11-17: YES!: Leveraging the Group’s Power: Leading Engaging Workshops

November 17, 2023

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00:04Able to opt out if you for some
00:07reason don't want to be part of the
00:10recording where you can opt in,
00:12as you probably see on
00:13your screen at the moment.
00:15So I'd like to get started by
00:18just welcoming you on behalf of
00:20the Center for Medical Education,
00:23formally thought of as the T to the the
00:27Teaching and Learning Center or the TLC.
00:30So the center is now has now expanded to
00:34include continuing medical education as well.
00:36So Andrea has just reminded you that
00:39you can also get continuing medical
00:42education credit for attending this
00:45session if you go to the link.
00:48So the YES series or the Yale Medical
00:52Education series, Yes for sure.
00:54That occurs every other Friday
00:57approximately each month.
00:59Sometimes when there's a lot
01:01of holidays as coming up soon,
01:04we may not present in that particular month,
01:07but you'll be able to figure that
01:10out by looking at the calendar
01:12at the centre's website.
01:13We also sponsor a meta discussion
01:16group monthly,
01:16so we invite you to check all of our
01:20faculty development opportunities
01:21out at the centre's website,
01:24and maybe Ed can also put the
01:26link in in the chat as well.
01:28The Doctor Andres Martin from the
01:30Child Study Center and Doctor Dana
01:33Dunn from Internal Medicine are the
01:35Co directors of the Yas series,
01:36and Doctor Martin happens to
01:38be our presenter today.
01:40Most of you know, but in case you don't,
01:43Doctor Martin is the Riva
01:46Ariella Rifa Professor.
01:48It's a tongue tie,
01:50a tongue twister in the Child Study
01:53Center and is professor of psychiatry.
01:55He also facilitates a discussion series
01:57on qualitative research methods,
01:59so some of you may also want
02:01to check that out with him.
02:03So rather than taking more time,
02:05I I want to turn the rest of the
02:08afternoon session over to Doctor
02:10Martin and to give him a break.
02:12I'll also monitor the chat as we go.
02:15Thank you, John,
02:16and thank you all for coming
02:18here on this Friday afternoon.
02:20I'm excited to share some stuff today.
02:24So we're going to talk about
02:26teaching in small groups,
02:27something that is very useful
02:29when it comes to workshops and
02:32many other formats that we
02:34that we that we use. Oops,
02:39yeah. So I have nothing to
02:43disclose there. You have that.
02:45And to get your CME credits,
02:48we'll remind you a couple
02:49of times during the talk.
02:50But you can text that number,
02:5439539 to that other
02:55number and we have a beast
02:57in one Merit. Lava
03:00the Left. So we encourage you
03:03to get those credits. OK, first
03:10quiz here. Can anyone tell me,
03:13does anyone know recognize
03:15where my pointer is pointing?
03:17Does anyone know what that means?
03:23No. So so this means that this image was
03:29created with artificial intelligence and
03:31specifically with a program called Dali
03:36DADAL EE. And what I did is that I
03:39knowing that I was going to come here,
03:41I said give me an image in watercolours
03:44about medical students solving
03:47problems together and this is what
03:49artificial intelligence spit out.
03:51Pretty cool, right?
03:53Now I I start with with this
03:55image and with the idea of AI.
03:58To make the point that in in
03:59my comments today I'm going
04:01to try to bring technology,
04:02not as ******** technology as AI,
04:06but some technology,
04:07to the teaching.
04:10OK, so a couple of core
04:15points to start off with.
04:17This is how teaching unfortunately
04:19traditionally happens.
04:20There's an orange person pontificating
04:23on a bunch of blue people,
04:26and the information exchange is limited.
04:31The fun is very minimal,
04:33and not a whole lot happens.
04:35And yet this is historically how teaching
04:37has been done and how most most of us,
04:39certainly I learned when we were
04:41in medical school and other places.
04:43But fortunately things have changed.
04:45And here at Yale,
04:46we are in an environment of a
04:48lot of innovation and teaching,
04:49which is very exciting.
04:52And after whoops,
04:53after these innovations,
04:54what we hope for is something more like this,
04:57that there's very active
04:59iterative interaction between
05:01all the participants .1 and .2.
05:03That it doesn't have this verticality
05:05and this hierarchy of the left image,
05:08but rather it's a more horizontal
05:11everybody can learn from each other.
05:14In so doing,
05:15the number of arrows increase and the
05:18number of teaching moments per hour,
05:21if you will,
05:22increase,
05:22and that's what we're going to
05:24be aiming for today.
05:25How can we unleash those educational units?
05:33Those images, by the way,
05:34come from this very nice reviewed
05:36paper by Burgess on how to facilitate
05:39small groups if anyone is interested.
05:42And another image that I sort of like, but
05:44not fully like from that paper is this one.
05:47I think that the starting
05:48premise is a good one.
05:49When you are teaching in a small group,
05:51you have three tasks at hand.
05:53You have to manage the learning, the
05:55content of what it is that you are sharing.
05:59You need to manage the group,
06:02those who talk too much,
06:03those who talk too little,
06:04those who, this, those who, that,
06:05and you need to manage the activities.
06:08Whatever those activities are.
06:09We're going to see examples of those.
06:12So far, so good.
06:13But what I think is missing from this
06:17paper from the ancient year 2020 is this,
06:21that you also have to manage the
06:25technology and its discontents.
06:28You need to be really ready to do that.
06:30Even as I speak to you,
06:32you're not seeing this.
06:33But in my I,
06:34I have to be dealing not just with
06:36a PowerPoint and with my screen,
06:39but also with a zoom screen which happens
06:41to interfere with my PowerPoint screen.
06:43And this is just a very basic task.
06:45As you start including other things,
06:47it gets complex.
06:48And many of these things really love
06:51to crash and breakdown and you need
06:53to know how to March on and not be,
06:56you know, taken down by that.
06:59And the third image from that paper,
07:01which I also sort of but not
07:03really agree with, is this.
07:05For a long time,
07:06the idea of small groups has
07:08been this 3P approach.
07:10You pose a question to the whole group,
07:13You pause, you allow them to think.
07:16And then like a tiger,
07:17you pounce on some unsuspecting person
07:20and you tell them by their name and
07:23they feel humiliated and frozen.
07:24And it's not a particularly
07:27good learning environment.
07:28But I invite you as we go on to
07:32think of this third P instead
07:34of pouncing as an invitation to
07:36playing because there can be
07:39these very playful elements.
07:41I think particularly when we bring
07:43technology and we bring some
07:45of these things that that make
07:46the the learning different.
07:52OK,
07:55one final thought on background and theory.
07:59Ish is about small groups,
08:02small group learning in TBL,
08:04and team based learning,
08:05which is the classic way of doing this.
08:11I think that there's a lot to be said
08:13for TBLS, but it's rare in this day and
08:16age that they're done in the absolute
08:19classic way that they were described.
08:21And yet, there are elements of TBS.
08:27There are elements of TBL that
08:31can be maintained and be useful.
08:33So in TBL, for those of you
08:35who have or have not tried it,
08:36the idea is that the learning
08:39starts before the class.
08:41It starts in home based preparation,
08:45at home in the library individually
08:49and that's an important precondition.
08:52Without which it is very hard to do
08:55what follows because what follows
08:57is the content at the class.
09:00Don't pay too much attention
09:02to the to these little arrows.
09:04Let's let's look above.
09:07Here the second phase of TBL is what's
09:11called readiness and and and assurance.
09:16And the idea is that during some
09:17period of time it says here 40 minutes,
09:19but it can be 20 minutes, it can be brief.
09:22You do some test in which you
09:25assess how much the learners took
09:27in and what questions they have.
09:30Traditionally there's an individual test,
09:32then a team test.
09:33There can be,
09:34which again doesn't sound
09:35very nice written appeals,
09:36which is more like clarifying questions.
09:40And this part is done in
09:43with the knowledge that the
09:45students should really have.
09:47But the really fun part comes in the end.
09:49You see the much longer,
09:50longer piece which is application
09:53oriented in which you apply everything
09:56that came here and in which for optimal
10:01results there isn't 1 correct answer.
10:04We're going to come back to that.
10:09So when we have both the individual
10:14work that happened at home and in the
10:18readiness in the classroom and then
10:20small groups coming together and total
10:22discussion that what has the the big,
10:24the big impact on learning
10:26what we're going after,
10:30I don't know how to get rid of this.
10:33OK. So what we're going to do now
10:36is I'm going to do a little bit of
10:39an exercise with you guys and rest
10:42assured that we're not going to go
10:44into breakout rooms because my in my
10:47experience whenever we go into breakout
10:49rooms we lose half of the people
10:51and that can be awkward if you're
10:52you're not in a group that you know.
10:54I also assure you there's going to
10:56be no assessment in it of any time.
10:58And very importantly,
10:59it doesn't matter what your area
11:01is of expertise, what specialty of
11:03your physician or what whatever.
11:05If you're not a physician,
11:06it doesn't matter.
11:08I'm going to ask you for this to be
11:10a general is not an expert and we'll
11:14assess some general breadth of of knowledge.
11:19So you're in luck today because I think
11:21John mentioned I'm a psychiatrist,
11:23a child psychiatrist.
11:24So because of that,
11:25I guess that my default is that
11:27we're going to have a little bit
11:28of a psychiatry refresher.
11:29So sit far away from Doctor Wilkins,
11:33who I saw my fellow psychiatrist here,
11:36so she will know some of these answers.
11:38But it doesn't matter.
11:39It doesn't matter.
11:40It's more about the process
11:41that we're going after.
11:42So let's start with some
11:45basic facts about depression.
11:47It's a worldwide hidden burden.
11:51It's a disorder that affects over
11:55350 million people in the world,
11:57and that's dated by now.
12:01Almost one people,
12:0211 million people,
12:03take their own lives every year.
12:05This is a disorder that disproportionately
12:08effects women in general and women during the
12:11childbearing years of life in particular.
12:13So that's just to Orient us to the
12:19the severity of this condition.
12:22Now I want you to now take,
12:24I don't know,
12:26a minute and just think in
12:29your own mind's eye what your
12:31understanding is of depression.
12:32What are some of the symptoms of depression,
12:34What it looks like you can think about
12:38it if you want to jot it down South.
12:41Clinically, what does it look like next?
12:44What are some of the causes of
12:46depression that you can come up with?
12:48And finally, what treatments do you know of?
12:50Have you heard from a patient?
12:53From a relative?
12:54From a loved one?
12:56From oneself?
12:56What are some of the treatments
12:59of depression?
12:59So let's just give you a
13:01few seconds to do that.
13:12Doctor Wilkins, I'm so happy to see
13:14you here. May I give you a task?
13:17Yes. Your task is going
13:18to be to take the most contrarian
13:21responses and answers that you
13:22can think of. OK OK OK All right.
13:29All right. So let's move on.
13:34And what I'm going to do now is show
13:36you a clip. It's a 2 minute clip,
13:412 minute and 22nd clip.
13:43And I'll just let the tape roll.
13:45And you've thought a little
13:47bit about depression.
13:48Let's see how your thoughts
13:50change after you do this.
13:55By the way, if we had been in a
13:57classroom rather than zoom at this point,
14:00I might have given you some initial
14:01assessments, some little paper and pencil,
14:03something to write along
14:05the lines that I asked you.
14:07But here we're going to,
14:07we're going to move on. OK.
14:10So let's, let's meet this pair. I
14:14I've had depression on and off my whole life,
14:19but I've I've never had anything like this.
14:23This is worse than anything.
14:25This is the worst that I've
14:26seen her in my entire life,
14:29and I'm honestly really scared by it.
14:34I yeah, it's terrifying me
14:36to be completely honest.
14:38Depression can look like a lot of
14:40different things for different people.
14:41Can you maybe describe to me what your
14:43depression has looked like recently?
14:45I just don't have any energy,
14:50no energy to do anything.
14:52I just want to.
14:55I want to sleep.
14:56I can't sleep.
14:59Every time I come over to come see her,
15:01I I'm there every day now because she
15:05just doesn't have the energy to get out
15:07of bed or just take care of her cat.
15:10Or she used to help me with my sons,
15:13help them come up from daycare and from
15:15school, and she just doesn't have the
15:18energy to leave her apartment anymore.
15:21Are you able to do things like pay your
15:24bills on time? No, I help her with that.
15:27OK. And has that always been the case?
15:29No. No, that's been recently.
15:31How about things as simple as getting
15:33out of bed to brush your teeth,
15:35take a shower in the morning?
15:37I mean eventually.
15:39Have there been days this week for example,
15:41that you were unable to do any
15:44of those things?
15:45I had to call her and remind her.
15:49When you're in low energy,
15:51sleep is not great.
15:54Difficulty falling asleep.
15:56Difficulty falling asleep,
15:59difficulty staying asleep,
16:01Waking up in the morning
16:04earlier than usual.
16:05I don't want to get out of bed.
16:07Like wake up.
16:11Have you been feeling sad? I
16:15don't
16:19know if I can
16:19even really like describe
16:22exactly how I feel. Kind of numb.
16:27Does that sound like being numb?
16:29She's just like she doesn't.
16:32I don't want to say care, but that's
16:34probably the best word I can find.
16:47OK, so again, I want you in your
16:50mind site to to put that together
16:53and what I'm going to ask you now,
16:55you only need to do this once
16:57but it would be great if you all
17:01could log on to pull everywhere.
17:03Some of you I know have used it,
17:06but these there are three ways,
17:07whatever all of them are the same.
17:09The easiest one is take your your cell
17:11phone and aim it at that QR code and
17:14it'll take exactly where you need to be.
17:16You can also do it through the
17:18website and Linda if you're kind
17:19enough to also put it on the
17:23on the on the chat. And if for some
17:27reason you you lose it, it will be
17:29in all all the relevant slides. So
17:33by the way, it'll ask you
17:34for your for your name.
17:35You don't need to put your name, so
17:39you can just move on.
17:45OK, so let's get started
17:48and let's start with this.
17:51Let's start with, we're going to
17:52have four questions, by the way.
17:54It's not going to be 100 questions,
17:55but each one is going to have
17:57a different goal. So this one,
18:01what lab abnormality is most
18:04commonly associated with depression?
18:05Vitamin B12, hematocrit,
18:11thyroid hormone,
18:12warfarin or VDRL for syphilis.
18:16So you can just.
18:18I see that five of you,
18:19six of you have already voted.
18:21So people are getting it.
18:22That's great.
18:27Oh, 15 good. OK,
18:31so let's see, let's see
18:33people's thoughts about this.
18:36All right,
18:39once I found, oh, there we go.
18:42OK, we have 17 responses,
18:45and this is what it looks like.
18:48So TSH was a big winner.
18:51Thyroid. The DRL was a big loser.
18:57OK, does anyone want to just
18:59talk about what they voted for?
19:02We we know who's going to be
19:03the contrarian in the group.
19:04But does anyone want to?
19:09Kristen, you're you're you as a
19:10contrarian and my fellow psychiatrist,
19:12do you want to break the ice here
19:14with why you decided the VDRL?
19:16Look, look at that.
19:17No one else voted with you.
19:18Kristen, why did you do that?
19:20Well, I just, I think I remember
19:23reading somewhere that people
19:24with depression had risk taking
19:26behaviors or something like that.
19:28And so I figured if they were maybe
19:31sexually promiscuous that they might
19:32be likely to contract syphilis.
19:34That's great. That's great.
19:35And you know, let me add to that
19:37very good thought that 100 years ago,
19:40the number one leading cause of
19:42mental illness of all types was
19:44syphilis through tertiary syphilis.
19:45So for those of you lovers of history,
19:49if you went to an asylum 150 years ago,
19:51you would have seen a
19:52lot of tertiary syphilis.
19:54But yeah, I think that the most of
19:56you didn't go for it and I understand.
19:58So do we have anyone for porphyrin?
20:05All right. You're going to, you're shy.
20:06So I'm going to,
20:07I'm going to speak for porphyrin.
20:08So, you know, porphyrin is there
20:10because it always has to be in the
20:12differential and it never happens.
20:13And it was invented only for the boards.
20:16But you know, we put it there.
20:17It's a rare thing.
20:18It's a classic zebra.
20:19But yeah, could it relate to depression?
20:22Sure. It can't.
20:23And you know,
20:24there was that famous movie of King
20:25George the Third who had some psychotic
20:28disorder related to porphyrin.
20:30So very, very rare, but there you go.
20:33I'm curious about those of you who
20:36talked about hematocrit and blood.
20:38Can anyone speak to that?
20:46I can do it. Go
20:48for it, go for it can't
20:50be on for you right now.
20:51But I put H&amp;H just because
20:55women of childbearing age are
20:57commonly anemic and they're
20:59commonly affected by depression.
21:00And that's really it. Well,
21:03I think that that's great.
21:04I think that that's great.
21:05Certainly a high risk population
21:07and when we do Routine Labs,
21:09that's one place where we can
21:11commonly find abnormality.
21:12So I think that you're thinking
21:14is spot on and that's great B12.
21:24So again not not common, not very common,
21:27but it's something that can happen
21:28and we don't routinely test for it,
21:30but you know it can happen.
21:31And and it sounds like TCTSH is
21:34something that many of you thought
21:35about and I think that that's right.
21:37Does anyone want to speak
21:38on behalf of the thyroid?
21:44Great, I will. OK.
21:46So hypothyroidism is very common
21:48as we know and it can be related to
21:51subclinical or clinical depression.
21:54So it's a wise thing to check it out.
21:56Good, good, good, good.
21:57Now you maybe had some of the tools
22:00to answer this, maybe you didn't.
22:02So that was entirely fair.
22:04But we'll we'll come back to that.
22:07OK. Now
22:12what I want you to do now is you
22:13you've already been thinking
22:15about symptoms of depression.
22:17It'd be great if you could just jot
22:19down the symptoms that you can remember.
22:20And to help you remember,
22:22some of you may have heard of
22:25this acronym called CIGGY CAPS.
22:27It's common for depressive symptoms.
22:29So try to name as many symptoms as you can
22:31and if they fit within that acronym, great.
22:33If not, just put down whatever.
22:36We all know what depression
22:38is in the vernacular,
22:39so I think it's, you know,
22:41perfectly fine too.
22:44So let's see
23:16Very good. So we have well 1314 of
23:20you have responded. So let let's
23:22see what you what you thought.
23:27OK. Sleep disturbance. Sleep OK
23:32Sleep is going strong. Sleep sadness.
23:40Interest Decrease Insomnia,
23:47Comorbidities.
23:51Sleep,
23:55Don't eat even when hungry.
23:57Change an appetite.
24:02Appetite.
24:08OK, so it sounds that that you as a
24:12as a group are adding some stuff.
24:16Sleeplessness, crying energy, low anhedonia,
24:19which is inability to enjoy things.
24:24Sadness. Irritability. Lethargy.
24:26Sadness. Homniacs asleep. Great.
24:29So I think that the the picture is,
24:30is is is thickening.
24:32You're doing a great job force happiness.
24:35That's that's very interesting.
24:38Crankiness. Terrific.
24:40So let's now move to this because I
24:44think that you hit most of the symptoms.
24:48Everybody talked about sleep.
24:51I think that interests were mentioned
24:53both by you and in the video.
24:54Guilt. I can't remember if it
24:57was mentioned or put in there,
24:59but this refers to feeling like a burden
25:02on the other, especially on loved ones.
25:05Low energy for sure.
25:07Appetite was mentioned.
25:09Suicide, suicidality was mentioned.
25:11Perhaps Les mentioned was psychomotor
25:14agitation and retardation.
25:16Feeling shaky, feeling very slowed down.
25:19Concentration.
25:20But this is a way of remembering
25:24these symptoms.
25:25So This is why I'm giving you this acronym,
25:28and this is the same acronym and
25:30some of the same things that we
25:32use with our medical students.
25:33So today you're pretending
25:36to be a medical student.
25:40Now, now that we know what depression
25:43is a little bit what it looks like,
25:47the news is not all bad.
25:48Because once we recognize depression,
25:49there's a lot that we can do to help.
25:52Now, fortunately, yesterday you
25:57we're going to start with this.
25:59Let's start with any antidepressant
26:01that you can mention and you can
26:04put more than one in the in the
26:06field but but let's see how many
26:08antidepressants you can name
26:11if any antidepressant treatments you can name
26:17doesn't have to just be a medication.
26:41OK, so let's let's see
26:44what you what you answered
26:50Prosaic
26:53ethics or
27:01CBT. So cognitive behavioral therapy good.
27:03So a non medication meditation good.
27:09Excise the depression through exercise.
27:11Exercise problem. Raw cookie dough.
27:13I like that. I like that.
27:14Although that may be more of
27:15the problem than the solution.
27:17Oh, we're getting fancy Lyrica Zoloft.
27:19Prozac, electrotherapy.
27:21Cognitive behavioral
27:22therapy exercise sertraline
27:28good. So what I'm seeing here is
27:30that most of you are familiar with at
27:32least some at least one medication,
27:35usually medication fewer of you are as
27:39familiar with non medication treatments.
27:41That's fine. And for those non
27:44medication treatments things like
27:46exercise and puppies are you know,
27:49common things that can that can help.
27:51OK, So what do we do with this information?
27:57So as you recall, you're part of this course
28:02and you got your homework and you were
28:04at home and you studied it very closely.
28:07And now you're going to use the
28:09information from your homework
28:10assignment to answer a question.
28:12Now I know that the dog ate your homework,
28:15so that's fine.
28:15So we're going to give it back to you.
28:17We're going to put it in the text.
28:18It's A1 pager, Linda, if you don't mind.
28:21And I'm also going to go over
28:22it on the screen.
28:23We're going to spend, you know,
28:25a minute or two or three going over this.
28:28And with the information
28:29that you're going to see,
28:31we're then going to ask you to put your
28:34heads together and come up with an answer.
28:37OK, Again, I'm not going to
28:38divide you into small groups,
28:40but we're going to do something
28:42quite similar to that.
28:43OK.
28:45So in this list of you know the
28:48notes that you took at home from the
28:50lectures and the podcasts and whatever,
28:53you have these five treatments
28:55that you remember.
28:56And you took some notes about aripiprazole
28:59or Abilify any typical antipsychotic.
29:03It acts on dopamine and serotonin,
29:05traditionally used for schizophrenia,
29:07but has also been used in
29:09treatment resistant depression,
29:11especially as a adjunct in
29:14addition to an antidepressant.
29:16Weight gain liability can
29:17be a common side effect.
29:19So that's one treatment,
29:21aripiprazole,
29:24very different treatment is non medication
29:28and they're organized alphabetically.
29:31Electroconvulsive therapy is
29:34an old treatment that goes back
29:36to the 1920s and it's the first
29:38effective antidepressant we had,
29:40can be safe and can have a rapid
29:43onset treatment of choice for
29:45depression with psychotic features
29:46and for severe depression including,
29:48which may sound really counterintuitive
29:51or depression during pregnancy,
29:52for example.
29:55And the electric stimuli stimuli are
29:58delivered either one side or both
30:00sides of the head, so that's ECT.
30:04And so that's the second one that
30:06you remember from your notes.
30:09Third one is ketamine,
30:11which is a very the new kid on the block,
30:14it's an NMDA receptor.
30:15It actually started in anaesthesia
30:18as a dissociative anaesthetic.
30:20It acts very quickly.
30:22Within the first dose you can
30:24see dramatic improvements.
30:25Unfortunately it has a very short half life.
30:28Unfortunately it has to
30:30be given intravenously.
30:31But in this day and age we're using
30:33more something called esketamine
30:35that's given as a nasal spray and
30:37this treatment can also be used in
30:39addition to others as a combination.
30:41But it's a very current treatment.
30:494th and and ultimate one is RTMS.
30:52Repetitive transcranial magnetic stimulation.
30:55Non invasive, it uses magnetic fields
30:58that are put surrounding the the head.
31:02The magnetic fields can go some 2
31:04inches into the cortex. Very safe.
31:08Does not require anaesthesia,
31:10essentially no side effects.
31:12One in a million people can have
31:14seizures is very rare and given
31:16its low side effect burden,
31:17it's it's often really liked and preferred
31:21by patients because it's so easy.
31:24And the final treatment is
31:26another medication, venlafaxine.
31:28It's an SNRI serotonin
31:32norepinephrine inhibitor.
31:34It's commonly used as a second line
31:36antidepressant when let's say the SSRI,
31:38the pro sex of the world haven't worked
31:43it. We use it in children.
31:46Duloxetine, which is a cousin is
31:49particularly used for patients
31:51who have Co occurring pain.
31:53OK, so now this was a reminder
31:56of your your homework.
31:58Again, you have it,
31:59it's a Word document if you
32:01want it for this next phase.
32:04So whoops. So the question is what
32:11treatment use for the patient that you saw.
32:13And don't don't rush it, just take your time.
32:16What I'm going to ask you is
32:18not just to put your vote down,
32:21but then it'll really help make all
32:25the teaching points if you then defend
32:27if you will, or justify your choice.
32:30OK. So
32:35you'll be able to pick just one.
32:37If we were in a room together,
32:39I would ask you to form little
32:43groups and it's less about the group.
32:46You know, we could do groups in in,
32:50in breakout rooms,
32:51but it's more about the continuity of groups.
32:54So I find that if it's a class where the same
32:56students are meeting and they form groups,
32:59then this really works very well.
33:01When the group is a 11 only
33:04time getting together,
33:05it doesn't work quite as well.
33:07But for now you're going
33:07to do it individually.
33:08And let me give you a minute
33:10and make up your mind
33:39now, Andrea says. As people
33:40are making up their minds,
33:42could I just remind people
33:44that with so many in the room,
33:45it's difficult to see hand hands raised.
33:48So just feel free to defend
33:52your answer orally by unmuting
33:54and defending your answer.
33:56Or you can also put information,
33:58questions, comments and chat
34:01and I'll monitor that.
34:03Thanks. Great.
34:33And remember, we're we're choosing
34:36treatment for the patient.
34:38We saw in the video, a woman
34:41probably in her early 60s, mid 60s,
34:46recurrent episodes of depression.
34:48But by far this is the worst and
34:50her usual treatment has not worked,
34:52and it's having an impact on
34:55her family life, taking care of
34:57her grandchildren and so forth.
35:05OK, let's let's see what what
35:09do you guys thought? OK,
35:18OK, very interesting. OK. So first of all,
35:31I I think it's important to say that
35:34none of the options are horrific.
35:37You know, no one would send you to psychiatry
35:39jail for doing any of the five things.
35:41I think that they're so and and
35:43that's why we want to hear.
35:45Now you're thinking, right,
35:46it's not about I won and you lost, but why?
35:49So it it's interesting and and curiously
35:51it's not what I would have predicted,
35:53which is what makes this always fun.
35:55So why don't we start with our contrarian?
36:01Kristen, Why, Kristen, why?
36:02Why did you pick erypiprazole augmentation?
36:08Well, just looking at the woman,
36:09I was concerned about psychosis and she
36:12just seemed so flat and so withdrawn.
36:15Although we didn't ask her about
36:16psychotic symptoms in the interview,
36:18I'm just I I worry that's
36:19the direction she's going.
36:20So I feel like she's going
36:21to need an antipsychotic.
36:22And it could help her depression too.
36:25Yeah. And can you tell us what made you
36:27think of the possibility of psychosis?
36:31Well, she just looked so, you know,
36:33just sort of flat and withdrawn and
36:34and was kind of slow to respond.
36:36I almost wondered if she was
36:37having some thought blocking.
36:38Maybe she was paranoid about the whole
36:40situation that was going on with her
36:42daughter there talking to the doctor.
36:44And I wondered if she
36:45might, you know, might be having
36:46some kind of violence and delusions,
36:48that sort of thing.
36:50No, that's good. And I would also add
36:52to your thinking that she had been on
36:55her previous medication for a while and
36:57she had been doing well for a while.
36:59So that's maybe the ideals
37:00of augmentation right?
37:01Now let's not take out something that
37:03was at least helpful for a long time.
37:05So, so thank you, but you know,
37:07unfortunately, you, you,
37:08you're you're alone on this one.
37:10Let's see what your buddies thought.
37:12OK, so ECT Does anyone?
37:16I'm going to go in in their
37:18order of frequency, ECT.
37:19Anyone.
37:29Come on, people. You. You know who you are.
37:38No, no, ECT.
37:42OK, well, I'll. I'll come to your
37:45rescue and maybe you'll pipe in.
37:47I actually think that ECT would be
37:49a really good option for this woman.
37:54As far as she we know she doesn't
37:55have a a complex medical history,
37:57but she does look a little bit frail.
38:00She has not responded.
38:01She has responded very well in the past,
38:04but now has had this very dramatic
38:07decrease in in her function.
38:12She is missing out on a lot of things
38:16and this could very quickly get worse,
38:20worse in the direction of
38:21depression as Kirsten mentioned,
38:23or worse in the depression of the
38:25depression getting really, really frozen.
38:27We already see some frozenness
38:29in her movement.
38:31She's very slowed down.
38:32We don't know her from before,
38:33but I would bet that that's not her baseline.
38:36So I think that ECT would be a very,
38:38very good option and I think that
38:40someone in this crowd might be
38:42with me because does anyone want to
38:44support that view and that vote.
38:50OK, OK. All right. So what about ketamine
38:55and venlafaxine seem to be tied.
38:57Anyone I want to speak for either one.
39:06Deb, I'm going to pick on you before
39:08because little earlier you had you
39:10were about to say something and
39:12and I think that I skipped it if
39:14I'm right, is that is that fair?
39:17I was going to say something
39:18when I was I can't even remember
39:20back that far now but yet I
39:23was oh, it was on anemia
39:25and B12 being leaked
39:28on the RTMS,
39:29on anything on whatever you
39:31voted or whatever you want. So I
39:35hooked, I choose RTMS and I
39:37happy to be picked on by the way.
39:40But no, I chose it because it's
39:42something that you introduced,
39:44something that I'm not familiar
39:46with and in my clinical setting
39:48it wouldn't be an option.
39:49So I was intrigued by the lower side effect
39:52profile for someone caring for children.
39:55And a lot of these other options
39:57would have a risk of either,
40:00you know, altering sedation level,
40:03either sedation or overstimulation
40:04kind of in either direction.
40:07And some might interact with her
40:10desire to say be independently caring
40:12for small children.
40:14Yeah no I'm I'm so,
40:15I'm so glad that you're thinking with
40:17with the children in mind, right.
40:19That's not typically how we think.
40:20We think just patient in mind.
40:21But I think that here thinking
40:22generationally is, is very important.
40:25So that's good, you know RTMS.
40:27The the advantage would be
40:28that it's non invasive,
40:29it's user friendly.
40:31She would go for it.
40:33I think that probably it wouldn't be my top,
40:36top, top choice because I don't
40:37know that it would take her out
40:39of this depth of depression.
40:40But if she is not as accepting or
40:44exciting about ECT for example,
40:46this could be a pathway to
40:48get her more comfortable with
40:50interventional approaches for example.
40:52So you know, thank you for that, William.
40:55Bill, did you do you want to defend a vote?
40:59Any vote.
41:01I I Full disclosure,
41:03not a psychiatrist. So no
41:06one's perfect, no one's perfect.
41:09But my my rationale was the
41:13non invasive aspect of it.
41:15I understand that previously
41:17she was on a medication,
41:18so this does represent a real change in
41:23therapy that might itself just give her
41:26some hope and positiveness about it.
41:28I worried maybe it won't be strong enough,
41:34but I thought it was a good
41:36first intervention as you said
41:38to get her used to the idea of
41:40something other than medication.
41:44And so those were those
41:46were my thoughts on that.
41:48Thank you. No, that's great.
41:50And venlafaxine could also
41:51be a very good choice.
41:53It would be a substitution of of the
41:56SSRI that she is on for venlafaxine.
41:59As I say any of the five options could be,
42:02could be a good one and that that was a
42:05point to start thinking about these these
42:06issues and we saw some nice examples
42:08thinking about the grandchildren.
42:09We typically don't do that thinking
42:11about the medical comorbidity,
42:13thinking about previous treatments.
42:14These are some of the things
42:16that as future physicians you're
42:17going to be thinking about.
42:18So, so good job with that.
42:21Now,
42:26I'm going to say that,
42:30well, I'm gonna ask beforehand how many
42:33of you have seen ECT, know what ECT is?
42:40And this time I probably
42:42anticipate a few hands will go up.
42:44Not even Kirsten.
42:45I I know Kirsten has seen it.
42:47So, Kirsten. OK, Deb.
42:49OK, so since we talked about ECT and
42:53there was so much discussion about it,
42:56I want you to see what it looks like and
42:58then give you an opportunity to ask any
43:00questions or thoughts that you might have.
43:02This is a video of this
43:04patient during one minute.
43:06It's a one minute video of ECT.
43:09And this is done with real doctors,
43:12real nurses and a non real patient.
43:16This is a simulated participant.
43:17We filmed this in the simulation center,
43:21so here we go.
43:22One minute
43:23I'm ready. Green light.
43:25It's been about 90 seconds.
43:27Treat delivering the stimulus.
44:11Looks like the convulsions have
44:12ended, but she's still seasoned
44:18all right and the seizure has stopped.
44:23OK, so
44:27does anyone have any thoughts,
44:29observations, reflections about the
44:31ECT or about the treatment in general?
44:38Yes Chelsea, I see.
44:39I see your your hand up.
44:40Tell him go ahead What what are?
44:42What are some of your thoughts?
44:43Please share with us.
44:47I was grabbing my water bottle.
44:49If you're talking to me
44:53and and any thoughts and
44:54and and any reflections
45:00I do not have any at this moment
45:03I'm just you're taking it all in
45:05not not coming from a clinical
45:08background so I'm just here
45:10but you know
45:11I I that's exactly why I wanted
45:13to reach out to you as a non.
45:15I know you're not a clinician
45:16and but just as a, you know,
45:18member of society what,
45:20what are your thoughts when you,
45:21you know, as you saw ECT,
45:23Did you have any idea in your
45:26mind's eye of what it was or not?
45:30I didn't exactly have anything in mind.
45:32I just wonder, I just had a question
45:34that I was questioning for myself.
45:36I was just wondering at what point do you
45:39know if ECT is is working for the patient is
45:42what I was was really reflecting on.
45:44Yeah. Yeah, yeah. No, so that's,
45:46I mean that that's a great question.
45:48And you know typically this treatment
45:51is done three times a week for the
45:53first week and then after twice a week
45:56usually it takes about eight or ten such
45:59treatments till we see full recovery.
46:02But as I had mentioned it's
46:03it's a very quick treatment.
46:04So sometimes after one or two treatments
46:06we already see the patient feeling better.
46:08And so yeah, no that that's great.
46:11That's a great question.
46:12And and again I was picking on you Chelsea,
46:15because as a non clinician I I
46:18think that it's very important to
46:20think about what are the perceptions
46:21of the public when they hear ECT.
46:23In general those perceptions are very bad.
46:25You know something terrible is
46:27going to happen.
46:28So part of what we're also doing is
46:31breaking that stigma a little bit
46:33that not all of you are going to be
46:35psychiatrists and for many of you doctors,
46:37non psychiatrists,
46:37it may elicit all sorts of things.
46:39So that's why I thought especially
46:42when you hear the Electro, you know
46:45again not being clinician, being
46:46from just the general public,
46:49if I was the patient
46:51and one of those treatment
46:52options were given to me,
46:53I might not go towards ECT because
46:59I would hear the word Electro
47:00and be like, oh, you know,
47:02the stigma around around it.
47:05Yeah. And that's why you,
47:06you voted for RTMS because you said,
47:08Oh well that sounds less invasive,
47:10maybe she'll go for it.
47:11These are the kind of clinical
47:12discussions that we have.
47:13So thank you. Thank you. So
47:18with with this, I'm gonna just about
47:22to close before a cameo appearance,
47:25but what we just went through
47:26let let's put this into a little
47:28bit of a meta level, right?
47:30I mean the purpose today was not
47:32to have a lecture on depression,
47:34but it was to exemplify how to
47:38use group based interventions.
47:40Now I I feel that having them on Zoom
47:45is not the same as doing them in person,
47:48you know, and we're going to
47:50comment more about that.
47:51But when we do it in Zoom,
47:53we can also use certain other skills
47:56or or tools or tricks like we saw
47:59with the electronic response system,
48:02ways of engaging students.
48:03I think that the more that we
48:06can make clinical cases be real,
48:09like we saw depression, we saw ECT,
48:12the better it's going to be.
48:13And sometimes we can bring real patients,
48:15sometimes we do that,
48:16sometimes videotape patients rich
48:19clinical vignettes and engaging as much
48:22as we can the participation of the group.
48:25Now what here is a little bit tough to do
48:28in ZOOM is the intergroup participation,
48:30right.
48:31Because if we had PODS that would
48:34have happened as I say and I
48:36learned this the the hard way.
48:38Sometimes when we do the breakout
48:40rooms in ZOOM rapidly in this context,
48:43we can rapidly lose most participants.
48:45So that's not good.
48:46So that's those are the,
48:47the choices.
48:48Last slide,
48:49I just want to put things into
48:52a little bit of a meta context
48:54and this is what we did.
48:57We start by defining the learning objectives.
48:58You got it in the invitation.
49:01You got it a little bit.
49:02As I describe,
49:03we're going to be learning about
49:06depression and then we had some silent
49:11reflection or individual reflection
49:15in which you started gelling the
49:17thoughts based on what you knew,
49:18based on your prior knowledge,
49:19maybe based on the homework you had done.
49:22The red letters here, by the way,
49:24are terms that Steve Holt in
49:26Internal Medicine came up with.
49:28I find them very helpful.
49:30And in the purple,
49:31these are the terms from a classic
49:34old paper from 1965 of Tuchman
49:37developmental sequence in small groups.
49:39So how do groups form?
49:41So during the silent reflection
49:43today was individual.
49:44But think that you were in a in
49:46a classroom with with a small
49:47group trying to form that group.
49:49And indeed we formed a kind of group,
49:51all of us together.
49:55Then there's this diagnosing learners.
49:58I really like this, not not diagnosing
50:00in the sense of do you have a pathology,
50:03but diagnosing in the sense of where
50:05are you in your knowledge about this.
50:07And and again, Chelsea, you were a
50:09very good sport when I picked on you.
50:11You know, that was part of diagnosing
50:13the learners and you started by saying,
50:15oh, but I'm not a clinician.
50:16I said that was a sin and I said no,
50:18that's a strength, that's great.
50:20But I need probably to pitch it differently
50:22to you than I would to someone else.
50:24So that's a diagnosing of the
50:26learners or let's norm so that we
50:28can get to a unified point.
50:32This is my favorite one,
50:34creating struggle or storming.
50:36And that's what was exemplified in the
50:40choose one of these five treatments.
50:43There isn't one that is right.
50:45And if you said, oh,
50:47this has all the right fills,
50:51all the right boxes,
50:53that's not the right approach.
50:54It's not a multiple question, yes no,
50:56you want to have some internal struggle ECT.
50:58Sounds great, but this lady won't go for it.
51:01RCT sounds user friendly,
51:03but it's probably vanilla etcetera,
51:05etcetera, etcetera.
51:06So that was a creating struggle.
51:08And then finally we can do it either breakout
51:11groups or individually the performing,
51:14you know the answering the getting
51:16in there and doing the task and
51:19finally what we're doing now which
51:21is the consolidation of the learning
51:25in this case less about depression.
51:28My heart won't be broken if you don't
51:30know these treatments of depression,
51:32but more about from a learning point of view,
51:34from a pedagogy point of view,
51:35what did we learn?
51:36And then we close this phase.
51:38If the group is a repeated group over time,
51:41the closure has a different meaning.
51:43You know,
51:44we've been together for 10
51:46sessions now we're coming apart,
51:47etcetera.
51:48Now in the last five minutes,
51:51I
51:52Andreas, could you do you have time to
51:55answer a quick question and chat with.
51:57So Deb had a question.
51:58Do you have thoughts on finding
52:01a balance in engaging students
52:03or participants and not focusing
52:05too much on what participants
52:07feel about being called upon?
52:09Yeah, no, it it it, it's a tricky one
52:12And and I think I also exemplified
52:15this year because I took some risks.
52:17I happened to know Chelsea,
52:19so I knew that she was would likely be OK,
52:22even though I totally caught her by surprise.
52:24I know Kirsten and again,
52:27I diagnosed Kirsten. I, you know,
52:28she's a very senior psychiatrist.
52:31I'm not going to ask her Prozac questions,
52:33but to kind of put it on its head.
52:37So it's always tricky because you don't
52:40want to make anyone feel uncomfortable or
52:43ashamed or anything other than positive.
52:46So it's a tricky balance.
52:48I wish I had more to say.
52:50Usually the challenge is one of two
52:53either people being quiet and today as
52:55a group you are a little bit quiet,
52:57or the monopolizer who takes
53:00it all right in in in.
53:02Trying to balance those is
53:04something that just takes time.
53:06And that is harder in zoom because
53:08I can't quite read your facial
53:10expressions as well and for some
53:12of you I can't read them at all.
53:13So it's tricky,
53:14but that's a that's a great
53:17question and a great challenge.
53:19Now I want to.
53:20Yeah,
53:21Deb,
53:21no,
53:24I was mouthing. Thanks.
53:25I should have just typed it.
53:29I'm going to. I do want to have the last
53:31couple of minutes for Ann Elizabeth.
53:34Now, I started with,
53:38I started by showing you an AI image.
53:42Right. So this is another AI image.
53:44I'm going to leave it up there
53:45as Ann Elizabeth comes on board
53:46and you see here created with AI.
53:48Again the same question, but this
53:49time I some other problem because AI.
53:52Elizabeth knows a lot about AI,
53:55but that's not the reason why she's here.
53:56The reason why she's here
53:57is that she has recently.
53:59Well, she'll tell you the story.
54:00And Elizabeth, who are you?
54:01Are you here?
54:01Come on.
54:02Wow us.
54:04Hi everyone.
54:05I'm a second year MDPHD student.
54:08I work with Andres and the child and
54:11adolescent psychiatry interest group.
54:13But that's actually not why I'm here.
54:16I'm here because I can speak to
54:18the student perspective of being
54:20in a small group workshop.
54:23And specifically, I had the pleasure of being
54:26in Dean and Luzzi's workshop last week.
54:29That was in OB Guine workshop
54:32about preeclampsia.
54:33And somehow news of this incredible
54:36workshop got all the way to
54:38Dean Hafler and then to Andres.
54:40And then I am Now here I am to explain
54:42a little bit about what what worked
54:45really well and talk a little bit about,
54:46I guess, how to do this in person.
54:50So the diagram that Andre showed
54:52at the beginning of trying to have
54:54as many connections and as much
54:56of a conversation as possible as
54:58opposed to the one person sort
55:00of lecturing at the others.
55:02I think it's a really important point.
55:06Dina Luzzi,
55:07when she started the workshop,
55:10said, you know,
55:11you all are going on to clerkships
55:13very soon and so I want you all to
55:16practice talking amongst a group and
55:18trying to figure out what's going on.
55:20I want you to ask me for
55:23additional information.
55:24So she gave us the first page,
55:26but then she said, OK,
55:27now what labs do you want?
55:29What physical exam maneuvers
55:30do you want to do?
55:33What other information would you want?
55:35She said use me as a consultant
55:37and feel free to ask questions
55:39about the pathophysiology.
55:41But I'm trying to help you all,
55:42like build a framework for being
55:46able to approach a patient where you
55:48don't really know what's going on,
55:49but you do know vaguely what
55:52field you're rotating in.
55:55And yeah,
55:56so I thought what worked really
55:58well about her workshop was that
56:00it was quite student driven and
56:03relied on our curiosity and gave
56:06us an opportunity to apply some
56:08of these skills that we've been
56:10working on for a while,
56:11like figuring identifying
56:13what the next step should be.
56:17And it ended up being a really
56:19great group conversation because
56:20everyone felt comfortable.
56:22And Elizabeth
56:24and by the way I placed the the
56:26information for the evaluation.
56:27We really, really appreciate
56:29your doing the evaluation.
56:31But and Elizabeth, can you comment
56:33on the difference between an in
56:35vivo experience like you just
56:37described in the online experience,
56:40getting it group engagement like this one?
56:43Definitely. I think it is easier for it
56:45to be more conversational when you're
56:48in person and as as you mentioned
56:50it's much easier to read each other's
56:53faces and so if someone was confused
56:56you know we as a group would be able
56:59to tell and then talk about it more,
57:01whereas that's harder here.
57:02What's useful though about Zoom I
57:05think is when you have technology like
57:07pull everywhere or if we in TBLS we
57:10fill out a self-assessment on our own,
57:12then you can really assess your
57:15individual understanding.
57:16Whereas in a more conversational,
57:19in person based group,
57:20each of us is bringing something
57:22a little bit different.
57:23And so it ends up being collaborative
57:26learning, which is very helpful.
57:27But it doesn't necessarily tell me,
57:28do I know the pathophysiology
57:30of preeclampsia,
57:31yes or no or do I need to
57:32study this when I get home?
57:35Yeah,
57:39right. Thank you. And Elizabeth any any
57:43last thoughts, questions, comments,
57:48Well thank you all for, for joining us.
57:51And I I think that here the slide
57:55of what's coming up our very
57:57own and Elizabeth is going to
58:00be talking about ChatGPT that's
58:02going to be on Thursday the 14th.
58:05So that would be great.
58:07And then in I think the last
58:09one of the year December 15th,
58:10we're going to, I'll be talking about
58:13how to put together an abstract.
58:15So hope to see some of you then.
58:18Thank you, everyone.
58:20Thanks everyone. Thanks
58:22Andreas and Elizabeth. Thanks.