:31like yourselves who are committed
00:33to to training our our students and
00:36and and residents and and fellows.
00:40So learning climate is really one
00:42of the the most important and first
00:45steps in an educational process
00:47and the venue that we work in.
00:49And I I think if you leave with nothing
00:51else to remember the title of this slide,
00:53that learning climate changes the world,
00:56that enhancing learning effectiveness
00:58impacts all of us as individuals,
01:01as systems that we work in
01:03and the future of our society.
01:06This has been talked about and written
01:09about in medicine for many decades
01:11and there was really foundational
01:13work done by Kelly Skeff back in
01:15the 1980s that a reference here and
01:17in a couple of other slides out
01:20of Stanford University where they
01:21describe this kind of seven component
01:24framework to enhance learning,
01:25particularly adult learning in in medicine.
01:28And it starts with establishing
01:30a positive learning climate.
01:32This will allow you as the instructor
01:35to control the teaching session,
01:37to communicate the goals of
01:39the educational session,
01:40to understand and retain the information,
01:45to provide and receive evaluation
01:47and feedback and to promote
01:49self-directed learning.
01:51All of which are pillars of
01:53maintaining the content of the
01:55learning session on a long term basis.
01:58Next slide.
02:01OK, so to define learning climate,
02:05they really, they really one
02:06of the best definitions,
02:06just the prevailing conditions within
02:08an educational setting that promote
02:10knowledge or skills acquisition.
02:12And this reflects the tone or
02:15the atmosphere of the teaching
02:17environment wherever you're doing it.
02:19It reflects a degree of enthusiasm
02:22and comfort for the topic
02:24that you're instructing on.
02:26And it's very much influenced by
02:28the teachers, their enthusiasm,
02:30the learners, the setting,
02:33and really the interconnectedness
02:34and interdependence among the group.
02:36That's really what makes learning
02:38climates rich and very fruitful.
02:40And particularly if you just ask yourself,
02:42do trainees want to be in
02:44this environment as learners?
02:46If the answer to that is yes,
02:47then you're doing a good job.
02:48And if it's not,
02:49then there are things that
02:50need to be modified.
02:52That's often a question we always
02:54need to ask ourselves whenever we're
02:57teaching in any form or setting.
02:59Next slide.
03:01So why do you care as a
03:03medical educator in any field?
03:05Well, again,
03:06a good learning climate as many impacts.
03:09First,
03:10it influences your effectiveness
03:11as a as a teacher and encourages
03:14participation among the learners
03:16in the in the session.
03:18It will affect the wellbeing of
03:20the residents and the students
03:22or fellows in your session.
03:24It increases patient safety as a
03:28byproduct of improving knowledge of
03:30the people that you're trying to train.
03:32And of course,
03:33it affects your own evaluations
03:35that are used for promotion
03:37purposes no matter what track
03:39you're in on the Yale faculty,
03:41your teaching evaluations are measured
03:43and are used and are accountable for
03:47when you get identified for promotion.
03:50And the skills as a medical educator
03:52in in creating learning climate
03:54can really be extracted to many
03:56situations where leadership skills
03:58are needed in the inpatient setting
04:01and ambitory bedside education,
04:02in lectures and on research teams
04:05and mentoring junior faculty or
04:07colleagues and developing programs.
04:09And it really it's it's critical as a
04:13educational leader to make this safe space.
04:17And you know,
04:17people have said that the best leaders
04:20are the ones who make you feel safe.
04:22And this is a situation where
04:23you can actually do that.
04:25Next slide.
04:28So the important thing to remember
04:30is that the learning climate does
04:32affect your perception as a faculty.
04:34And this actually has been studied
04:36and was published many years ago and
04:39still holds true that a positive role
04:42models as faculty in teaching have
04:45several traits that seem to be shared.
04:48One is they spend a significant
04:49amount of time with the team
04:51that they are working with.
04:52Particularly in a clinical environment,
04:54more than 25 hours per week was found
04:57to be associated with a positive role
05:00model perception of that faculty member.
05:02Second is that the leader,
05:04the faculty leader shares their professional
05:07life experiences with that team.
05:09That puts people on an even playing
05:11field at kind of an interpersonal level.
05:14That always improves effectiveness
05:15of communication of whatever it
05:18is that you're trying to teach.
05:20The individual who is successful
05:22often has formal training in teaching,
05:24and that's again one of the purposes
05:26of questions like today.
05:28They emphasize interactions
05:30between patients and physicians,
05:32particularly in the bedside environment,
05:35and they emphasize psychosocial
05:37aspects of medicine.
05:38The patient has an entire entity,
05:41not just a group of
05:43physiological abnormalities,
05:44and then providing specific feedback,
05:47both formative and summative feedback.
05:50These are all kind of standard
05:52criteria that were established at
05:54that time and still hold true today.
05:57And it's probably not new to most of you.
06:00But interestingly,
06:00what they found in this one study is
06:02that less than half of the faculty
06:04were viewed as excellent role
06:06models to have all of these traits,
06:08and that faculty may be unaware
06:10of behaviors that they have and
06:12that they can improve their skills
06:13by faculty development.
06:15This is something that can be learned.
06:18Next slide.
06:20Great.
06:21So I'll turn back over to Shauna
06:22now to go through learning
06:24climate characteristics.
06:26Great, Thank you so much, Vinny.
06:28So Vinny has laid out the case for
06:31why learning climate is so important.
06:34And as he mentioned, these are really
06:37a set of skills that you can learn.
06:40So what does a good learning
06:42climate actually look like?
06:43Well, we can certainly contrast it to what
06:45a poor learning climate might look like.
06:47And I think unfortunately many
06:49of us have experienced this and
06:51just as we're about to get hit,
06:53I think by Tropical Storm Ophelia,
06:55I think they've named it this weekend.
06:57You know, we can relate to how how that
07:01can feel out of control and chaotic.
07:04And unfortunately,
07:04poor learning comments can also
07:06feel hostile to to learners.
07:11A common pitfall that people have
07:13as educators is to think about what
07:16they're interested in teaching.
07:17So being educator focused creates
07:19a poor learning climate and
07:21then being boring so you know,
07:23not being interested in what
07:24you're teaching about or not
07:26teaching it in an interesting way.
07:27All of these things can contribute to
07:30per learning climates and you can imagine
07:32moving to a sunny blue sky place for a good.
07:35Learning climate is essentially the opposite.
07:37So characteristics of a good learning
07:39climate or that it would it's friendly,
07:41organized and structured,
07:43the focus on what is on what the
07:45learner needs and the educators
07:47are engaging in their teaching.
07:49So how do you actually accomplish these?
07:53So luckily these are behaviors
07:55which you can you can learn,
07:57you can think about how to
07:59implement some of them.
08:00So in terms of being friendly,
08:02that seems pretty straightforward forward,
08:04but knowing and using your
08:06learner's names as much as possible,
08:08obviously you're going to be all of
08:09you teach in many different settings.
08:10I'm sure there might be situations
08:12like this where it's harder to to
08:14know and use your learner's names,
08:16but certainly on your teams
08:18that you're working with.
08:19Learn your who your learners are and
08:22write their names down if you have trouble
08:24remembering them or pronouncing them.
08:26And and use their names.
08:27Use your body language to convey openness.
08:30All those skills that we've learned to use
08:33with our patients such as eye contact,
08:36active listening, nodding, smiling,
08:38encouraging your learners when
08:40they're speaking to you,
08:42all of those things are really,
08:43really helpful to be a friendly atmosphere.
08:46Avoiding ridicule seems pretty self-evident.
08:49However,
08:50I think especially as someone personally
08:52who likes to use humor to sort of,
08:55you know, lighten the mood a little bit,
08:57it can be a little bit of a slippery slope.
09:00If you're using humor,
09:01try not to make fun of your learners.
09:03Sometimes it it can feel tempting
09:05to do that funny things happen,
09:08we all know that.
09:09But remember,
09:10even though we're all trying to flatten
09:12the hierarchy in medical education,
09:14unfortunately the learners probably
09:15perceive A hierarchy much more than we do.
09:18And so sometimes when when we
09:20tease our learners,
09:20that is not received in the
09:22way in which we mean it.
09:23So a good rule of thumb that I have
09:26is to only make fun of yourself
09:28and actually that that goes down
09:30quite well and then acknowledge
09:32your expectations can really help
09:34to establish that.
09:36You know,
09:36we're all in the process of learning
09:38that we all didn't sort of appear
09:40fully formed with the the knowledge and
09:43experience and skills that we have.
09:45And so learning your learners know
09:47that you're still learning or let
09:48them know where you were at their
09:50stage and and the struggles that
09:51you had can be really helpful to
09:54create that friendly atmosphere.
09:57Next is really important to be
09:59organized and structured.
10:00So think about what you want to teach.
10:03Set an agenda for for what you want to
10:06get through during that teaching session,
10:08whether that's on rounds,
10:09during the attending rounds,
10:11or during a more formal teaching session
10:14like this, and try to stay on topic.
10:16Now, sometimes your learners are
10:17going to be off topic because they're
10:19going to be interested in something.
10:20A side topic that you alluded to
10:22or a minor topic that you weren't
10:25going to spend much time on.
10:27Acknowledge that if that happened.
10:28So you can either say, you know,
10:30seems like people are really interested
10:32in talking about this instead of XYZ,
10:34which I had planned.
10:35We can keep going and talk about,
10:37you know, this topic that you're
10:40interested in or you know,
10:42we can come back to this another time.
10:45So again, just try to stay on topic,
10:47but if it looks like you're
10:48really veering off, that's fine.
10:49Just sort of acknowledge that.
10:50Let them know you're aware that that the
10:54topic might be changing a little bit,
10:57Think about being structured.
10:59Really try to allocate the amount of
11:01time you need for each agenda item.
11:03I'm actually the worst at this.
11:05I tend to be really worried that I'm
11:08going to run out of time or sorry.
11:10I'm always worried I'm not going
11:12to have enough material.
11:13Exactly the opposite always happens to me.
11:15I always run out of time when I'm speaking
11:18because I I try to cram too much in.
11:20So I'm trying to work on this myself.
11:22But be be thoughtful about how much time
11:24you think everything's going to need.
11:26And then respond to your learners,
11:29especially if you're in a more
11:30of a small group setting.
11:31You know,
11:32see what they seem to be
11:33really grasping quickly,
11:34or maybe what they already know
11:36and and speed through that.
11:37And you can literally just ask them,
11:39you know,
11:39It seems like you all
11:40understand this pretty well.
11:41Can we get me and move on to the
11:43next topic or slow down if they seem
11:45to be struggling with that concept.
11:47So respond to how they how they're
11:50absorbing the information and then
11:53really think about being learner focused.
11:54And in many ways this this might
11:56be the most important part of
11:59establishing a good learning climate.
12:01First thing is to identify what
12:02your learners are and they're
12:03really two ways to do this.
12:05The 1st is to ask them for the beginning
12:08of any teaching session or or rotation
12:10that you may be working with people.
12:12Find out what your learners want to learn
12:13about or they think they need to know.
12:17The other thing is you can observe them,
12:18especially if you're working with them
12:21on on some sort of rotation or team.
12:23It's very interesting.
12:25Sometimes they're identified needs or not,
12:27where you see their needs to be
12:29when you're actually working with
12:31them in the clinical setting.
12:32And so those are the two ways in which
12:34you can identify needs and and it
12:36tells you a lot about your learner.
12:38If you ask them what they need to
12:40learn and they're really off base in
12:42terms of what where they actually are
12:44and what they actually need to learn
12:46and then meet them where they are,
12:48You know, don't don't try to to
12:51teach too much over where they are
12:53or or too under where they are.
12:55And again,
12:56that's sort of responding to their,
12:59you know, how they are interacting
13:02with you when you're teaching,
13:04you know, again,
13:06just really sort of speed up,
13:09slow down according to where they are
13:11in terms of their knowledge availability.
13:13It seems like a strange thing to
13:16put into a learning climate talk.
13:19But availability just it turns out to
13:21be one of the most important aspects
13:25of attendings for for residents
13:28and fellows when we're evaluated,
13:30that feeling like you care enough
13:33about the team,
13:34you care enough about your learners
13:36to be present for them to be
13:38able to answer their questions,
13:40to be able to give input on on patients,
13:42just to be around even.
13:44And that helps to set a really
13:46great learning climate.
13:47It also allows you, like I said,
13:48to get to know your team and
13:50and know what their needs are,
13:51ask their opinions about about patience,
13:54about things that come up when you're
13:57working with them and then respect them.
14:00This is also incredibly important,
14:01you know, acknowledge their struggles.
14:04You know,
14:05I'm old enough that I trained at a time
14:07when there were there were no duty hours.
14:09We often worked, you know,
14:10over 100 hours a week and it's
14:13very easy sometimes for old
14:14timers like me to sort of say,
14:16oh this, you know, this group,
14:18they they get to go home every
14:20evening or whatever it is.
14:22But you know,
14:23they have their own struggles and
14:25they're working with work compression,
14:27right.
14:27They have to get the same amount.
14:28Probably a lot more work done actually
14:30in in much last time than we had to.
14:32And medicine is more complex,
14:34it's more detailed,
14:35there's there are high expectations
14:37for the the trainees are doing so
14:39acknowledge their struggles and have
14:40empathy for for where they are.
14:42Residency is never easy,
14:43and it's never going to be easy,
14:45nor fellowship.
14:46And then invite them to discuss
14:49their limitations again.
14:50If you've established that it's okay
14:52to talk about your limitations by
14:55acknowledging your own limitations,
14:56they're going to be much more willing and
14:59open to share their struggles with you.
15:02And that's going to really
15:04allow you to teach to
15:05where they are and what
15:07they need more easily.
15:10And then lastly, be engaging.
15:12And this is always the part of the
15:13talk that feels a little meta for me.
15:14So now I'm going to try and show
15:17more enthusiasm for the topic,
15:18but think about how you're
15:19speaking about something.
15:20Are you using an animated voice?
15:22What's your body language?
15:23I actually, when I teach on the wards,
15:25I really like to and my turning rounds
15:27go up to the board and and use the board
15:30because that gets me up and walking around.
15:32It makes me more, you know,
15:34in motion and more interesting to look
15:37at and then encourage participation.
15:39You know these You don't want to
15:41be a spoon feeder of information.
15:43You want your learners to be
15:45answering questions,
15:46to be participating.
15:48Use your higher level learners.
15:49If you're in a sort of a mixed group to
15:52teach some of your lower level learners,
15:54make it a group process.
15:58Along those same lines.
15:59Avoid monopolizing the discussion.
16:01Really,
16:01people don't want to just sit and listen
16:03to you drone on about your pet project.
16:05You really want this again to
16:07be a conversation that you're
16:09having with your learners okay.
16:12So really quickly this is
16:13actually not from medicine,
16:15this is from the business world.
16:16But I think it's a really nice
16:18schematic of how to think about,
16:20you know,
16:21what kind of educator you can be.
16:22And so you can be either somebody
16:25who offers a high support or low
16:28support and or challenges your
16:29learners or or doesn't challenge them.
16:32And we're going to go around the four
16:34quadrants to sort of talk about the
16:37different type of educators that that
16:38fall into each of these quadrants.
16:40So if you give a lot of support
16:42but you're not challenging,
16:44you end up being a protector and that
16:46those are the types of educators who
16:48know everything about their team.
16:50They bring Donuts every morning.
16:51Everybody loves them, but they're they're,
16:54they don't ask much of the team.
16:55They're not really asking them to
16:57participate in their education there.
16:59Again,
16:59spoon feeding information,
17:01They're sort of doing as much
17:02as they can for them,
17:03but they're not helping their learners grow.
17:05And that's really an important
17:07part of what educators need to do.
17:10This group down here,
17:12the abdicators don't offer much support.
17:14They don't really know their team that well.
17:17I think of this as sort of
17:19the absent attendings and they
17:20don't challenge them either.
17:22So they're not asking a lot.
17:23They're not, they're not really,
17:26you know,
17:26having them participate in their
17:28education and that they just don't
17:30get to know the team very much.
17:31That creates a culture of apathy.
17:33We've all had tonnings like that I'm
17:36sure and and we all know sort of how
17:39demoralizing it is to work with them.
17:41And then the dominator quadrant,
17:44this was a favorite when I was resident.
17:47These are high challenge,
17:48low support
17:49ask a lot of their teams.
17:51They, they pimp as we used to say
17:54on rounds all the time and they're
17:56but they don't really get to
17:58know who you are or ask you know,
18:00really understand what your needs
18:02are as a learner and and that creates
18:05unfortunately a culture of fear.
18:07So where we hope everyone ends up is
18:11up here in this Liberator quadrant
18:13where you're giving a lot of support
18:15and you're challenging your team.
18:16So you know who your team is.
18:17You've established a really
18:18great learning climate.
18:19You are getting to know them individually,
18:22what their needs are,
18:24who they are, what they want.
18:25And you're asking them to be
18:27participants in their education.
18:29You're challenging them to
18:30push themselves to learn,
18:32to grow and that really creates
18:35that culture of empowerment.
18:37So with that,
18:38I'm going to turn it back over
18:39to Vinny and he's going to talk
18:41about challenges and barriers.
18:43Okay, thanks, Shona.
18:45So Shona outlined all the kind of the,
18:48the specific aspects of the of delivering
18:52the positive learning climate.
18:54We all recognize in the practical
18:56setting that there are many
18:58challenges and barriers that we face.
19:00First is the overcrowded
19:01clinical environment,
19:02whether it be the ambulatory
19:04setting or the inpatient setting.
19:05We all recognize this.
19:07There are patients and being
19:09transported back and forth and
19:11there are RT's being called and
19:14there are family members who come
19:16in and ask questions and there's a
19:18lot of busyness in the hallways and
19:21in the and in the hospital rooms.
19:23So it ends up being a very challenging
19:26environment often to to teach in.
19:28Second is of course our clinical
19:30workload and service commitments overall
19:33that there's so many expectations of
19:35us as attendings that challenge the time,
19:37there's only a certain amount
19:39of time in a day, right.
19:40And that we have commitments
19:42outside even in the attending time,
19:44right.
19:44We're constantly getting emailed
19:46and text messages about things
19:48and other programs and other
19:49responsibilities that we have
19:51while we are on the wards or in
19:52the clinic in a teaching setting.
19:55Third is that often we don't
19:57define exactly what the learner
19:59needs are and this is a critical
20:01component as was addressed by Shona.
20:04And we don't necessarily have them state
20:06what their goals and objectives are.
20:08So that's why these are critical
20:10aspects to the to establishing
20:12the positive learning climate.
20:15Additionally, the actual physical
20:17space that we have is is very limited.
20:19We all scramble around for
20:21conference rooms in the amateur
20:23setting or in the OR on the wards.
20:25That is often, you know,
20:27competing needs for that same space.
20:30So just having a place where you
20:32can gather even for 1/2 an hour
20:34to talk is often a challenge.
20:36There's time limitations.
20:38There's always the need for admitting
20:41new patients or discharging patients,
20:43or family meetings or meeting with nurses
20:45and P SMS on the floor meeting with clinic.
20:47Managers and people have very
20:52complicated lives on a daily basis,
20:55and time is one of those major limitations.
20:59Additionally,
20:59faculty and learner attitudes towards
21:01what education should be is often
21:04variable and this remains a challenge
21:06as well as the overall institutional
21:08support at the section you work in,
21:11at the department you work
21:12in and within the school,
21:14different people come in with
21:16different levels of support for
21:17different aspects of their jobs.
21:19So that some people have more time
21:22and availability because they're
21:23supported to do that,
21:25other people do not.
21:26And therefore this can impact
21:28their overall learning climate.
21:31Next slide.
21:32So I think what we're going to
21:34do is discuss now two cases and
21:36identify behaviors in those cases
21:39and small group settings where
21:41that contribute to either a good
21:43or a poor learning climate.
21:44So that's showing it.
21:46Now to start with the first case
21:48that I can read and then I think
21:51she will break us up into groups,
21:53yes. So just a little bit of
21:56instruction before we do this.
21:57Vinny will read the case to you.
21:59There's going to be two cases.
22:01Both of them have both good and bad
22:04aspects of the learning climate.
22:07So as you're reading the cases,
22:10take notes on what you see
22:12as as both either good or bad
22:15components of learning climate.
22:17We'll break you out then
22:19into breakout groups.
22:20They'll be about 8 to 9 people.
22:22Vinny and I will not join
22:24our rooms and I guess Janet,
22:26etcetera can decide whether they
22:27want to pop into a room or not.
22:29So they should be about between five
22:31to seven people in each room to
22:33discuss and then we will come back and
22:36talk about it briefly as a larger group.
22:38So let me know if you have any questions.
22:40I'm having a trouble seeing the chat
22:42and doing everything at the same time.
22:44So unmute if you have a question
22:45about any of this as we go along
22:50Okay. So the first case your
22:53inpatient team is post call
22:55gathered in the conference room to
22:57hear about the overnight admissions.
22:59It's your first day as attending
23:00and the residents, interns,
23:01and students are waiting.
23:03Faculty member quote Sorry I'm late.
23:06I wasn't supposed to attend this block,
23:07but there was a last minute switch.
23:09I found out about two days ago.
23:10It's not going to be easy for
23:12me to get here by 7:30 AM.
23:13I have to drop my son off at daycare.
23:15Early resident quote, we have 4 overnights,
23:192 unit transfers, faculty okay.
23:23Doesn't that take us over the cap?
23:25Resident No. We cap attempt for intern.
23:28Faculty okay. Well,
23:29I have a research team meeting at 9:00 AM,
23:31so let's just hear about the overnights.
23:33Now you guys can call,
23:34call me around on your can,
23:36round on your own,
23:38and I'll catch up later with you.
23:40Next slide, the resident presents
23:42patient with communic acquired pneumonia.
23:45The faculty responds to text
23:47message during the presentation.
23:48Faculty then during the
23:50resident presentation.
23:50I'm not sure why this patient was admitted.
23:53Interns, what are the criteria for
23:55admission for communicoid pneumonia?
23:56There's no immediate response.
23:58So the faculty continues,
23:59students, one of the most common
24:02causes of communicator pneumonia.
24:03Interns and students,
24:05think about responses.
24:06Faculty,
24:06come on guys,
24:07you got to know this next slide.
24:11I think that's it. Yes, okay.
24:13So I'm going to put everybody into
24:18into a breakout room.
24:19We will be in breakout rooms
24:21for seven minutes, I think.
24:24I think of the timing.
24:25Yeah, 7 minutes seems about right.
24:28So I'll set a timer.
24:28I'll bring everybody back.
24:30You'll have some warning before
24:32we come back into the room and
24:34just discuss amongst yourselves
24:35what you saw maybe or examples
24:38of good and poor learning,
24:39climate, climate strategies.
24:42And now
24:45you go
24:57about 5 seconds. Everybody should reappear.
25:10Not fair. We were having so
25:11much fun in our group. Yeah,
25:14dragged us back too quickly.
25:17Agreed. Agreed. We can.
25:20We can give you guys a little
25:21longer for the next one.
25:31All right. We should have everybody
25:33back now. So, Vinny, if you want
25:35to. OK. All right. So welcome back
25:38for a quick debrief on the case.
25:41So I guess we could start with
25:43what aspects of the case do
25:46you think the faculty did well?
25:52He showed up. He was there in person. OK,
25:57that's that's a start, right?
25:59Yep. He did challenge
26:01the young professionals,
26:03asking them questions.
26:05OK, Anything else
26:10you apologize for being late? OK.
26:17Anything else?
26:19So one thing we think that the person
26:21didn't do terribly well but but could
26:24have been a positive was acknowledging
26:26some of the challenges that were
26:28going on that particular morning.
26:29And so I think it's helpful
26:31for trainees to see that,
26:33although I don't know that this faculty
26:34member made the most of putting some
26:38structure to that to make it not chaotic.
26:42All
26:44right. Anyone else have any other positive
26:48things that the faculty member did to add
26:53Okay? How about the things that the
26:56faculty member did that were not ideal?
27:00Essentially, learning is didn't
27:04correlate with climate because
27:08learning environment is always good.
27:13Yeah, it's in the classroom, right.
27:16Well, when I when I told,
27:17it's just a conference
27:18room is what we're told.
27:19Conference room in the.
27:22So it's probably a computer room
27:24slash conference room on the wards.
27:27Yes. In the classroom,
27:28in the lab or in a clinic.
27:30So there are low climates changing.
27:34Yes, yes, absolutely.
27:39Anything else? People identified
27:40that he didn't do well or he,
27:43he or she didn't do well?
27:44There's a degree of intimidation going
27:46on when he that sentence. Come on, guys.
27:48You know, you should know this.
27:50I didn't think that was appropriate.
27:52OK, OK, So this was, you know,
27:55first time you're meeting the team,
27:56first patient, you hear,
27:59and you're already just showing
28:01dissatisfaction with their lack
28:03of response to the questions.
28:05OK, All right, good.
28:07Anything else?
28:07How about the very beginning?
28:11So at the very beginning,
28:12he sets the tone by not even asking, hey,
28:14how did things go or how are you guys doing?
28:16Kind of acknowledging that they're
28:18coming out of or ending a a night call
28:21or a night shift and kind of trying to
28:23to show a little bit of of empathy or
28:26or learning where they're coming from.
28:28He just kind of quickly went
28:30into sorry I'm late, you know,
28:32I'm going to be late, you know,
28:34almost like not not even asking
28:37who's present or who. You know,
28:39he didn't care about who was in the room,
28:42right. So there was no, there was no
28:44introduction of of of the attending,
28:46no asking the names or the backgrounds
28:50or anything of the of the team. Right.
28:53It was all about the attending, right.
28:56The attending shows up and says about,
29:00you know, how this was the last minute switch
29:02that they weren't supposed to be there,
29:04that they can have a problem getting there.
29:06It was all how this,
29:07it was kind of interrupting their life
29:10before anything happens on the team, right.
29:12And then asking about, you know,
29:14whether or not it's over
29:15the cap and you know,
29:16did they require all these transfers
29:19and all those kinds of kind of
29:22administrative things that really
29:23don't necessarily lend towards a
29:26positive learning environment.
29:28We're all the way the attending
29:30started the session.
29:32So those were all less than
29:34optimal behaviors.
29:36I
29:37think it's simple.
29:38If just say, how are you?
29:40How was call? I mean,
29:41there was nothing, you know?
29:43And if you're rounding with
29:44a team that's post call,
29:45most of them look like they're post call.
29:47So just whether the guy or gal
29:50is as empathetic as they come,
29:52that intro would show no empathy
29:54toward this team that may have not
29:56gotten a minute's sleep last night.
29:59Sure, sure, Absolutely So.
30:01So from the very beginning the tone
30:04was set at a very unfortunate point
30:07where it was more attending focused,
30:11how this was affecting the attending
30:13and not recognizing or empathizing
30:16with the team that worked up
30:18all these admissions overnight.
30:20Nor did the he or she introduced themselves
30:24or the OR the team members okay.
30:27And then how about we
30:29also talked about boundaries issues.
30:32You know, there's the cliche of I'm
30:34working on my phone, I'm not, you know,
30:36you're telling me about patience,
30:37but I'm not really present
30:40or available to you.
30:42So, you know, it's that culture of
30:46apathy and the abdicator role and the
30:50importance of setting boundaries around
30:52something you consider important.
30:53If it's not important,
30:55then it doesn't really matter.
30:58Sure. So the fact that the attendee
31:00is responding to a text message
31:02during the presentation by the by
31:05the team shows not only disrespect,
31:07but again no empathy for the team and
31:10the and the needs for them as learners.
31:13It it sends a lot of messages
31:14that this is not important,
31:15as important as what the text message is.
31:18And this is picked up on by teams
31:21all the time when this happens.
31:23Okay. Anything else
31:27that anyone noted that the attending
31:28did or that the attending didn't
31:30do that they should have done.
31:37One of the things that came up in
31:39our small group was just kind of
31:43role modeling behavior that you know,
31:46that they just weren't prioritizing
31:48patient care or learning.
31:50I have a meeting at 9:00 and you
31:53know answering the text message and
31:56you know the the, the flip side of
31:58that which I really appreciated.
32:00One of our one of our participants
32:01was saying, well there's nothing wrong
32:03with modeling that you have a lot going on.
32:06It's just how you set the priorities,
32:08how you inquire what what does
32:09the team have to do this morning,
32:11when is morning report,
32:12when are these other things,
32:13do they have to get their 11:00
32:15AM discharges done?
32:16I have these meetings let's,
32:17you know come up with a plan together
32:19would have been a way that could have
32:21been done in a more productive way.
32:24Karen Hutchinson made a very
32:26good point about, you know,
32:29how you mentor and how you model and what
32:33that means down the line to learners.
32:36Karen, I don't want to steal your Thunder,
32:41absolutely limited Thunder,
32:44but simply I'm just
32:46but for the little bit of Thunder,
32:47I was just referencing the
32:49clear program from the A/C GME
32:51and how that that was founded.
32:53Basically in recognition of the
32:56fact that our trainees behave
32:59as they were trained to behave.
33:02And if 15 years out they they imitate
33:05as you know like we imitate our parents,
33:07they imitate their attending.
33:08So this is not a medical knowledge
33:10or patient care issue.
33:11This is just how they were treated,
33:13is how they treat others and we know this,
33:15but it's a huge focus for the A/C GME well
33:19and you know how important because you
33:22you throw a Pebble in the pond and
33:25the ripples go out quite a distance.
33:28So if you're trying to change
33:30culture and it doesn't start with
33:31you as an individual modeling,
33:33setting the environment,
33:34modeling the things you want people to see,
33:37how many years is this going to take until
33:40the environment can substantially change?
33:45Absolutely all, all excellent points,
33:48not only the concrete issues,
33:51but the impact of those issues
33:54lasting years and generations. So.
33:56So if we were just kind of like
33:58summarize what people were saying,
33:59that the behavioral limitations of
34:02the faculty member was that they
34:05never introduced his or her name,
34:07never asked the learners their names,
34:09didn't ask the learners their learning goals.
34:12There was a lack of enthusiasm for patient
34:14care with divided attention, right?
34:16Was worried about their own research
34:17meeting and the text messages they
34:19were receiving during the presentation.
34:21They were unfriendly and questioning and
34:24refer to learners as interns and students
34:27and not by their individual names.
34:30So the session overall was not
34:33learner focused and was disease
34:35focused and not patient oriented.
34:37So these are concrete things that we
34:40can identify in this setting that were
34:44limitations in the behavior exactly number.
34:48Thank you. I'm going to
34:49move on to case two just in
34:51the interest of time,
34:51I want to make sure we have time
34:53to discuss this one as well.
34:55So again, please, you'll pay attention,
34:58take notes during the reading of the
35:01case and then we'll break you out into
35:03breakout readings again to discuss
35:05what you see is both the good and bad
35:08learning climate strategies displayed.
35:10So, same situation.
35:12Faculty says good morning team,
35:15my name is Joanna Brown.
35:16I'm excited to start as you're
35:18attending today.
35:19I know you must have had a busy night,
35:20but before we begin,
35:21I was wondering if we could take
35:235 to 10 minutes to gather our
35:25thoughts together about how we best
35:27do work rounds and teaching rounds,
35:29the resident says. Okay.
35:31Sure.
35:32First,
35:32I'd like to each I'd like each of you to
35:35know that I've been attending several years,
35:36but I still learn medicine every day
35:39from our patients, our residents,
35:40our interns, and our students.
35:41We all have gaps in our knowledge,
35:43but we can learn from each other and as a
35:45team, give the best care to our patients.
35:48I'd like each of you to tell us your
35:49name and something important about you.
35:51I'll start.
35:51I'm Joanna.
35:52I'm a proud mother of two boys,
35:53and I was a former Yale intern.
35:56The residents, interns,
35:57and students introduce themselves with a
35:59brief personal feature about themselves,
36:02Faculty okay.
36:03I'd like the most junior member of the
36:04team to present the patients each day.
36:06The students get the first opportunity,
36:08then interns and residents.
36:09If possible,
36:10I'd like you to try to present
36:11at the bedside for each patient
36:12and mention only the key elements
36:14in the patient's story that are
36:16relevant to the submission.
36:17We can invite the patient to clarify
36:18any issues and describe our plan for the day.
36:21Residents, intern,
36:22Students not in agreement.
36:23Later in the day,
36:24we can all read about the key issues
36:26that arise in our patients and
36:27discuss them together at teaching rounds.
36:29I will try to identify original literature
36:31that illustrates important points,
36:33and at our first teaching rounds I'd
36:34like each of you to identify your
36:36learning goals for the rotation.
36:37We can meet at the end of the week
36:39to give each other feedback as to
36:40whether those goals were achieved
36:42and whether we need to change or
36:43workflow or teaching sessions.
36:45Residents. That sounds great.
36:47Does anyone have any questions
36:48or advice at this point?
36:49If not,
36:50why don't we go evaluate the
36:52first patient and we invite Lisa,
36:54our student,
36:54to please present at the bedside.
36:56All right.
36:57I'm going to put you back into
36:59your breakout rooms and we'll
37:02see you in about 7 minutes.
37:10Welcome
37:12back, don't talk about.
37:15Sorry. Welcome back, everybody.
37:18Let's give everyone a second to sort of
37:22come back just in the interest of time.
37:24We only have 5 more minutes.
37:26I'm just going to summarize what we see
37:30as the the aspects of this attendings,
37:37learning climate strategies that were
37:38good and then the few that were poor.
37:41Be very happy to hear if people
37:42have other thoughts about it.
37:43But if you go through, you know,
37:45the the five characteristics
37:47of a good learning climate,
37:48she really hits many of them, right?
37:50So right off the bat, she's friendly.
37:52She introduces herself.
37:53She's interested in learning
37:55about her learners,
37:56ask them questions about themselves.
38:00She's she seems to be
38:01organized and structured.
38:02We don't see how the actual
38:03teaching session goes,
38:04but she's being very organized and thoughtful
38:07about how their their rounds will go.
38:10She's very learner focused.
38:11She asks them to identify goals,
38:14asks what the things that they'll
38:17be wanting to learn about,
38:19and it included all levels of learners,
38:22right?
38:22She has having her students
38:24present 1st and then you know,
38:27having at the different levels
38:29present after the students.
38:31I mean then you know,
38:32we don't know how engaging she is,
38:33but she seemed to be, you know,
38:35warm and and outgoing and she certainly
38:38was engaged with her learners.
38:40So a very different feeling of a
38:42learning climate from the first case,
38:43however,
38:44not perfect.
38:44And so I think there are some
38:46things that she could maybe
38:48have done a little bit better.
38:50You know,
38:50she's seeking feedback on how things
38:52are going, but not for a week.
38:54And after they've been together,
38:57that seems like kind of a long time
38:58to be checking in to see if if things
39:01are working well for the team.
39:02And she doesn't ask sort of upfront
39:05for input about how how to run things.
39:09She sort of tells the team
39:11how it's going to go.
39:12Many of us really like our residents
39:15to be the ones running the service and
39:17running the team and and coming up with,
39:19you know, how rounds are going to run.
39:21And so she's a little bit, you know,
39:24not learner focused in that way.
39:26Many of us would again really invite our
39:29our residents to actually participate
39:31a lot more right up front about about
39:33how the service is going to run.
39:35So those are the big things
39:37that I've identified it.
39:38Does anybody have any quick thoughts?
39:40Just before we we move on
39:42and and take questions,
39:45one person in our group noticed that
39:49she tapped the student and thought it
39:51may have been more appropriate to say
39:54we'll have you presented the bedside.
39:56Are you comfortable with that? Yes.
39:59Before putting her into that position,
40:01Yes, that's a really good point. Thank you.
40:06All right. So with that.
40:14Hopefully you leave here understanding
40:16that learning climate is a miliere in
40:19which learning takes place per learning
40:21climate diminishes the effectiveness
40:23of the teaching that you do.
40:24A good learning climate enhances
40:26teaching and helps with team building,
40:28and it really is foundational to
40:30everything else that you do in education.
40:32But the good news is learning
40:34climate involves a set of skills
40:36which can be practiced and mastered.
40:38And hopefully you feel like you've
40:40learned something here today
40:42that that can help you with that.
40:44So this is the hopefully you
40:46can all see this,
40:47this is the evaluation form.
40:51I don't know if Linda can pop this
40:53into the Zoom chat for us.
40:55It's in the chat, so.
40:57Oh, thank you. Thanks, Janet.
40:58And there's the, the QR code you can use.
41:02And we're going to set a timer
41:04for a minute to give everybody
41:08a chance to give us evaluation.
41:10And again, we are very interested
41:12in your feedback on the session,
41:15what went well,
41:15what we could do to improve things
41:17And then we'll be open for questions.
41:22And feel free to ask questions now, I guess.
41:24Yeah, just to say that the QR
41:26code is taking us to a different
41:29session when we. Yeah, the 6th. No,
41:35Linda, any thoughts is how about
41:37the URL works to the right one. OK.
41:40Oh, thank you. Thanks, John. Yeah,
41:42the one in chat takes us to the correct one.
41:44OK. Thank you everybody for realizing that.
41:51Hello.
41:56Any questions while people are
41:58doing their evaluations and we're
42:00happy to answer them just because
42:02we're officially out of time.
42:06We appreciate having such a
42:08great diverse audience of people
42:10with such a broad expertise and
42:12different levels of of training.
42:14It's great to have all of you here.
42:16We appreciate any input you can give
42:18to us to constantly improve this.
42:21So the CMA code says sorry,
42:27there was a problem with it.
42:28Linda's taking everyone's name down
42:30and she will submit them that we.
42:33Yeah, let's see the the
42:35text code did not work. OK.
42:38But all your names been registered,
42:40so you'll receive the credit.
42:43Yeah. It's a great session.
42:44Thank you. Thank you.
42:46And again, any any comments,
42:48last thoughts or questions,
42:49we're I'm happy to stay on for a
42:51few minutes and and answer them.
42:53And thank you so much for,
42:54for participating and the upcoming
42:56sessions are going to be amazing.
42:59These are all wonderful educators,
43:00so I strongly encourage you to attend them.
43:03Thank you so much. Thank you.
43:07Thank you very much.
43:08Great session. Thank you.