video1177655631

Transcript

• 00:10Well, first of all,
• 00:13I loved,
• 00:14reading your CV. As I
• 00:15said, I love doing this
• 00:17because I always learn things
• 00:18about the individuals,
• 00:20with whom I have the
• 00:21privilege to work. And so,
• 00:24I think all of, you
• 00:26know, Jadeep,
• 00:28but Jadeep did his,
• 00:30got his MD at Tufts
• 00:32and then did his residency
• 00:34and chief resident,
• 00:36in med pedes. So the
• 00:38chief residency was in Pete's,
• 00:40correct? Yep.
• 00:43Our game.
• 00:44And he actually, as you
• 00:47heard us kind of talking
• 00:48about, clinically, he's been very
• 00:50active,
• 00:51in the med peds clinic,
• 00:53as well as really an
• 00:55integral part of the,
• 00:58transition
• 00:59for our CF patients,
• 01:01our patients with CF to,
• 01:04internal medicine.
• 01:06From an educational
• 01:07standpoint,
• 01:09Jadeep has served as the
• 01:11associate program director of the
• 01:13med peds program,
• 01:15the director of the physical
• 01:17exam
• 01:18skills,
• 01:20I guess it would be
• 01:22course or curriculum,
• 01:24and then director of clinical
• 01:26skills, and then most recently
• 01:29as the assistant dean for
• 01:30education
• 01:32at the med school.
• 01:34Jadeep really is,
• 01:37you know, just,
• 01:38such an amazing role model.
• 01:41He has certainly,
• 01:45you know, just shown himself
• 01:46to be,
• 01:47the
• 01:48educator both at Yale where
• 01:50he won the Charles Bamforth
• 01:52Teaching
• 01:53Award, as well as the
• 01:54Alvin R. Feinstein Clinical Skills
• 01:57Teaching Award.
• 01:58And then the Brendan Kelly
• 01:59Award for Teaching Excellence, Collaborative
• 02:02Leadership and Compassionate.
• 02:07I thought it was interesting.
• 02:08I had forgotten that,
• 02:10you are involved in one
• 02:12of the grants on modeling
• 02:14professional attitudes
• 02:15and teaching humanistic
• 02:17communication to remedy implicit bias
• 02:19and promote
• 02:20cultural humidity,
• 02:21humility in health care, and
• 02:23that's with my friend
• 02:24Fred Krone.
• 02:26So yeah, I had actually
• 02:28forgotten about that.
• 02:30And he's had invited
• 02:32speaking engagements,
• 02:33you know, kind of multiple,
• 02:36internationalnational.
• 02:40And he's also editor of
• 02:41the pediatric primary care curriculum.
• 02:44And so with that CV,
• 02:46I mean, I just want
• 02:47to say that Jaydeep is
• 02:48really one of the most,
• 02:50I think the
• 02:51what really summarizes it to
• 02:53me is really the Brendan
• 02:55Kelly Award in terms of
• 02:57collaborative
• 02:58leadership,
• 02:58compassionate care, and teaching excellence.
• 03:01So, Jiti, thank you so
• 03:03much for, doing this. We're
• 03:05a small intimate bunch today.
• 03:07But thank you so much
• 03:09for,
• 03:10for leading this session.
• 03:12Great. Thank you, Padina. That
• 03:14was a very nice introduction.
• 03:15And I think back fondly
• 03:17that chief here because we
• 03:18act that was when I
• 03:18got to know you
• 03:20when, you were my attending,
• 03:22at Bridgeport,
• 03:23for a couple of the
• 03:24blocks.
• 03:25So it was, you know,
• 03:26it's been it's been a
• 03:27long, road together. So thanks
• 03:30for inviting me. Hello, everybody.
• 03:31I know almost
• 03:33everybody here.
• 03:35And,
• 03:36you know, knowing many of
• 03:38you, I know that what
• 03:39I'm actually gonna be talking
• 03:40about is something that many
• 03:41of you are familiar with.
• 03:41So, what, Penina asked me
• 03:44to talk about was
• 03:45supporting learners in relationship centered
• 03:48interviewing.
• 03:49And,
• 03:51you all know how to
• 03:51interview
• 03:53patients.
• 03:54What I wanna talk about
• 03:56is the curriculum that we
• 03:57teach the Yale medical students
• 03:59related to relationship centered interviewing,
• 04:02which will hopefully help you
• 04:03find some tips and techniques
• 04:05to give feedback
• 04:07on clinical skills. We know
• 04:09that residents
• 04:11and medical students on their
• 04:13clerkship year are eager
• 04:15to get observation and feedback
• 04:17from from faculty. We we
• 04:18tend to give them feedback
• 04:20a lot more on their
• 04:21decision making. We're sitting in
• 04:23this I'm in the precepting
• 04:24room. Right? I talk to
• 04:25my residents about
• 04:26their their choices of medications
• 04:28or what they're gonna do
• 04:29for the kid with asthma.
• 04:31We talk a lot less
• 04:32about what they're doing at
• 04:33the bedside and how they
• 04:34might have approached the situation
• 04:35differently with their communication skills
• 04:37or their physical exam. So
• 04:39I wanna unpack a method
• 04:41that we teach the medical
• 04:42students.
• 04:43Hopefully, you can leave here
• 04:44with some tips to the
• 04:45next time you're observing your
• 04:47learners, to give them feedback.
• 04:49So I'm gonna share my
• 04:50screen.
• 04:51And
• 04:52as I'm getting that organized,
• 04:54a couple
• 04:55of housekeeping
• 04:58points.
• 05:00As I'm sharing my screen
• 05:01and talking, I have a
• 05:02hard time looking at the
• 05:03chat and
• 05:05talking to you. So if
• 05:06there's someone who if there's
• 05:11interrupt me. I think that's
• 05:12probably the easiest. But if
• 05:13there's something you wanna put
• 05:14in the chat, can someone
• 05:15just interrupt me if I
• 05:16don't see it? I would
• 05:17appreciate that.
• 05:18And then I will also
• 05:19say that much of what
• 05:20I'm talking about here
• 05:22is an adult centered model.
• 05:26Ruchika, you know, Ruchika runs
• 05:27our,
• 05:29pre clerkship
• 05:30session on pediatrics. And,
• 05:32one of the things that
• 05:33we've done in that session
• 05:34is we've tried to help
• 05:35the students see that and
• 05:37you'll all see this very
• 05:38clearly, that the adult center
• 05:40model that we teach them
• 05:42is something that they should
• 05:43bring into the pediatric visit
• 05:45at really any stage. And,
• 05:47you know, it starts with
• 05:48showing interest in the patient.
• 05:50And even if that patient
• 05:51is nonverbal,
• 05:52or preverbal,
• 05:54showing interest in the patient
• 05:55and giving the patient some
• 05:56space to have the the
• 05:58the spotlight during the visit
• 05:59is a good place to
• 06:00start.
• 06:02So these are the objectives
• 06:03here to recognize the value
• 06:05of the history,
• 06:06as a therapeutic tool,
• 06:08explore the relationship center model
• 06:10that we teach to the
• 06:11Yale medical students, and then,
• 06:13I'll spend most of my
• 06:13time. We'll we'll talk about
• 06:14some concrete tips.
• 06:18So very quickly, I'm gonna
• 06:20distill
• 06:21maybe, like, four hours of
• 06:23of lecture content into two
• 06:25slides here. So this is
• 06:26sort of the preamble that
• 06:27we give students
• 06:28relate. And I should say
• 06:29we don't really give them
• 06:30any lecture content at all.
• 06:31This is all video and
• 06:32flipped curriculum stuff, but we
• 06:34have them prepped to,
• 06:35really try to convince them
• 06:37why history is so important,
• 06:38why it's important to be
• 06:39a good communicator. So no
• 06:40surprise to this audience. We
• 06:41can make the diagnosis more
• 06:41than eighty percent of the
• 06:41time. This is a study
• 06:41from an emergency department. I
• 06:41think
• 06:43more
• 06:43than eighty percent of the
• 06:44time. This is a study
• 06:44from an emergency department. I
• 06:44think in more office based
• 06:44specialties, this is probably higher
• 06:46than eighty percent that the
• 06:47history alone,
• 06:48leads us to the right
• 06:49diagnosis. So it's diagnostically
• 06:52useful.
• 06:56But what I try to
• 06:56convince the students is that
• 06:58done the right way in
• 06:59a patient centered relationship centered
• 07:01way,
• 07:02history is actually a therapeutic
• 07:03tool. So
• 07:04all adult outcomes here, I'm
• 07:06not aware of pediatric data,
• 07:07but I think
• 07:09intuitively, it makes sense to
• 07:10me that the same principles
• 07:11would apply.
• 07:12When doctors are good communicators
• 07:14with their patients, diabetes controls
• 07:16improved, hypertension outcomes are better,
• 07:18post ops days are better,
• 07:20there's less analgesic use postoperatively,
• 07:22and patients just feel better.
• 07:23Your patient says, doc, I'm
• 07:24feel better having come to
• 07:26see you today.
• 07:27Importantly, patients stay with their
• 07:28doc in primary care and
• 07:29continuity fields. I think that's
• 07:31really important.
• 07:32Patients like their doctor, and
• 07:33they don't shop around. And
• 07:35from the physician standpoint,
• 07:37there's a literature to show
• 07:38that we as docs are
• 07:39more professionally satisfied
• 07:41when we have good relationships
• 07:42with our patients. And doctors
• 07:44who use relationship centered communication
• 07:47skills,
• 07:48are more professionally satisfied. So
• 07:50few good reasons there to
• 07:51learn this technique. I show
• 07:53up there the textbook that
• 07:54we use that was written
• 07:55by August Fortin, who is
• 07:56a recently retired faculty member
• 07:57in internal medicine. He ran
• 07:59our communication skills curriculum.
• 08:02So we teach students that
• 08:03they need to be patient
• 08:04centered, and you see all
• 08:05the, you know, the point
• 08:06I'm not gonna read these
• 08:07to you, but the points
• 08:07related to related to patient
• 08:09centeredness on this side of
• 08:10the screen. But we teach
• 08:13them
• 08:15mission centeredness because the patient
• 08:17doesn't know everything that you
• 08:19need to know to help
• 08:20them with whatever they're coming
• 08:21to see you. So we
• 08:23start we tell the students
• 08:24to start the interview with
• 08:25a patient centered model where
• 08:26the information flow is controlled
• 08:27by the patient. But at
• 08:29some point in the interview,
• 08:30we need to transition to
• 08:31a a situation where the
• 08:32information flow is controlled by
• 08:34us, where we're asking more
• 08:36pointed questions to get at
• 08:37information that,
• 08:38is important to the clinician
• 08:40based on what we know
• 08:41about the patient to that
• 08:42point. And you see some
• 08:43of the differences between those,
• 08:45those two approaches. All of
• 08:46this will look familiar to
• 08:47you.
• 08:51So that was my four
• 08:52hours of precontent distilled into
• 08:53two quick slides. So I'm
• 08:54gonna focus mostly on these
• 08:56other things today because I
• 08:57you know, I'm gonna take
• 08:58it for granted that that
• 08:59you all have some familiarity
• 09:00with the the give and
• 09:02take of the balance between
• 09:03patient centered and, and clinician
• 09:06centered interviewing. So I'm gonna
• 09:07talk now about,
• 09:09some of the ways that
• 09:10we teach the students this.
• 09:12So here's the model that
• 09:13we teach them. And, if
• 09:14if it's not clear, I'll
• 09:16try to make some connections
• 09:17to to how this connects
• 09:18to a pediatric visit. But
• 09:19if it's not clear, please
• 09:21interrupt me, and I will
• 09:22go there earlier. So we
• 09:24tell them to start the
• 09:24interview very quickly with a
• 09:26greeting and then setting the
• 09:27agenda.
• 09:29You know, especially in primary
• 09:30care. And even in my
• 09:31CF clinic, I do this.
• 09:32You know, it it I
• 09:33take it for some people,
• 09:35I think, would take it
• 09:35for granted. You're seeing someone
• 09:36in a in a super
• 09:38specialty clinic. Everybody knows why
• 09:39they're there. But I think
• 09:41that assumption is dangerous because
• 09:42there may be things that
• 09:43the patient wants to talk
• 09:44about that wouldn't come up
• 09:46on our checklist of things
• 09:47that we would go over
• 09:48through the routine of what
• 09:49we're talking about that day.
• 09:50It doesn't mean that we
• 09:51need to actually address all
• 09:53of those things, but understanding
• 09:54what the patient has on
• 09:56their agenda and then negotiating
• 09:57that agenda is an important
• 09:58component to the visit. Even
• 09:59it means that you're gonna
• 10:00turf that
• 10:02agenda item that doesn't fall
• 10:03within your domain to somebody
• 10:05else or to a future
• 10:06visit. So that's where the
• 10:07residents are where the students,
• 10:08we teach them to start.
• 10:11I'm gonna show I'm gonna
• 10:12take a little risk here.
• 10:13I'm gonna show you a
• 10:14little demo. I show this
• 10:15to I don't show this
• 10:17to the students, but I
• 10:18think,
• 10:18when I when I do
• 10:19this workshop at at,
• 10:21academic meetings, I usually have
• 10:23an actor,
• 10:25and and a faculty member,
• 10:26and we we do a
• 10:27little bit of a role
• 10:28play to show what this
• 10:29looks like. And this is
• 10:30just a recording where I
• 10:31did this with August Fortin
• 10:32a few years ago. Let's
• 10:34see if the oh, hopefully,
• 10:35the audio is gonna work.
• 10:37Nope. I need to put
• 10:37it on,
• 10:38slideshow. Sorry.
• 10:42And then it should play.
• 10:48Right.
• 10:50I have a backup ready
• 10:51to go, so just bear
• 10:52with me.
• 10:55I just need to share
• 10:56a different screen now.
• 11:04Too many windows open, folks.
• 11:06Here we go.
• 11:07Got it.
• 11:13Can you hear that? Hi.
• 11:14Hi. Mister Talwalkar? Yeah. JD
• 11:19Horton.
• 11:20Here's how you spell it
• 11:22because I know it's not
• 11:22a very common name. To
• 11:24meet you. Nice to meet
• 11:25you as well. I'm one
• 11:26of the
• 11:27medicine residents here,
• 11:29and, wanted to welcome you
• 11:30to the clinic. Thanks. Yeah.
• 11:32Any trouble getting here today?
• 11:35Except for the microphone.
• 11:36So, any any trouble getting
• 11:38here today?
• 11:39Well,
• 11:41that's what I wanna talk
• 11:42to you about. I normally
• 11:43would have walked here. I
• 11:44don't live that far away,
• 11:45but I'm having a little
• 11:46bit of difficulty. So Okay.
• 11:48For a rehab. Okay. I
• 11:50wanna hear about that in
• 11:51in just a second. But
• 11:52I wanted to let you
• 11:53know, this is a resident
• 11:54teaching clinic. So you and
• 11:56I are gonna talk. I'll
• 11:57examine you, and then I'm
• 11:58gonna step out and talk
• 11:59to my preceptor who's one
• 12:00of those supervising doctors. And
• 12:02then either I'll come back
• 12:03alone or we'll both come
• 12:04back, and we'll have a
• 12:05plan for you. Does that
• 12:06sound okay? Yeah. Yeah. Absolutely.
• 12:08Because you're a new patient,
• 12:09they've given us about thirty
• 12:10minutes together today, and I
• 12:12wanna obviously ask you a
• 12:13lot of questions to get
• 12:15to know you and, as
• 12:15I said, examine you. But
• 12:17first, I'd like to start
• 12:18with getting a list of
• 12:19the things that you wanna
• 12:20talk about today. So
• 12:22tell me what's what's on
• 12:23your list. Well, the main
• 12:24thing that I came in
• 12:25for is my belly has
• 12:26just been really hurting for
• 12:28the last So I'm gonna
• 12:29stop it there just in
• 12:30the interest of,
• 12:31time for this. So, basically,
• 12:33I'll go over what my
• 12:34agenda is. I I start
• 12:36rambling on telling my story,
• 12:37and he interrupts me in
• 12:39service to myself
• 12:40to pause and make sure
• 12:41that there's no other things
• 12:42that I wanted to talk
• 12:43about so we can then
• 12:44negotiate how we're gonna spend
• 12:45our time together and so
• 12:46on.
• 12:47You know, hopefully a paradigm
• 12:49that's familiar to all of
• 12:50us. I find that this
• 12:51is a major place that
• 12:52residents need reminding
• 12:54of,
• 12:55so that they can
• 12:56figure out time management in
• 12:58the visit.
• 12:59There's just so much that
• 13:01they
• 13:02can cover, but
• 13:03now I'm stalling, so I'm
• 13:04trying to find my slides
• 13:05again. So much they can
• 13:07cover, but not,
• 13:09not time or mental capacity
• 13:12to handle all of it
• 13:14in the course of
• 13:16a regular visit.
• 13:18Okay. So after that opening,
• 13:20you give the patient some
• 13:21time to tell their story.
• 13:22You pick the agenda item
• 13:23that they they wanna focus
• 13:24on, or sometimes there's an
• 13:26item that's too important for
• 13:27us. Right? So a kid
• 13:28is coming in for a
• 13:29well child visit with me,
• 13:31but the family is talking
• 13:33about how their asthma is
• 13:34I'm looking at Panina, so
• 13:35I keep talking about asthma.
• 13:37How their asthma is,
• 13:39is very poorly controlled, and
• 13:40they've been to the ED
• 13:42three times. I may
• 13:43prioritize the asthma over the
• 13:45well child visit today because
• 13:46that there's more critical need
• 13:48there. So, usually, it's something
• 13:49that the agenda is gonna
• 13:51come from what the patient
• 13:51wants to talk about, but
• 13:52there's room for negotiation there.
• 13:54So we get the story
• 13:55from the patient. And this
• 13:57is really what I wanna,
• 13:59some some,
• 14:00tips to think about. So
• 14:01we get the patient talking.
• 14:03We use skills to get
• 14:04them to continue to talk,
• 14:05to tell their story.
• 14:06And while they're talking, I'm
• 14:08gonna show you the step
• 14:09four here.
• 14:10We wanna hear three things
• 14:11from them. We wanna hear
• 14:12the symptoms that they're having,
• 14:13of course, the symptom story.
• 14:15We wanna hear the personal
• 14:16context in which they are
• 14:17experiencing those symptoms, and then
• 14:19we wanna hear the emotional
• 14:23may not be the kid
• 14:24telling us this stuff. I
• 14:25mean, if it's an adolescent,
• 14:26maybe it is. But if
• 14:28we're talking about a younger
• 14:29child,
• 14:30this could look like you
• 14:31come in the room, you
• 14:32do a little play with
• 14:33the with the, with the
• 14:35younger child. You get their
• 14:36story.
• 14:38You hear what they have
• 14:38to talk about, and then
• 14:40you have a shared conversation
• 14:41with the caregiver who's with
• 14:42them to hear more and
• 14:44unpack more about the personal
• 14:45context and emotional context. You
• 14:47know, what are they what
• 14:48are they worried about? What
• 14:49are they scared about? How
• 14:51is this affecting life? Maybe
• 14:52they're not they're not sleeping
• 14:53or they're missing work, etcetera,
• 14:54etcetera. All of that stuff,
• 14:56you know, the kid is
• 14:56coming in with asthma. That's
• 14:58the symptom.
• 14:59But what they're really coming
• 15:00in for is because it's
• 15:01their symptom is affecting their
• 15:03life in some way, and
• 15:05they're having some emotion around
• 15:06it. So we wanna use
• 15:07that early part of the
• 15:08interview to get it all
• 15:09of that, get that all
• 15:11out on the table. And
• 15:12once we feel like we
• 15:12have enough of an understanding
• 15:14about how this is impacting
• 15:16this person or this family's
• 15:17life, then we transition to
• 15:19the next part, which is
• 15:20our turn to now ask
• 15:21more focused questions.
• 15:23So this is just explodes
• 15:25that those three things out
• 15:26a little bit more. And
• 15:27this, I think, is a
• 15:28really critical aspect. I hear
• 15:29so often when I'm observing
• 15:31residents,
• 15:32and our residents are amazing,
• 15:33but still in the busyness
• 15:34and and with the maybe
• 15:36sometimes some of the negative
• 15:37role modeling that they see,
• 15:39they kinda forget
• 15:41to recognize
• 15:43the emotion.
• 15:44So,
• 15:45you know, listening for those
• 15:47emotional buzz buzzwords
• 15:49or asking questions to get
• 15:51those emotional buzzwords on the
• 15:52table, I think,
• 15:54really fast forwards the, I
• 15:56don't just think this. In
• 15:57in the adult literature, this
• 15:58has been shown to really
• 16:00fast forward rapport building,
• 16:02in a time constrained setting.
• 16:04And then once those emotions
• 16:05are on the table,
• 16:07finding out enough information about
• 16:09those emotions such that we
• 16:10can empathize with those emotions.
• 16:12And we teach the students
• 16:13this mnemonic that some of
• 16:14you have probably seen, nurse.
• 16:16So naming the emotion,
• 16:18understanding,
• 16:19respecting, and supporting. And I'm
• 16:21gonna show you some
• 16:23language that we,
• 16:24we tell the students to
• 16:26to use. We actually give
• 16:27them a card to try
• 16:28out. So for some of
• 16:29them, this stuff comes really
• 16:30naturally. And for others, it
• 16:32just does not. And we
• 16:33really ask them we invite
• 16:34them to step outside what
• 16:35they're comfortable doing and rely
• 16:37on language that we give
• 16:38them on a card to
• 16:39try out different prompts. You
• 16:41know, our residents hopefully are
• 16:42at the point where they've
• 16:43been able to make this
• 16:44their own and they they
• 16:45have the emotional language. They
• 16:46just need permission to
• 16:48use time during the visits
• 16:50to do this. But, you
• 16:51know, an example of naming
• 16:52so you say this knee
• 16:53pain makes you frustrated. So
• 16:55restating the name the emotion
• 16:56that the patient mentioned.
• 16:59I get how you could
• 16:59feel that way.
• 17:01I personally try to avoid
• 17:02using the word understand when
• 17:03I'm when I'm using this
• 17:04sort of a statement,
• 17:06because I think it's the
• 17:07rare circumstance where I I
• 17:08truly feel like I understand.
• 17:10I think that that can
• 17:11backfire if the patient, feels
• 17:13like, well, doc, you can't
• 17:14really get it. You don't
• 17:15you don't know me in
• 17:16this time we've spent together.
• 17:18But using whatever language feels
• 17:20right to,
• 17:21to show that, yeah, I
• 17:22get it.
• 17:24Showing a
• 17:27We'll work together to get
• 17:29to the bottom of this.
• 17:29So those are just some
• 17:30examples of things that,
• 17:32that one could say,
• 17:34when,
• 17:35when an emotion is, when
• 17:37confronted with an emotion from
• 17:38the patient during a visit
• 17:39or or the the parent.
• 17:41I'm I'm gonna pause there
• 17:42for a second because we're
• 17:43gonna shift into the next
• 17:44part here. Does anyone have
• 17:45any thoughts, questions and feel
• 17:46free to argue, criticize,
• 17:49express skepticism. I'm happy to
• 17:51engage in a conversation about
• 17:52any of that because again,
• 17:53the literature I'm talking about
• 17:54here, this is based on
• 17:55adults and my sense is
• 17:57that this works with kids
• 17:58too, but
• 17:59I'm happy to have a
• 18:00conversation about any of that.
• 18:05Alright, I'll keep moving on
• 18:07then. So I'm not going
• 18:08to show you the next
• 18:09part here, but basically,
• 18:11you know, if if you're
• 18:12interested in looking at what
• 18:13this looks like, you can
• 18:14you can go to this
• 18:15link. This may be my
• 18:17most heavily watched video posted
• 18:19on YouTube. I think it
• 18:20has, like, eighty thousand views
• 18:21to date because,
• 18:23you know, this is I
• 18:24think it's a good teaching
• 18:25tool when you're trying to
• 18:26learn how to how to
• 18:28teach this.
• 18:30Okay. So
• 18:33jump past that beginning part.
• 18:35What I just showed you
• 18:36in an adult centered visit
• 18:38is just the very beginning
• 18:40of the visit. So in
• 18:41a typical outpatient visit for
• 18:42an experienced clinician,
• 18:44maybe the first three to
• 18:45four minutes tops of the
• 18:47visit is that. The rest
• 18:48of the visit is what
• 18:49we're more familiar with seeing,
• 18:51which is the clinician centered.
• 18:52Here's the chief concern, and
• 18:53now I'm gonna pepper you
• 18:54with questions. So So what
• 18:56we really encourage learners to
• 18:57do is to take time
• 18:59at the beginning
• 19:00to do that, rapport building,
• 19:02allow the patient to tell
• 19:03their story, which then makes
• 19:05it much easier for us
• 19:07to ask questions and get
• 19:10reliable information from the patient
• 19:11as opposed to asking them
• 19:13prematurely where we wanna go
• 19:15because of all the things
• 19:16that are going on in
• 19:17our head,
• 19:19rather than filling in the
• 19:20gaps with what they haven't
• 19:21been able to tell us
• 19:22through their spontaneous narrative storytelling.
• 19:26So the rest of this
• 19:27looks like, you know, the
• 19:29clinician centered model that all
• 19:30of us are familiar with.
• 19:32I have these little islands
• 19:33of patient centeredness built in
• 19:34here because
• 19:35it doesn't mean that now
• 19:37that we're in this this
• 19:38part that we're following this,
• 19:39you know, the the more
• 19:40standard script asking and getting
• 19:42responses that we don't look
• 19:44for opportunities for patient centeredness.
• 19:46So if if a question
• 19:47seems to strike an emotion
• 19:49or some personal context, we
• 19:51can certainly go there and
• 19:52deviate from the the question
• 19:55response paradigm.
• 20:00So the three functions of
• 20:01the interview that we teach
• 20:03students are the one on
• 20:05the bottom left here obtaining
• 20:06information, I think is what
• 20:07they're,
• 20:09their preconception
• 20:10of what they're supposed to
• 20:11be doing is this. But
• 20:13I think these two things
• 20:14are equally important, establishing a
• 20:16relationship with that person
• 20:18and then educating and and
• 20:19informing.
• 20:22And these arrows are all
• 20:23bidirectional because we know that
• 20:27as a relationship is established,
• 20:32as a relationship is established,
• 20:34the patient is more willing
• 20:36to be educated and informed
• 20:37by you.
• 20:39And, you know, and so
• 20:40on.
• 20:43So another way to, to
• 20:46visualize those three elements of
• 20:47the story that we want
• 20:48to get during the interview
• 20:50symptom, personal and emotional context.
• 20:53And one of the reasons
• 20:55that we, tell the students
• 20:56to
• 20:57give voice to this, even
• 20:58though they're generally, and we
• 21:00all are carrying, you know,
• 21:02this,
• 21:03caring people who who who
• 21:05want patients to feel listened
• 21:07to and heard and supported.
• 21:08But in their vulnerability, I
• 21:10think again, I keep saying
• 21:11I think, but I know
• 21:12this to be true from
• 21:13literature. Patients don't notice our
• 21:15nonverbal empathy,
• 21:16because it's not a normal
• 21:18social interaction. So, we really
• 21:20try to teach the students
• 21:22words to
• 21:23to put words behind
• 21:25the
• 21:27feelings that they're feeling as
• 21:28they're hearing stories from patients.
• 21:29So as we get busier,
• 21:31we just fail to project
• 21:32empathy. So stopping and giving
• 21:34words to that can help
• 21:35our body language actually project,
• 21:39in a way that the
• 21:40patient can receive it.
• 21:42Alright. So I'm gonna stop
• 21:44again here, and,
• 21:46I wanna have a conversation
• 21:48about any I have more
• 21:49stuff if people wanna go
• 21:50there, but I wanted to
• 21:51really use time to have
• 21:52questions, doubts, challenges, or or
• 21:54talk more about a pediatric
• 21:57model if anyone has thoughts
• 21:58about any of this.
• 22:01I'm curious,
• 22:02Jaydeep, about,
• 22:04interrupting.
• 22:05There's some some sensibly reasonable
• 22:08literature that varies the time
• 22:10in which physicians do interrupt
• 22:11versus when you should interrupt,
• 22:14how long it's been encountered.
• 22:15But particularly, your thoughts on
• 22:16the difference between a pediatric
• 22:17and adult encounter
• 22:19as an interruption breaking the
• 22:21point
• 22:22from that beginning stage to
• 22:24the, you know, more thorough
• 22:25investigation stage. How long is
• 22:28too long?
• 22:31Is it better just to
• 22:32signpost and lead?
• 22:34Yeah.
• 22:35Thanks for that question, David.
• 22:36I think it really depends
• 22:37on the why you're interrupting.
• 22:39So in that first part
• 22:41of the story, in the
• 22:42the patient centered
• 22:44beginning of the interview,
• 22:46you interrupt
• 22:47when one of a few
• 22:48things happens. So one,
• 22:50when the information that you
• 22:52are receiving
• 22:54is no longer useful
• 22:55to the no longer in
• 22:57service to the patient.
• 22:59I think in pediatrics, the
• 23:00definition of that can stretch
• 23:01a little bit. If I'm
• 23:02talking to a four year
• 23:03old and they're tell you
• 23:04know, they come in again,
• 23:05Penina, I'm gonna look at
• 23:06you. They're coming in for
• 23:07asthma follow-up, but they're giving
• 23:09me a lovely story about
• 23:10their day in preschool yesterday.
• 23:13That may not be diagnostically
• 23:14useful information related to their
• 23:16asthma care, but I, you
• 23:17know, I'm not gonna interrupt
• 23:18that kid. Now if I'm
• 23:20talking to a forty year
• 23:21old for asthma follow-up
• 23:23and they're going into a
• 23:24lengthy explanation about their day
• 23:25at work yesterday and it
• 23:26seems peripheral to the reason
• 23:28that they're there, I'm gonna
• 23:29interrupt them sooner. Right? So
• 23:30I think number one is
• 23:32is the information use
• 23:36in helping to serve the
• 23:37patient. And, you know, I
• 23:39think the line that's a
• 23:40soft line in terms of
• 23:41what's useful.
• 23:42Number two is when the
• 23:43patient starts to repeat themselves.
• 23:45So, right, that that early
• 23:47part of the interview, the
• 23:49by design, it's meant for
• 23:51us to continue to say,
• 23:52tell me more. What else?
• 23:54Tell me more. Right? I'd
• 23:55like to hear more about
• 23:56this. Right? So you are
• 23:59using gentle
• 24:00ways to,
• 24:02encourage the patient to keep
• 24:03the story going, both verbally
• 24:05and nonverbally. But at some
• 24:06point, everyone is gonna start
• 24:08repeating themselves because there's just
• 24:10not more to tell.
• 24:13Right? So,
• 24:14if the patient starts circling
• 24:15back to stuff that they've
• 24:16already told you, that's that's
• 24:18a call to interrupt.
• 24:20And
• 24:21and then there's a third
• 24:23one.
• 24:24Oh, the third one is
• 24:25if the dynamic is just
• 24:26not not if I'm if
• 24:27I'm seeing a sixteen year
• 24:28old and I'm getting a
• 24:29blank response to my invitation
• 24:31to open storytelling,
• 24:33then I might need to
• 24:33try another tactic to get
• 24:35at what I need to
• 24:36get at. So right, also
• 24:38factoring the patient's communication style.
• 24:40I mean, that may be
• 24:41not so much interrupting what
• 24:42they're saying, but it it's
• 24:43interrupting the model or the
• 24:44approach to the interview because
• 24:46this style is just not
• 24:47working for this circumstance.
• 24:51So interrupting is fine. I
• 24:52don't like to put a
• 24:53specific time on how early
• 24:55is too early because it
• 24:56depends on why you're interrupting.
• 24:58If we're doing the, we're
• 25:00really early and we're doing
• 25:01agenda setting. Right? The patient
• 25:02comes in to see me.
• 25:03You know, thanks for coming
• 25:04in to see me today.
• 25:05I'd like to make a
• 25:06list of all the things
• 25:07that you wanted to cover
• 25:08so we can figure out
• 25:09how best to use our
• 25:10time together. You know, what's
• 25:11the first thing on your
• 25:12list? And they start going
• 25:14into a story about the
• 25:15first thing on their list.
• 25:17I'm probably gonna interrupt them
• 25:18a lot sooner because I'm
• 25:19not ready for the story.
• 25:21I'm ready for just the
• 25:22I wanted to talk about
• 25:23my cough that's been keeping
• 25:24me up this last week.
• 25:25Alright. Great. So we have
• 25:27the cough. What else? Right.
• 25:29So there, my time to
• 25:31on the clock to interrupt
• 25:32is gonna be a lot
• 25:33shorter, but because I'm not
• 25:34at the point yet where
• 25:35I want them to to
• 25:36explain.
• 25:43JD, I had two observations
• 25:45and then a question.
• 25:47So thank you so much
• 25:48for that background. I found
• 25:51that
• 25:52the deliberate,
• 25:55like, yes, I guess, expression
• 25:57of
• 25:58expressions of empathy
• 26:00were something that I wasn't
• 26:02trained as when I went
• 26:04through it and the way
• 26:05that I learned about it,
• 26:07or like re educated myself
• 26:09was when my daughter went
• 26:10to was in med school,
• 26:12which she still is, and
• 26:14she's going through her interview
• 26:16and, you know, there's this
• 26:18explicit
• 26:19to express
• 26:20empathy. And so I actually
• 26:22think that I improved my
• 26:24own,
• 26:25interviewing skills by doing that,
• 26:27which,
• 26:29like, your comment was very
• 26:30well founded. Like, I would
• 26:31think that I would project
• 26:33it, but I didn't deliberately
• 26:35say it. So, you know,
• 26:37think
• 26:41I guess the other thing
• 26:42is just an observation is
• 26:44I don't think the residents
• 26:45probably set agenda.
• 26:47I was just thinking about
• 26:49this in terms of,
• 26:51like, I have four residents
• 26:52who are rotating through my
• 26:54whole clinic, and I am
• 26:56pretty sure they don't say,
• 26:58you know, I'm gonna come
• 26:59back with my attending blah
• 27:01blah blah. And so I
• 27:02think that's really, really
• 27:05an important observation. And so
• 27:07I'll I'll and then I'll
• 27:08ask my question,
• 27:10which was
• 27:12when you have, let's say,
• 27:13an adolescent
• 27:14and you want the parent
• 27:16to leave the room,
• 27:17how does that change,
• 27:20if any way, your approach?
• 27:23So as I said, two
• 27:24observations and a question.
• 27:26Yeah. Great. Thank you for
• 27:27that. So,
• 27:28the first observation
• 27:31on hearing about this, teaching
• 27:33this, and then it impacting
• 27:34your clinical practice. I feel
• 27:36that every day that I'm
• 27:37with students.
• 27:39I I I hear that
• 27:40voice reminding me that I
• 27:41need to also do this,
• 27:43because it it's easy not
• 27:44to, when you're when you're
• 27:46running around doing stuff. So
• 27:47I appreciate that.
• 27:48Some of the feedback we
• 27:49get from the early clerkship
• 27:51students, I think well founded,
• 27:52is that they're sort of
• 27:54going overboard
• 27:55on these expressions of empathy,
• 27:58and everyone looks at them
• 27:59like it's odd. And it
• 28:00is odd.
• 28:02But the right. It's it's
• 28:04odd if you're just per
• 28:04separating on this rather than
• 28:06also thinking about the symptoms
• 28:08story. So I think it's
• 28:09totally reasonable to give feedback
• 28:10to clinical students that
• 28:13you've learned this model. There's
• 28:14a place for this, but
• 28:15not
• 28:16to focus on the emotional
• 28:17context
• 28:19at the expense of actually
• 28:20hearing the symptoms. So, you
• 28:22know, there are some students
• 28:23who get so
• 28:24excited about, I'm okay. Great.
• 28:26I can help peep. I
• 28:27don't know anything yet medically,
• 28:28but I can help someone
• 28:29feel better by letting them
• 28:30talk to me, which is
• 28:31great. We want them to
• 28:32do that, but not at
• 28:33the expense of also
• 28:35doing the biology of what
• 28:36they need to do. So,
• 28:37I think both of those
• 28:38things need to they need
• 28:39to find that balance.
• 28:41Alright. So your question about
• 28:42how this works in an
• 28:43adolescent visit, I mean, I
• 28:44think this is really a
• 28:45lot of it is just
• 28:46personal style, and I don't
• 28:47know that there's data here.
• 28:48What I do personally is
• 28:50I do the I when
• 28:51I'm doing the beginning introduction,
• 28:54I set out what we're
• 28:55gonna do at the beginning
• 28:56of the visit. I'm gonna,
• 28:56you know, we're gonna, talk
• 28:58here together for a few
• 28:59minutes, and I'm gonna ask
• 29:00your whatever caregiver this is
• 29:01to step out. We'll we'll
• 29:03have time, together alone, and
• 29:05then we'll reconvene at the
• 29:06end. Right? So that dynamic
• 29:07is set up right at
• 29:07the right at the beginning.
• 29:09And then I do agenda
• 29:10setting together
• 29:11so that everyone's agendas because
• 29:13the the worst thing, not
• 29:15the worst thing, but a
• 29:16terrible thing is if the
• 29:17parent is not there at
• 29:18all, and then they come
• 29:19in at the end of
• 29:20the visit and, oh,
• 29:22you know, Mikey, did you
• 29:23tell the doctor about, right,
• 29:25about x? Right? And, of
• 29:27course, they didn't. And now
• 29:28the parent feels
• 29:30like even though we may
• 29:31have had a wonderful conversation
• 29:33about something else,
• 29:34the parent feels like their
• 29:35agenda item has been dismissed.
• 29:37So I do the I
• 29:37tried to do the agenda
• 29:38setting together.
• 29:44Find that in a continuity
• 29:46type practice,
• 29:48once you start doing you
• 29:49were talking about the residents
• 29:50not setting laying out preamble.
• 29:55When I do this over
• 29:56and over and over again,
• 29:58I don't I actually don't
• 29:59need to keep doing it
• 30:00because the patients understand the
• 30:01dynamic because they're coming in
• 30:03to see me repeatedly.
• 30:04So they start knowing that
• 30:06we're gonna talk about the
• 30:07agenda in the first thirty
• 30:08seconds of the visit, and
• 30:09they come and stay their
• 30:10agenda. Not everyone, but, right,
• 30:12people are coachable,
• 30:13and I think we can
• 30:15coach people on how to
• 30:16interact
• 30:17successfully with the health care
• 30:18system. Adolescents, especially, Penina, you
• 30:20mentioned up front transition being
• 30:21one of the things I
• 30:22do. I think one of
• 30:23the things that we know
• 30:24as pediatricians that we need
• 30:25to coach,
• 30:27emerging adults to be able
• 30:28to do is how to
• 30:29interact with the doctor successfully
• 30:31to make best use of
• 30:32that those those health care
• 30:33opportunities.
• 30:34So coming in with an
• 30:35agenda,
• 30:36having thought about beforehand, what
• 30:37am I gonna talk to
• 30:38the doctor about today,
• 30:40and recognizing that you have
• 30:42power to negotiate that with
• 30:43the health care team, I
• 30:45think, is important. So,
• 30:47I I agree with you.
• 30:47I don't I see the
• 30:48residents needing to do this
• 30:49more,
• 30:50but I also see that
• 30:51the residents who do this
• 30:52really well in a continuity
• 30:53practice end up not needing
• 30:55to do it as much
• 30:55as they keep seeing
• 30:57because their patients know.
• 31:00Yeah. And, JT, do you
• 31:01actually I know that the
• 31:03med peds
• 31:04residents,
• 31:05you know, kind of profit
• 31:07from your experience and your
• 31:09approach. Do you also teach
• 31:10the peds residents
• 31:12kind of this approach or
• 31:13not?
• 31:15Me personally, only in so
• 31:16much as it's a chapter
• 31:18in the pediatric outpatient curriculum.
• 31:20Oh, right. But I don't
• 31:21really interact with the peds
• 31:22residents
• 31:23directly Right. Out of teaching
• 31:25settings.
• 31:26Okay. It's usually not on
• 31:28this topic. I'm usually talking
• 31:29to them about something else
• 31:30if I get asked to
• 31:31speak with them.
• 31:32Interest I think it's actually
• 31:34really, really an important area
• 31:36that I'm not sure that
• 31:37they get. Yeah. There is
• 31:39a chapter in the
• 31:41pediatric
• 31:42curriculum where, I don't remember
• 31:44who wrote it, but it's,
• 31:46it's
• 31:47pediatric focused, a lot of
• 31:49what I'm talking about here.
• 31:50But, again, it's it's not
• 31:51based on I mean, this
• 31:52is, like, I think maybe
• 31:53a a research opportunity for
• 31:55someone who's interested in, patient
• 31:57centeredness. You know? That
• 31:59it's all of it is
• 32:00common sense extrapolations of what
• 32:02we know from interacting with
• 32:03adults.
• 32:04Thank you.
• 32:06Other questions or comments?
• 32:17I might call, put Ruchika
• 32:18on the spot. I don't
• 32:20know if you're in a
• 32:20in a place where you
• 32:21can
• 32:22contribute, but Ruchika teaches this
• 32:25in our,
• 32:26pre clerkship module for the
• 32:27medical students. We actually go
• 32:30to patient rooms and try
• 32:31to model some of these,
• 32:33behaviors. I mean, we are
• 32:35very
• 32:36explicit with the students about
• 32:38the objective here to go
• 32:39to rooms with kids of
• 32:40all different ages and developmental
• 32:42stages
• 32:43and try out these techniques
• 32:45and see what works
• 32:48you pack. Well, why might
• 32:50this approach have worked or
• 32:51not worked with this person,
• 32:53and how does their, you
• 32:55know, the the imperfect alignment
• 32:57between age and development and
• 32:58your assumptions about
• 33:00who might be able to
• 33:01actually give you a really
• 33:02coherent medical narrative and who
• 33:04who can't?
• 33:05Richika, do you wanna say
• 33:06anything? I think, yeah, I
• 33:08think that that, kind it's
• 33:10kind of like the workshop,
• 33:11but that session runs really
• 33:12well. And I think the
• 33:13students
• 33:14like, we do try to
• 33:16send a group and a
• 33:17toddler in the same group,
• 33:18maybe a second patient with
• 33:20the adolescent to kind of
• 33:21just figure out the difference,
• 33:23between who's giving the history
• 33:25and kind of how the
• 33:27the students also have to
• 33:29direct questions a little differently
• 33:31to get the, history out.
• 33:32And I I I I
• 33:33really loved what I was,
• 33:35doing these sessions with the
• 33:37with the students.
• 33:40I am I'm sorry. I
• 33:41mean, I am in clinic
• 33:42with, a lot of people
• 33:43around me, but so I
• 33:44may have not if there
• 33:45was an exact question, I
• 33:46missed that for me. But
• 33:47No. No. There wasn't a
• 33:48question. I just wanted to
• 33:49spotlight what you're doing there
• 33:50and see if you can
• 33:50Yeah. Yeah. Thank
• 33:52you. No. But I, yeah,
• 33:53it's it's great. This this
• 33:54curriculum is great. Just as
• 33:55Farina mentioned, it was not
• 33:57something as a part of
• 33:58my training in med school
• 34:00too, so I learned as
• 34:02well when I was doing
• 34:03these, you know, introduction. Like,
• 34:05I also learned this model,
• 34:06and I taught myself on
• 34:08the go kind of, which
• 34:09is which is really good.
• 34:12And when I'm precepting,
• 34:14this looks different because I'm
• 34:16walking into a
• 34:18room where the resident and
• 34:20the family have already had
• 34:21an established conversation for ten,
• 34:23fifteen, twenty minutes before I
• 34:25walk in.
• 34:26So there, I'm a little
• 34:28more
• 34:29you know, I might I
• 34:30you know, I'm obviously not
• 34:31going in and restarting this
• 34:33all from scratch. I'm focusing
• 34:34on what the resident asked
• 34:35me to focus on when
• 34:36I walk in. And in
• 34:37a into the primary care
• 34:38practice,
• 34:39different in CF. But,
• 34:41there, I'm paying much more
• 34:43attention to body language and
• 34:44some of the nonverbals
• 34:46when I walk in because
• 34:47I will sometimes walk in,
• 34:49and I get, you know,
• 34:50a side eye from the
• 34:51the parent or something that,
• 34:53you know, I wasn't quite
• 34:54prepared for why they're
• 34:56receiving me when I walk
• 34:57in that way. And then
• 34:58I'll actually call out what
• 35:00I'm observing
• 35:02out of curiosity.
• 35:03You know? Did I did
• 35:04I do something? Or,
• 35:07and the most common response
• 35:09is that they were made
• 35:10to wait for so long
• 35:11because the resident was in
• 35:12line trying to find me.
• 35:13Right? But,
• 35:14as a preceptor, I think
• 35:15we can fast forward some
• 35:17of this and get right
• 35:19at the way someone is
• 35:20feeling. And, again, unfortunately, too
• 35:22often, it's negative because of
• 35:23the weight or because of
• 35:24something.
• 35:25Maybe it was the agenda
• 35:26setting opinion. Alright? Maybe the
• 35:28resident didn't explain what,
• 35:30adequately what the next step
• 35:31was gonna be that some
• 35:32somebody they didn't know was
• 35:33gonna come in and, and
• 35:35see them. But
• 35:37So, JD, what's your go
• 35:39to line for when you
• 35:40walk in and the parent
• 35:44seems
• 35:46unhappy
• 35:47or angry. Like, I always
• 35:50there's
• 35:53you you seem,
• 35:55you know, you seem not,
• 35:59it's like even then I
• 36:00I have difficulty finding the
• 36:02word because there are some
• 36:03individuals who can come across
• 36:05as fairly
• 36:07abrupt. And
• 36:08I always
• 36:10I always find myself in
• 36:11that situation. They usually have
• 36:13to be pretty pissed for
• 36:14me to,
• 36:16to broach the subject, but
• 36:17any good go to lines.
• 36:19I think I have a
• 36:19pretty low threshold for calling
• 36:21it out,
• 36:23or naming it. It it
• 36:25hopefully, the resident has primed
• 36:26me if they knew that
• 36:28this was going on. Right?
• 36:29So if the patient Yeah.
• 36:30That that one's an easier
• 36:31one. Yeah. That's easier.
• 36:33But if I walk in
• 36:34not
• 36:35having been prepped that there
• 36:36was there was something going
• 36:38on,
• 36:39I'll just say that. You
• 36:40know? You know, I just
• 36:41I introduced myself. I just
• 36:43walked in, but I'm I'm
• 36:44feeling an emotion here. You
• 36:45know? I I'm just meeting
• 36:46you, so I'm not gonna
• 36:47guess what's going on. But,
• 36:48yeah, can you share with
• 36:49me what what you're feeling?
• 36:51Okay. Which doesn't always land,
• 36:54but
• 36:55if it's No. I actually
• 36:56like that better than saying
• 36:57you seem unhappy or you
• 36:59seem
• 37:00angry. I think that's a
• 37:01much better way.
• 37:03I like that. Gonna if
• 37:04you are gonna call out
• 37:05an emotion, if you're gonna
• 37:06try to to guess or
• 37:08name the emotion, I would
• 37:09recommend starting with a lower
• 37:11valence emotion. Yeah. So angry
• 37:13is a high valence. I
• 37:14know. That's always struggle.
• 37:17But but frustrated.
• 37:18Right? Or Mhmm. Or concerned
• 37:20or right. Something that is
• 37:22a little bit of a
• 37:23softer emotion is a nice
• 37:25toe in the water. And
• 37:27then, you know, if someone
• 37:28I think people are generous
• 37:29if they then give us
• 37:30their higher valence emotion.
• 37:32But if I name the
• 37:33higher valence emotion and that's
• 37:34not what they're feeling or
• 37:35even it is what they're
• 37:36feeling, it could come across
• 37:37as being confrontational for me,
• 37:39which is not what I'm
• 37:40trying to do.
• 37:41Yeah. Thank you. I I
• 37:43like that. I like that,
• 37:44conceptual framework better.
• 37:51Great. Well, I if there's
• 37:53other questions, I'm happy to
• 37:54talk about those. I have
• 37:54a couple of other things
• 37:55I can go over with
• 37:56you about stuff that we
• 37:57teach the students
• 37:59related to communication skills beyond
• 38:00the basics.
• 38:04Alright. Then let me get
• 38:05my slides back up here.
• 38:18Okay.
• 38:19So,
• 38:21these are
• 38:22six other things that we
• 38:24talked to them about,
• 38:27and
• 38:28it's a choose your own
• 38:29adventure. So I won't you
• 38:30know, we obviously don't have
• 38:31time for all of this,
• 38:32but are there
• 38:34paradigms or checklists? I'm showing
• 38:35this to you so that
• 38:37you have structure to give
• 38:38feedback to students or or
• 38:40residents or fellows
• 38:42about how they're doing things
• 38:43when you watch them in
• 38:45any of these circumstances.
• 38:47Do any of these speak
• 38:47to any of you that
• 38:48you wanna spend a minute
• 38:49or two going over?
• 38:52That's what I'm about to
• 38:53do. Right?
• 38:54And then
• 38:58Amazing. This is something we
• 38:59cover with the medical students
• 39:00in fourth year before they
• 39:02graduate,
• 39:03and it is astonishing to
• 39:05me how few of them
• 39:06when I ask them
• 39:07how many of you had
• 39:08seen error disclosure conversations throughout
• 39:11your training at this point.
• 39:12So few of them,
• 39:15have.
• 39:16And the reason that astonishes
• 39:17me is I feel like
• 39:18there's errors happening every day.
• 39:20I feel like I'm involved
• 39:21in some sort of an
• 39:22error disclosure,
• 39:23right, like, almost every time
• 39:25I'm with patients. The error
• 39:26can be something as small
• 39:27as,
• 39:28we made you wait for
• 39:30half an hour past your
• 39:31your visit, and, you know,
• 39:32you had to scramble to
• 39:33have someone pick your kid
• 39:34up at the bus stop.
• 39:35Right? Like, that's an error.
• 39:36So these skills that I'm
• 39:37gonna talk about here,
• 39:39are designed to be, you
• 39:40know, bigger e errors, but
• 39:42I think we can apply
• 39:43these to,
• 39:45building connections anytime we've we've
• 39:47failed our own expectations for
• 39:48how we,
• 39:50approach a situation with a
• 39:51patient. So this is just
• 39:53a checklist that what we
• 39:54the setup here is the
• 39:55students,
• 39:57are interviewing a standardized patient
• 39:58while their classmate
• 40:01is looking at this checklist
• 40:03and then giving them feedback
• 40:04at the end. So you
• 40:04see some of the things
• 40:05that are on the checklist
• 40:06here. These are all based
• 40:08on,
• 40:09published
• 40:10our group pulled a bunch
• 40:12of,
• 40:13published rubrics related to best
• 40:14practices with air disclosure and
• 40:16then created a, a checklist,
• 40:18for our workshop.
• 40:21So,
• 40:23yeah,
• 40:24some of the you see
• 40:25it all listed up there,
• 40:26so I'm not gonna read
• 40:26it to you. But, I
• 40:27think some of the the
• 40:29important things that maybe surprised
• 40:30the students, number five, stating
• 40:32a clear apology,
• 40:33just owning it,
• 40:35not deflecting it to somebody
• 40:36else. The scenario we we
• 40:38present to the students during
• 40:39this workshop is that the
• 40:41intern,
• 40:42didn't respond to an X-ray
• 40:44result because they didn't get
• 40:45the red flag alert from
• 40:47radiology
• 40:48overnight. So they had put
• 40:49in the order for the
• 40:50X-ray. They had gone about
• 40:51done their other busy work
• 40:53that they needed to do,
• 40:54and they never got the
• 40:55red flag alert from radiology.
• 40:57And then, you know, the
• 40:58patient has a complication as
• 40:59a result of that, and
• 41:00now they're in the situation.
• 41:01I'd be going and apologize.
• 41:03Done wrong is, you know,
• 41:04that damn radiologist didn't call
• 41:06me. Right? I mean, nobody
• 41:07would say that, but
• 41:09the even a subtle
• 41:10nod to a subtle acknowledgment
• 41:13of the fact that somebody
• 41:14was supposed to call me
• 41:15is punting the responsibility. Whereas
• 41:17what you wanna do is
• 41:18own the responsibility
• 41:20and apologize,
• 41:21which can be really hard
• 41:22for a trainee to to
• 41:25do because it's often not
• 41:26their decision that they're apologizing
• 41:28about. So this, you know,
• 41:29this sort of conversation this
• 41:31sort of,
• 41:32model brings up some really
• 41:33good conversations with trainees about
• 41:35what you own and what
• 41:36you don't own, how much
• 41:37you should question your supervisor
• 41:39you're attending
• 41:40when you're doing something,
• 41:42that you may not fully
• 41:44understand why you're doing it.
• 41:45Right? So it gets that
• 41:46you shouldn't put in the
• 41:47order unless you really understand
• 41:48why you're doing doing this
• 41:50outside of an emergency because
• 41:51you're the one who owns
• 41:52it. You're the person who's
• 41:53the patient's doctor.
• 41:55We try to get the
• 41:56fourth year students to really
• 41:57start to own
• 42:01very,
• 42:02very soon.
• 42:03Any questions or or thoughts
• 42:05about this model?
• 42:09In your chili, they're not
• 42:10doing anything. I think it's
• 42:11a perfectly reasonable model that's
• 42:15probably
• 42:17backed up by more than
• 42:17just your paper. But I'm
• 42:19curious
• 42:20how this links into
• 42:23why it changes models of,
• 42:26disclosure
• 42:27of error or
• 42:30in particular,
• 42:31rather than
• 42:33this is my error or
• 42:34this is
• 42:35our team's error. This is
• 42:37how do we deal with
• 42:37this as a system,
• 42:39especially for patients who
• 42:43want to vent a bit
• 42:44more and it's and they
• 42:46don't wanna vent at you
• 42:47because they like you, but
• 42:48they really want to complain?
• 42:50Yeah. Well, I mean, I
• 42:51think we have mechanisms in
• 42:52place within the health care
• 42:53system to handle this. I
• 42:54mean, at the hospital,
• 42:56the,
• 42:57patient serve patient relations team
• 42:58is wonderful.
• 43:00You know, they they can
• 43:01absolutely come in and and
• 43:03help with,
• 43:04bigger systems type, issues. Often,
• 43:07as attendings, we are
• 43:09apologizing for things that we
• 43:10have zero control over, but
• 43:12that absolutely impact
• 43:15the care of the patient
• 43:16in that hospital bed. Right?
• 43:17They,
• 43:18they didn't like the,
• 43:20the interaction in the in
• 43:22the parking lot, or the
• 43:24the the tray from the
• 43:25cafeteria,
• 43:26didn't arrive for two hours
• 43:28because there was a problem
• 43:29in the kitchen. Right? Those
• 43:29are still things that we
• 43:31need to own. I'm on
• 43:32rounds in the morning. I
• 43:33am apologizing for that. I'm
• 43:34not claiming that I have
• 43:36ability to impact change for
• 43:38that immediately, but what I
• 43:39have the ability to do
• 43:40is maybe talk to the
• 43:41charge nurse to then,
• 43:44figure out
• 43:45how this for this patient
• 43:47or for the whole floor,
• 43:48this sort of thing can
• 43:49be dealt with or prevented
• 43:50or what the hospital can
• 43:51do to talk the patient
• 43:52down from their anger, whatever
• 43:54they're feeling about that. And
• 43:55the people in patient relations
• 43:57are really good about that.
• 43:57I mean, think about everything
• 43:58that happens every day in
• 43:59the hospital. The patient's phone
• 44:01got lost in the transition
• 44:02from the ED to the
• 44:04maybe not a teenager's. Right?
• 44:05But, like,
• 44:06you could see how
• 44:07important things that have nothing
• 44:08to do with us,
• 44:10we are the, the face
• 44:11that that needs to answer
• 44:12to the patient. And those
• 44:14are all errors. Right? Because
• 44:15we're we're the face of
• 44:16the system as the attending
• 44:17on the care team.
• 44:21Alright. Let's see. I think
• 44:22we have time for one
• 44:24more. Is there another one
• 44:25that anyone is curious about?
• 44:30I think goals of care
• 44:32is always a difficult conversation
• 44:34for many patients Sure. And
• 44:36families?
• 44:38So,
• 44:40this scenario is, so we
• 44:42make a distinction here between
• 44:43goals of care and palliative
• 44:45care. The goals of care
• 44:46is
• 44:47a setup where a you're
• 44:49talking to a family member,
• 44:51about their loved one who
• 44:52has a terminal
• 44:54condition.
• 44:55And it's really
• 44:56allowing the students to
• 44:58in a family meeting to
• 45:00use the hard language and
• 45:01not talk around
• 45:06to to grapple with, you
• 45:08know, using
• 45:09the word die and death.
• 45:13You know, not not
• 45:15presenting
• 45:16options to I'm I'm not
• 45:18gonna read the whole list.
• 45:19I'm just sort of explaining
• 45:20the broader categories here. Not
• 45:22not presenting things to patients
• 45:24as a menu
• 45:25of options
• 45:26which they can choose from
• 45:28with even waiting,
• 45:29but
• 45:30giving them some guidance about
• 45:33the realities of what their
• 45:35loved one is facing so
• 45:36that they they can make
• 45:37a decision that's weighted
• 45:39based on our opinion of
• 45:40the medical situation.
• 45:42You know, we see this
• 45:43in adult medicine all the
• 45:44time, trainees
• 45:46going through a DNR conversation
• 45:48like it's a menu,
• 45:49and doing it in a
• 45:50checkbox
• 45:51way
• 45:52rather than starting with what
• 45:54the patient's goals and wishes
• 45:55are and talking about prognosis
• 45:58and then what would happen
• 45:59in the case of
• 46:01a resuscitation
• 46:02situation.
• 46:04And, you know, fortunately, this
• 46:06is
• 46:07less common in pediatrics, but
• 46:08I think the idea of
• 46:10being direct with people,
• 46:11not wanting to strip them
• 46:12of hope, but also not
• 46:14giving them false
• 46:15equivalence
• 46:16between options when,
• 46:18when you're having to make
• 46:19some tough choices.
• 46:21But you gotta know if
• 46:21there was something else you
• 46:22were thinking about or had
• 46:24in mind about goals of
• 46:25care.
• 46:25No. No. I was think
• 46:27I mean, this this is
• 46:28I mean, for for my
• 46:29subspecialty, they apply sometimes or
• 46:31even in the NICU when
• 46:32you have an extremely preemie
• 46:33baby and a complex
• 46:35other medical condition. I think
• 46:37we do have to have
• 46:38these conversations with the families.
• 46:40So I think this is
• 46:41very relevant in that scenario.
• 46:43Agreed rarer, but it it
• 46:44does,
• 46:46come up. Yeah. So I
• 46:47don't do inpatient peds anymore.
• 46:49But when I'm on inpatient
• 46:50medicine and we're about to
• 46:51go and have a family
• 46:52meeting, I'll literally go and
• 46:53pull up this checklist, and
• 46:55I'll, you know, just review
• 46:56this with the team before
• 46:57we go in so they
• 46:58they can see. Whether it's
• 46:59the senior resident or me
• 47:01running the meeting,
• 47:02they can see that this
• 47:03is actually a procedure. There
• 47:04are steps. They don't need
• 47:06to go in this order,
• 47:06and it shouldn't look like
• 47:07a procedure to the family.
• 47:08But there are steps that
• 47:10you are taking
• 47:11to make this,
• 47:13conversation go well and successfully.
• 47:17Because, Richard, I'm sure that,
• 47:18you know, when you've done
• 47:19this
• 47:20in front of trainees,
• 47:22it it looks easy and
• 47:24automatic even though the conversation's
• 47:26hard, and that's because
• 47:27we've we've all spent a
• 47:28lot of time training and
• 47:29practicing,
• 47:30these things. And and at
• 47:32some point, the actual step
• 47:34by step nature of what
• 47:34we're doing
• 47:36becomes automatic to us, and
• 47:37we're not thinking about it
• 47:38this way.
• 47:43Alright.
• 47:44I think it's twelve fifty
• 47:45two. Can we do one
• 47:46more? I think we do
• 47:47let's do one more.
• 47:52I'll go for angry patient,
• 47:54which I always feel to
• 47:55be is personally stressful.
• 47:58Yeah.
• 47:59So we talked about this
• 48:00a little bit already. The
• 48:02the key here is that
• 48:03when this is the situation
• 48:05here is that you're walking
• 48:06into a room with,
• 48:11Right. You feel we've all
• 48:12been in this situation. You
• 48:14feel like you haven't done
• 48:15anything to
• 48:16have that anger be warranted.
• 48:19And the point here is
• 48:20that when a patient has
• 48:21a really high level emotion,
• 48:24it usually has nothing to
• 48:25do with you. So if
• 48:26the patient is angry
• 48:28at you, they're probably not
• 48:29actually angry at you. They're
• 48:31probably angry at the situation
• 48:33that they are in, and
• 48:34you just happen to be
• 48:35the one delivering that message
• 48:36or you just happen to
• 48:37be there when they're feeling
• 48:38this emotion.
• 48:40So this is more than
• 48:41just about delivering serious news.
• 48:42This is about,
• 48:44you know, the patient has
• 48:45a long history about what's
• 48:47happened to them in life
• 48:48either inside or outside the
• 48:49medical system before you walk
• 48:51in the room, and you
• 48:52don't know what you're walking
• 48:53into. And so
• 48:55giving the patient
• 48:56room and space to feel
• 48:57what they're feeling
• 49:00allows them to vent a
• 49:02little bit and allows you
• 49:04to not react. Because when
• 49:05we walk into a room
• 49:06and the patient is attacking
• 49:08us,
• 49:09right, our our blood starts
• 49:11to boil. At least my
• 49:12blood starts to boil. And
• 49:13that time, allowing myself to
• 49:15sort of step back, be
• 49:16quiet, and let the patient
• 49:18just keep giving it to
• 49:18me
• 49:19allows me to collect myself
• 49:21and then respond in the
• 49:22way that I would want
• 49:23to,
• 49:24which is with support and
• 49:25empathy rather than trying to
• 49:27meet their emotion, which is
• 49:28just gonna escalate it. Usually,
• 49:30these high intensity emotions are
• 49:33symptomatic of something else going
• 49:34on. Anger is easy,
• 49:37but, you know, fear of
• 49:38one's mortality
• 49:39or,
• 49:41you know, there there are
• 49:42usually deeper,
• 49:46there's usually a deeper story
• 49:47to why they're feeling this
• 49:48way, and it it's incumbent
• 49:50upon us to allow that
• 49:53to actually come out in
• 49:54the conversation.
• 49:55Sometimes it can't come out
• 49:56right then either because of
• 49:58the way the patient is
• 49:59acting or feeling or the
• 50:01way we're feeling in response.
• 50:02So I also tell trainees
• 50:03in this session that it
• 50:04is okay to take a
• 50:05break if you need it.
• 50:07It's okay to call a
• 50:08friend, right, to come in
• 50:09with you if you need
• 50:10it,
• 50:11especially if the anger starts
• 50:13to become personal as it
• 50:14it unfortunately sometimes does.
• 50:17And, again, that personal attack
• 50:19is usually not about
• 50:20you.
• 50:22You just happen to be
• 50:23the one receiving it. But
• 50:24having an ally there to
• 50:25to help that when those
• 50:26attacks do become more personal
• 50:28can make it much easier
• 50:30to,
• 50:31stay connected to what the
• 50:32patient needs.
• 50:34Jadeep, do you also teach
• 50:36them about, you know, kind
• 50:37of, I mean, when it
• 50:39does cross over in terms
• 50:41of patient to mistreatment
• 50:43Yep.
• 50:44And setting limits.
• 50:46Do you teach them about
• 50:47that, and what's your approach?
• 50:49Yeah. So there's lots of
• 50:51strategies to, to do that.
• 50:53So the ERACE model may
• 50:55be one that you've heard
• 50:55about. I don't remember what
• 50:56the mnemonic stands for, but
• 50:57they have a couple of
• 50:58workshops
• 50:59where they learn techniques to,
• 51:01it's harder to speak up
• 51:02for yourself, but to to
• 51:04have techniques to speak up
• 51:05for a team member when
• 51:07the team member is being
• 51:08attacked.
• 51:09And so
• 51:12interrupting
• 51:16a neutral statement
• 51:18to,
• 51:19sort of call out the
• 51:20surprise that somebody just said
• 51:21something.
• 51:22Right?
• 51:24So
• 51:26an example,
• 51:29might be an an ouch
• 51:30statement. Right? So if I'm
• 51:32working with
• 51:33a,
• 51:34I'm trying to, like, think
• 51:35about things that might have,
• 51:37might have happened fairly recently.
• 51:38I'm working with a female
• 51:40resident,
• 51:41and the, the patient I
• 51:43walk in the room, and
• 51:44the patient all of a
• 51:45sudden is talking to me
• 51:46and speaking about the,
• 51:49female resident in a way
• 51:50that really is,
• 51:52belittling to their role because
• 51:53they're a woman. Right?
• 51:55Using words like this girl
• 51:57or she doesn't know. Right?
• 51:59And I might use an
• 52:01ouch statement
• 52:02and then reframe it that,
• 52:04you know, doctor so and
• 52:05so,
• 52:07is a valuable member of
• 52:08this team and correct.
• 52:11Maybe not the best example.
• 52:13No. That was a good
• 52:14example, Jaydeep. I'm just curious
• 52:16as to what the students
• 52:17are learning in those situations,
• 52:19and I actually like the
• 52:21ouch model.
• 52:22And so I was I
• 52:24was just kinda curious about
• 52:26that. I mean, we do
• 52:27teach them that they don't
• 52:28need to take it, but
• 52:29we also teach them that
• 52:30it's okay to take it.
• 52:31You don't need to all
• 52:33your first step doesn't need
• 52:34to always be that you
• 52:35need to defend. The first
• 52:36step is to understand what's
• 52:38happening.
• 52:39Right? So that might be
• 52:40you know, again, depending on
• 52:41what is said, you know,
• 52:43I'm not sure I heard
• 52:44that right. Can you repeat
• 52:45what you said? Or, you
• 52:47know,
• 52:48did you you know, what
• 52:49you just said, did I
• 52:50did I hear that right?
• 52:52Right? To kinda get the
• 52:53patient to think for a
• 52:54second, is that where I
• 52:55actually want this conversation to
• 52:57go?
• 52:58Because there there may be
• 52:59room to remedy and then
• 53:01debrief outside of the room
• 53:02rather than confronting. And, you
• 53:04know, you're basically
• 53:06probably throwing away that encounter.
• 53:08And when you're that's your
• 53:09only time of the date
• 53:10around,
• 53:10you may wanna
• 53:12recalibrate
• 53:12the patient so that you
• 53:14can actually get done what
• 53:15you need to do medically.
• 53:17Great. No. Thank you so
• 53:19much, JD.
• 53:22Great. Well, thank you everyone
• 53:24for your, your interest. That
• 53:25was great. Thank you so
• 53:27much. I actually have to
• 53:28say I'm very humbled by
• 53:29your,
• 53:31deliberate approach to communication
• 53:33because
• 53:34I feel like in comparison,
• 53:38I tend to I'm not
• 53:39gonna say knee jerk, but
• 53:41do what I usually do
• 53:42versus
• 53:43kind of using the checklist,
• 53:44and it's really nice to
• 53:46slow down and look at
• 53:47the components of what you're
• 53:50teaching. So thank you so
• 53:51much. That was just great,
• 53:53JD. Thank you. Anyone who's
• 53:55interested in diving in and
• 53:56teaching, we're always looking for,
• 53:58pediatric
• 53:59facilitators. Yeah. Doctor me or
• 54:01Ruchika.
• 54:02And, Penina, I know your
• 54:04your
• 54:05pet project, bigger than a
• 54:06pet, one of your main
• 54:07projects is getting more good
• 54:09pediatric Yes. In front of
• 54:10the students to inspire them.
• 54:12So,
• 54:13yeah, please reach out if
• 54:14you're interested in getting more
• 54:20Hey, clinic. Thanks, everybody. Bye,
• 54:21everybody.