9-22-23 YES!: Learning Climate
September 25, 2023ID10740
To CiteDCA Citation Guide
- 00:00The slides, right. So
- 00:03yes, I'll run the sides. OK,
- 00:06With Vinny and Chada and everyone,
- 00:07I'm going to record it because there
- 00:09are some people who wanted. OK.
- 00:12OK. That sounds great.
- 00:13Sounds good. OK. So welcome, everyone.
- 00:17Thanks for your time and taking the time
- 00:19out to to attend this session today.
- 00:21Like Shona had indicated,
- 00:22there's a great opportunity for us to
- 00:26constantly modify this talk to try to reach,
- 00:29you know, outstanding educators
- 00:31like yourselves who are committed
- 00:33to to training our our students and
- 00:36and and residents and and fellows.
- 00:40So learning climate is really one
- 00:42of the the most important and first
- 00:45steps in an educational process
- 00:47and the venue that we work in.
- 00:49And I I think if you leave with nothing
- 00:51else to remember the title of this slide,
- 00:53that learning climate changes the world,
- 00:56that enhancing learning effectiveness
- 00:58impacts all of us as individuals,
- 01:01as systems that we work in
- 01:03and the future of our society.
- 01:06This has been talked about and written
- 01:09about in medicine for many decades
- 01:11and there was really foundational
- 01:13work done by Kelly Skeff back in
- 01:15the 1980s that a reference here and
- 01:17in a couple of other slides out
- 01:20of Stanford University where they
- 01:21describe this kind of seven component
- 01:24framework to enhance learning,
- 01:25particularly adult learning in in medicine.
- 01:28And it starts with establishing
- 01:30a positive learning climate.
- 01:32This will allow you as the instructor
- 01:35to control the teaching session,
- 01:37to communicate the goals of
- 01:39the educational session,
- 01:40to understand and retain the information,
- 01:45to provide and receive evaluation
- 01:47and feedback and to promote
- 01:49self-directed learning.
- 01:51All of which are pillars of
- 01:53maintaining the content of the
- 01:55learning session on a long term basis.
- 01:58Next slide.
- 02:01OK, so to define learning climate,
- 02:05they really, they really one
- 02:06of the best definitions,
- 02:06just the prevailing conditions within
- 02:08an educational setting that promote
- 02:10knowledge or skills acquisition.
- 02:12And this reflects the tone or
- 02:15the atmosphere of the teaching
- 02:17environment wherever you're doing it.
- 02:19It reflects a degree of enthusiasm
- 02:22and comfort for the topic
- 02:24that you're instructing on.
- 02:26And it's very much influenced by
- 02:28the teachers, their enthusiasm,
- 02:30the learners, the setting,
- 02:33and really the interconnectedness
- 02:34and interdependence among the group.
- 02:36That's really what makes learning
- 02:38climates rich and very fruitful.
- 02:40And particularly if you just ask yourself,
- 02:42do trainees want to be in
- 02:44this environment as learners?
- 02:46If the answer to that is yes,
- 02:47then you're doing a good job.
- 02:48And if it's not,
- 02:49then there are things that
- 02:50need to be modified.
- 02:52That's often a question we always
- 02:54need to ask ourselves whenever we're
- 02:57teaching in any form or setting.
- 02:59Next slide.
- 03:01So why do you care as a
- 03:03medical educator in any field?
- 03:05Well, again,
- 03:06a good learning climate as many impacts.
- 03:09First,
- 03:10it influences your effectiveness
- 03:11as a as a teacher and encourages
- 03:14participation among the learners
- 03:16in the in the session.
- 03:18It will affect the wellbeing of
- 03:20the residents and the students
- 03:22or fellows in your session.
- 03:24It increases patient safety as a
- 03:28byproduct of improving knowledge of
- 03:30the people that you're trying to train.
- 03:32And of course,
- 03:33it affects your own evaluations
- 03:35that are used for promotion
- 03:37purposes no matter what track
- 03:39you're in on the Yale faculty,
- 03:41your teaching evaluations are measured
- 03:43and are used and are accountable for
- 03:47when you get identified for promotion.
- 03:50And the skills as a medical educator
- 03:52in in creating learning climate
- 03:54can really be extracted to many
- 03:56situations where leadership skills
- 03:58are needed in the inpatient setting
- 04:01and ambitory bedside education,
- 04:02in lectures and on research teams
- 04:05and mentoring junior faculty or
- 04:07colleagues and developing programs.
- 04:09And it really it's it's critical as a
- 04:13educational leader to make this safe space.
- 04:17And you know,
- 04:17people have said that the best leaders
- 04:20are the ones who make you feel safe.
- 04:22And this is a situation where
- 04:23you can actually do that.
- 04:25Next slide.
- 04:28So the important thing to remember
- 04:30is that the learning climate does
- 04:32affect your perception as a faculty.
- 04:34And this actually has been studied
- 04:36and was published many years ago and
- 04:39still holds true that a positive role
- 04:42models as faculty in teaching have
- 04:45several traits that seem to be shared.
- 04:48One is they spend a significant
- 04:49amount of time with the team
- 04:51that they are working with.
- 04:52Particularly in a clinical environment,
- 04:54more than 25 hours per week was found
- 04:57to be associated with a positive role
- 05:00model perception of that faculty member.
- 05:02Second is that the leader,
- 05:04the faculty leader shares their professional
- 05:07life experiences with that team.
- 05:09That puts people on an even playing
- 05:11field at kind of an interpersonal level.
- 05:14That always improves effectiveness
- 05:15of communication of whatever it
- 05:18is that you're trying to teach.
- 05:20The individual who is successful
- 05:22often has formal training in teaching,
- 05:24and that's again one of the purposes
- 05:26of questions like today.
- 05:28They emphasize interactions
- 05:30between patients and physicians,
- 05:32particularly in the bedside environment,
- 05:35and they emphasize psychosocial
- 05:37aspects of medicine.
- 05:38The patient has an entire entity,
- 05:41not just a group of
- 05:43physiological abnormalities,
- 05:44and then providing specific feedback,
- 05:47both formative and summative feedback.
- 05:50These are all kind of standard
- 05:52criteria that were established at
- 05:54that time and still hold true today.
- 05:57And it's probably not new to most of you.
- 06:00But interestingly,
- 06:00what they found in this one study is
- 06:02that less than half of the faculty
- 06:04were viewed as excellent role
- 06:06models to have all of these traits,
- 06:08and that faculty may be unaware
- 06:10of behaviors that they have and
- 06:12that they can improve their skills
- 06:13by faculty development.
- 06:15This is something that can be learned.
- 06:18Next slide.
- 06:20Great.
- 06:21So I'll turn back over to Shauna
- 06:22now to go through learning
- 06:24climate characteristics.
- 06:26Great, Thank you so much, Vinny.
- 06:28So Vinny has laid out the case for
- 06:31why learning climate is so important.
- 06:34And as he mentioned, these are really
- 06:37a set of skills that you can learn.
- 06:40So what does a good learning
- 06:42climate actually look like?
- 06:43Well, we can certainly contrast it to what
- 06:45a poor learning climate might look like.
- 06:47And I think unfortunately many
- 06:49of us have experienced this and
- 06:51just as we're about to get hit,
- 06:53I think by Tropical Storm Ophelia,
- 06:55I think they've named it this weekend.
- 06:57You know, we can relate to how how that
- 07:01can feel out of control and chaotic.
- 07:04And unfortunately,
- 07:04poor learning comments can also
- 07:06feel hostile to to learners.
- 07:11A common pitfall that people have
- 07:13as educators is to think about what
- 07:16they're interested in teaching.
- 07:17So being educator focused creates
- 07:19a poor learning climate and
- 07:21then being boring so you know,
- 07:23not being interested in what
- 07:24you're teaching about or not
- 07:26teaching it in an interesting way.
- 07:27All of these things can contribute to
- 07:30per learning climates and you can imagine
- 07:32moving to a sunny blue sky place for a good.
- 07:35Learning climate is essentially the opposite.
- 07:37So characteristics of a good learning
- 07:39climate or that it would it's friendly,
- 07:41organized and structured,
- 07:43the focus on what is on what the
- 07:45learner needs and the educators
- 07:47are engaging in their teaching.
- 07:49So how do you actually accomplish these?
- 07:53So luckily these are behaviors
- 07:55which you can you can learn,
- 07:57you can think about how to
- 07:59implement some of them.
- 08:00So in terms of being friendly,
- 08:02that seems pretty straightforward forward,
- 08:04but knowing and using your
- 08:06learner's names as much as possible,
- 08:08obviously you're going to be all of
- 08:09you teach in many different settings.
- 08:10I'm sure there might be situations
- 08:12like this where it's harder to to
- 08:14know and use your learner's names,
- 08:16but certainly on your teams
- 08:18that you're working with.
- 08:19Learn your who your learners are and
- 08:22write their names down if you have trouble
- 08:24remembering them or pronouncing them.
- 08:26And and use their names.
- 08:27Use your body language to convey openness.
- 08:30All those skills that we've learned to use
- 08:33with our patients such as eye contact,
- 08:36active listening, nodding, smiling,
- 08:38encouraging your learners when
- 08:40they're speaking to you,
- 08:42all of those things are really,
- 08:43really helpful to be a friendly atmosphere.
- 08:46Avoiding ridicule seems pretty self-evident.
- 08:49However,
- 08:50I think especially as someone personally
- 08:52who likes to use humor to sort of,
- 08:55you know, lighten the mood a little bit,
- 08:57it can be a little bit of a slippery slope.
- 09:00If you're using humor,
- 09:01try not to make fun of your learners.
- 09:03Sometimes it it can feel tempting
- 09:05to do that funny things happen,
- 09:08we all know that.
- 09:09But remember,
- 09:10even though we're all trying to flatten
- 09:12the hierarchy in medical education,
- 09:14unfortunately the learners probably
- 09:15perceive A hierarchy much more than we do.
- 09:18And so sometimes when when we
- 09:20tease our learners,
- 09:20that is not received in the
- 09:22way in which we mean it.
- 09:23So a good rule of thumb that I have
- 09:26is to only make fun of yourself
- 09:28and actually that that goes down
- 09:30quite well and then acknowledge
- 09:32your expectations can really help
- 09:34to establish that.
- 09:36You know,
- 09:36we're all in the process of learning
- 09:38that we all didn't sort of appear
- 09:40fully formed with the the knowledge and
- 09:43experience and skills that we have.
- 09:45And so learning your learners know
- 09:47that you're still learning or let
- 09:48them know where you were at their
- 09:50stage and and the struggles that
- 09:51you had can be really helpful to
- 09:54create that friendly atmosphere.
- 09:57Next is really important to be
- 09:59organized and structured.
- 10:00So think about what you want to teach.
- 10:03Set an agenda for for what you want to
- 10:06get through during that teaching session,
- 10:08whether that's on rounds,
- 10:09during the attending rounds,
- 10:11or during a more formal teaching session
- 10:14like this, and try to stay on topic.
- 10:16Now, sometimes your learners are
- 10:17going to be off topic because they're
- 10:19going to be interested in something.
- 10:20A side topic that you alluded to
- 10:22or a minor topic that you weren't
- 10:25going to spend much time on.
- 10:27Acknowledge that if that happened.
- 10:28So you can either say, you know,
- 10:30seems like people are really interested
- 10:32in talking about this instead of XYZ,
- 10:34which I had planned.
- 10:35We can keep going and talk about,
- 10:37you know, this topic that you're
- 10:40interested in or you know,
- 10:42we can come back to this another time.
- 10:45So again, just try to stay on topic,
- 10:47but if it looks like you're
- 10:48really veering off, that's fine.
- 10:49Just sort of acknowledge that.
- 10:50Let them know you're aware that that the
- 10:54topic might be changing a little bit,
- 10:57Think about being structured.
- 10:59Really try to allocate the amount of
- 11:01time you need for each agenda item.
- 11:03I'm actually the worst at this.
- 11:05I tend to be really worried that I'm
- 11:08going to run out of time or sorry.
- 11:10I'm always worried I'm not going
- 11:12to have enough material.
- 11:13Exactly the opposite always happens to me.
- 11:15I always run out of time when I'm speaking
- 11:18because I I try to cram too much in.
- 11:20So I'm trying to work on this myself.
- 11:22But be be thoughtful about how much time
- 11:24you think everything's going to need.
- 11:26And then respond to your learners,
- 11:29especially if you're in a more
- 11:30of a small group setting.
- 11:31You know,
- 11:32see what they seem to be
- 11:33really grasping quickly,
- 11:34or maybe what they already know
- 11:36and and speed through that.
- 11:37And you can literally just ask them,
- 11:39you know,
- 11:39It seems like you all
- 11:40understand this pretty well.
- 11:41Can we get me and move on to the
- 11:43next topic or slow down if they seem
- 11:45to be struggling with that concept.
- 11:47So respond to how they how they're
- 11:50absorbing the information and then
- 11:53really think about being learner focused.
- 11:54And in many ways this this might
- 11:56be the most important part of
- 11:59establishing a good learning climate.
- 12:01First thing is to identify what
- 12:02your learners are and they're
- 12:03really two ways to do this.
- 12:05The 1st is to ask them for the beginning
- 12:08of any teaching session or or rotation
- 12:10that you may be working with people.
- 12:12Find out what your learners want to learn
- 12:13about or they think they need to know.
- 12:17The other thing is you can observe them,
- 12:18especially if you're working with them
- 12:21on on some sort of rotation or team.
- 12:23It's very interesting.
- 12:25Sometimes they're identified needs or not,
- 12:27where you see their needs to be
- 12:29when you're actually working with
- 12:31them in the clinical setting.
- 12:32And so those are the two ways in which
- 12:34you can identify needs and and it
- 12:36tells you a lot about your learner.
- 12:38If you ask them what they need to
- 12:40learn and they're really off base in
- 12:42terms of what where they actually are
- 12:44and what they actually need to learn
- 12:46and then meet them where they are,
- 12:48You know, don't don't try to to
- 12:51teach too much over where they are
- 12:53or or too under where they are.
- 12:55And again,
- 12:56that's sort of responding to their,
- 12:59you know, how they are interacting
- 13:02with you when you're teaching,
- 13:04you know, again,
- 13:06just really sort of speed up,
- 13:09slow down according to where they are
- 13:11in terms of their knowledge availability.
- 13:13It seems like a strange thing to
- 13:16put into a learning climate talk.
- 13:19But availability just it turns out to
- 13:21be one of the most important aspects
- 13:25of attendings for for residents
- 13:28and fellows when we're evaluated,
- 13:30that feeling like you care enough
- 13:33about the team,
- 13:34you care enough about your learners
- 13:36to be present for them to be
- 13:38able to answer their questions,
- 13:40to be able to give input on on patients,
- 13:42just to be around even.
- 13:44And that helps to set a really
- 13:46great learning climate.
- 13:47It also allows you, like I said,
- 13:48to get to know your team and
- 13:50and know what their needs are,
- 13:51ask their opinions about about patience,
- 13:54about things that come up when you're
- 13:57working with them and then respect them.
- 14:00This is also incredibly important,
- 14:01you know, acknowledge their struggles.
- 14:04You know,
- 14:05I'm old enough that I trained at a time
- 14:07when there were there were no duty hours.
- 14:09We often worked, you know,
- 14:10over 100 hours a week and it's
- 14:13very easy sometimes for old
- 14:14timers like me to sort of say,
- 14:16oh this, you know, this group,
- 14:18they they get to go home every
- 14:20evening or whatever it is.
- 14:22But you know,
- 14:23they have their own struggles and
- 14:25they're working with work compression,
- 14:27right.
- 14:27They have to get the same amount.
- 14:28Probably a lot more work done actually
- 14:30in in much last time than we had to.
- 14:32And medicine is more complex,
- 14:34it's more detailed,
- 14:35there's there are high expectations
- 14:37for the the trainees are doing so
- 14:39acknowledge their struggles and have
- 14:40empathy for for where they are.
- 14:42Residency is never easy,
- 14:43and it's never going to be easy,
- 14:45nor fellowship.
- 14:46And then invite them to discuss
- 14:49their limitations again.
- 14:50If you've established that it's okay
- 14:52to talk about your limitations by
- 14:55acknowledging your own limitations,
- 14:56they're going to be much more willing and
- 14:59open to share their struggles with you.
- 15:02And that's going to really
- 15:04allow you to teach to
- 15:05where they are and what
- 15:07they need more easily.
- 15:10And then lastly, be engaging.
- 15:12And this is always the part of the
- 15:13talk that feels a little meta for me.
- 15:14So now I'm going to try and show
- 15:17more enthusiasm for the topic,
- 15:18but think about how you're
- 15:19speaking about something.
- 15:20Are you using an animated voice?
- 15:22What's your body language?
- 15:23I actually, when I teach on the wards,
- 15:25I really like to and my turning rounds
- 15:27go up to the board and and use the board
- 15:30because that gets me up and walking around.
- 15:32It makes me more, you know,
- 15:34in motion and more interesting to look
- 15:37at and then encourage participation.
- 15:39You know these You don't want to
- 15:41be a spoon feeder of information.
- 15:43You want your learners to be
- 15:45answering questions,
- 15:46to be participating.
- 15:48Use your higher level learners.
- 15:49If you're in a sort of a mixed group to
- 15:52teach some of your lower level learners,
- 15:54make it a group process.
- 15:58Along those same lines.
- 15:59Avoid monopolizing the discussion.
- 16:01Really,
- 16:01people don't want to just sit and listen
- 16:03to you drone on about your pet project.
- 16:05You really want this again to
- 16:07be a conversation that you're
- 16:09having with your learners okay.
- 16:12So really quickly this is
- 16:13actually not from medicine,
- 16:15this is from the business world.
- 16:16But I think it's a really nice
- 16:18schematic of how to think about,
- 16:20you know,
- 16:21what kind of educator you can be.
- 16:22And so you can be either somebody
- 16:25who offers a high support or low
- 16:28support and or challenges your
- 16:29learners or or doesn't challenge them.
- 16:32And we're going to go around the four
- 16:34quadrants to sort of talk about the
- 16:37different type of educators that that
- 16:38fall into each of these quadrants.
- 16:40So if you give a lot of support
- 16:42but you're not challenging,
- 16:44you end up being a protector and that
- 16:46those are the types of educators who
- 16:48know everything about their team.
- 16:50They bring Donuts every morning.
- 16:51Everybody loves them, but they're they're,
- 16:54they don't ask much of the team.
- 16:55They're not really asking them to
- 16:57participate in their education there.
- 16:59Again,
- 16:59spoon feeding information,
- 17:01They're sort of doing as much
- 17:02as they can for them,
- 17:03but they're not helping their learners grow.
- 17:05And that's really an important
- 17:07part of what educators need to do.
- 17:10This group down here,
- 17:12the abdicators don't offer much support.
- 17:14They don't really know their team that well.
- 17:17I think of this as sort of
- 17:19the absent attendings and they
- 17:20don't challenge them either.
- 17:22So they're not asking a lot.
- 17:23They're not, they're not really,
- 17:26you know,
- 17:26having them participate in their
- 17:28education and that they just don't
- 17:30get to know the team very much.
- 17:31That creates a culture of apathy.
- 17:33We've all had tonnings like that I'm
- 17:36sure and and we all know sort of how
- 17:39demoralizing it is to work with them.
- 17:41And then the dominator quadrant,
- 17:44this was a favorite when I was resident.
- 17:47These are high challenge,
- 17:48low support
- 17:49ask a lot of their teams.
- 17:51They, they pimp as we used to say
- 17:54on rounds all the time and they're
- 17:56but they don't really get to
- 17:58know who you are or ask you know,
- 18:00really understand what your needs
- 18:02are as a learner and and that creates
- 18:05unfortunately a culture of fear.
- 18:07So where we hope everyone ends up is
- 18:11up here in this Liberator quadrant
- 18:13where you're giving a lot of support
- 18:15and you're challenging your team.
- 18:16So you know who your team is.
- 18:17You've established a really
- 18:18great learning climate.
- 18:19You are getting to know them individually,
- 18:22what their needs are,
- 18:24who they are, what they want.
- 18:25And you're asking them to be
- 18:27participants in their education.
- 18:29You're challenging them to
- 18:30push themselves to learn,
- 18:32to grow and that really creates
- 18:35that culture of empowerment.
- 18:37So with that,
- 18:38I'm going to turn it back over
- 18:39to Vinny and he's going to talk
- 18:41about challenges and barriers.
- 18:43Okay, thanks, Shona.
- 18:45So Shona outlined all the kind of the,
- 18:48the specific aspects of the of delivering
- 18:52the positive learning climate.
- 18:54We all recognize in the practical
- 18:56setting that there are many
- 18:58challenges and barriers that we face.
- 19:00First is the overcrowded
- 19:01clinical environment,
- 19:02whether it be the ambulatory
- 19:04setting or the inpatient setting.
- 19:05We all recognize this.
- 19:07There are patients and being
- 19:09transported back and forth and
- 19:11there are RT's being called and
- 19:14there are family members who come
- 19:16in and ask questions and there's a
- 19:18lot of busyness in the hallways and
- 19:21in the and in the hospital rooms.
- 19:23So it ends up being a very challenging
- 19:26environment often to to teach in.
- 19:28Second is of course our clinical
- 19:30workload and service commitments overall
- 19:33that there's so many expectations of
- 19:35us as attendings that challenge the time,
- 19:37there's only a certain amount
- 19:39of time in a day, right.
- 19:40And that we have commitments
- 19:42outside even in the attending time,
- 19:44right.
- 19:44We're constantly getting emailed
- 19:46and text messages about things
- 19:48and other programs and other
- 19:49responsibilities that we have
- 19:51while we are on the wards or in
- 19:52the clinic in a teaching setting.
- 19:55Third is that often we don't
- 19:57define exactly what the learner
- 19:59needs are and this is a critical
- 20:01component as was addressed by Shona.
- 20:04And we don't necessarily have them state
- 20:06what their goals and objectives are.
- 20:08So that's why these are critical
- 20:10aspects to the to establishing
- 20:12the positive learning climate.
- 20:15Additionally, the actual physical
- 20:17space that we have is is very limited.
- 20:19We all scramble around for
- 20:21conference rooms in the amateur
- 20:23setting or in the OR on the wards.
- 20:25That is often, you know,
- 20:27competing needs for that same space.
- 20:30So just having a place where you
- 20:32can gather even for 1/2 an hour
- 20:34to talk is often a challenge.
- 20:36There's time limitations.
- 20:38There's always the need for admitting
- 20:41new patients or discharging patients,
- 20:43or family meetings or meeting with nurses
- 20:45and P SMS on the floor meeting with clinic.
- 20:47Managers and people have very
- 20:52complicated lives on a daily basis,
- 20:55and time is one of those major limitations.
- 20:59Additionally,
- 20:59faculty and learner attitudes towards
- 21:01what education should be is often
- 21:04variable and this remains a challenge
- 21:06as well as the overall institutional
- 21:08support at the section you work in,
- 21:11at the department you work
- 21:12in and within the school,
- 21:14different people come in with
- 21:16different levels of support for
- 21:17different aspects of their jobs.
- 21:19So that some people have more time
- 21:22and availability because they're
- 21:23supported to do that,
- 21:25other people do not.
- 21:26And therefore this can impact
- 21:28their overall learning climate.
- 21:31Next slide.
- 21:32So I think what we're going to
- 21:34do is discuss now two cases and
- 21:36identify behaviors in those cases
- 21:39and small group settings where
- 21:41that contribute to either a good
- 21:43or a poor learning climate.
- 21:44So that's showing it.
- 21:46Now to start with the first case
- 21:48that I can read and then I think
- 21:51she will break us up into groups,
- 21:53yes. So just a little bit of
- 21:56instruction before we do this.
- 21:57Vinny will read the case to you.
- 21:59There's going to be two cases.
- 22:01Both of them have both good and bad
- 22:04aspects of the learning climate.
- 22:07So as you're reading the cases,
- 22:10take notes on what you see
- 22:12as as both either good or bad
- 22:15components of learning climate.
- 22:17We'll break you out then
- 22:19into breakout groups.
- 22:20They'll be about 8 to 9 people.
- 22:22Vinny and I will not join
- 22:24our rooms and I guess Janet,
- 22:26etcetera can decide whether they
- 22:27want to pop into a room or not.
- 22:29So they should be about between five
- 22:31to seven people in each room to
- 22:33discuss and then we will come back and
- 22:36talk about it briefly as a larger group.
- 22:38So let me know if you have any questions.
- 22:40I'm having a trouble seeing the chat
- 22:42and doing everything at the same time.
- 22:44So unmute if you have a question
- 22:45about any of this as we go along
- 22:50Okay. So the first case your
- 22:53inpatient team is post call
- 22:55gathered in the conference room to
- 22:57hear about the overnight admissions.
- 22:59It's your first day as attending
- 23:00and the residents, interns,
- 23:01and students are waiting.
- 23:03Faculty member quote Sorry I'm late.
- 23:06I wasn't supposed to attend this block,
- 23:07but there was a last minute switch.
- 23:09I found out about two days ago.
- 23:10It's not going to be easy for
- 23:12me to get here by 7:30 AM.
- 23:13I have to drop my son off at daycare.
- 23:15Early resident quote, we have 4 overnights,
- 23:192 unit transfers, faculty okay.
- 23:23Doesn't that take us over the cap?
- 23:25Resident No. We cap attempt for intern.
- 23:28Faculty okay. Well,
- 23:29I have a research team meeting at 9:00 AM,
- 23:31so let's just hear about the overnights.
- 23:33Now you guys can call,
- 23:34call me around on your can,
- 23:36round on your own,
- 23:38and I'll catch up later with you.
- 23:40Next slide, the resident presents
- 23:42patient with communic acquired pneumonia.
- 23:45The faculty responds to text
- 23:47message during the presentation.
- 23:48Faculty then during the
- 23:50resident presentation.
- 23:50I'm not sure why this patient was admitted.
- 23:53Interns, what are the criteria for
- 23:55admission for communicoid pneumonia?
- 23:56There's no immediate response.
- 23:58So the faculty continues,
- 23:59students, one of the most common
- 24:02causes of communicator pneumonia.
- 24:03Interns and students,
- 24:05think about responses.
- 24:06Faculty,
- 24:06come on guys,
- 24:07you got to know this next slide.
- 24:11I think that's it. Yes, okay.
- 24:13So I'm going to put everybody into
- 24:18into a breakout room.
- 24:19We will be in breakout rooms
- 24:21for seven minutes, I think.
- 24:24I think of the timing.
- 24:25Yeah, 7 minutes seems about right.
- 24:28So I'll set a timer.
- 24:28I'll bring everybody back.
- 24:30You'll have some warning before
- 24:32we come back into the room and
- 24:34just discuss amongst yourselves
- 24:35what you saw maybe or examples
- 24:38of good and poor learning,
- 24:39climate, climate strategies.
- 24:42And now
- 24:45you go
- 24:57about 5 seconds. Everybody should reappear.
- 25:10Not fair. We were having so
- 25:11much fun in our group. Yeah,
- 25:14dragged us back too quickly.
- 25:17Agreed. Agreed. We can.
- 25:20We can give you guys a little
- 25:21longer for the next one.
- 25:31All right. We should have everybody
- 25:33back now. So, Vinny, if you want
- 25:35to. OK. All right. So welcome back
- 25:38for a quick debrief on the case.
- 25:41So I guess we could start with
- 25:43what aspects of the case do
- 25:46you think the faculty did well?
- 25:52He showed up. He was there in person. OK,
- 25:57that's that's a start, right?
- 25:59Yep. He did challenge
- 26:01the young professionals,
- 26:03asking them questions.
- 26:05OK, Anything else
- 26:10you apologize for being late? OK.
- 26:17Anything else?
- 26:19So one thing we think that the person
- 26:21didn't do terribly well but but could
- 26:24have been a positive was acknowledging
- 26:26some of the challenges that were
- 26:28going on that particular morning.
- 26:29And so I think it's helpful
- 26:31for trainees to see that,
- 26:33although I don't know that this faculty
- 26:34member made the most of putting some
- 26:38structure to that to make it not chaotic.
- 26:42All
- 26:44right. Anyone else have any other positive
- 26:48things that the faculty member did to add
- 26:53Okay? How about the things that the
- 26:56faculty member did that were not ideal?
- 27:00Essentially, learning is didn't
- 27:04correlate with climate because
- 27:08learning environment is always good.
- 27:13Yeah, it's in the classroom, right.
- 27:16Well, when I when I told,
- 27:17it's just a conference
- 27:18room is what we're told.
- 27:19Conference room in the.
- 27:22So it's probably a computer room
- 27:24slash conference room on the wards.
- 27:27Yes. In the classroom,
- 27:28in the lab or in a clinic.
- 27:30So there are low climates changing.
- 27:34Yes, yes, absolutely.
- 27:39Anything else? People identified
- 27:40that he didn't do well or he,
- 27:43he or she didn't do well?
- 27:44There's a degree of intimidation going
- 27:46on when he that sentence. Come on, guys.
- 27:48You know, you should know this.
- 27:50I didn't think that was appropriate.
- 27:52OK, OK, So this was, you know,
- 27:55first time you're meeting the team,
- 27:56first patient, you hear,
- 27:59and you're already just showing
- 28:01dissatisfaction with their lack
- 28:03of response to the questions.
- 28:05OK, All right, good.
- 28:07Anything else?
- 28:07How about the very beginning?
- 28:11So at the very beginning,
- 28:12he sets the tone by not even asking, hey,
- 28:14how did things go or how are you guys doing?
- 28:16Kind of acknowledging that they're
- 28:18coming out of or ending a a night call
- 28:21or a night shift and kind of trying to
- 28:23to show a little bit of of empathy or
- 28:26or learning where they're coming from.
- 28:28He just kind of quickly went
- 28:30into sorry I'm late, you know,
- 28:32I'm going to be late, you know,
- 28:34almost like not not even asking
- 28:37who's present or who. You know,
- 28:39he didn't care about who was in the room,
- 28:42right. So there was no, there was no
- 28:44introduction of of of the attending,
- 28:46no asking the names or the backgrounds
- 28:50or anything of the of the team. Right.
- 28:53It was all about the attending, right.
- 28:56The attending shows up and says about,
- 29:00you know, how this was the last minute switch
- 29:02that they weren't supposed to be there,
- 29:04that they can have a problem getting there.
- 29:06It was all how this,
- 29:07it was kind of interrupting their life
- 29:10before anything happens on the team, right.
- 29:12And then asking about, you know,
- 29:14whether or not it's over
- 29:15the cap and you know,
- 29:16did they require all these transfers
- 29:19and all those kinds of kind of
- 29:22administrative things that really
- 29:23don't necessarily lend towards a
- 29:26positive learning environment.
- 29:28We're all the way the attending
- 29:30started the session.
- 29:32So those were all less than
- 29:34optimal behaviors.
- 29:36I
- 29:37think it's simple.
- 29:38If just say, how are you?
- 29:40How was call? I mean,
- 29:41there was nothing, you know?
- 29:43And if you're rounding with
- 29:44a team that's post call,
- 29:45most of them look like they're post call.
- 29:47So just whether the guy or gal
- 29:50is as empathetic as they come,
- 29:52that intro would show no empathy
- 29:54toward this team that may have not
- 29:56gotten a minute's sleep last night.
- 29:59Sure, sure, Absolutely So.
- 30:01So from the very beginning the tone
- 30:04was set at a very unfortunate point
- 30:07where it was more attending focused,
- 30:11how this was affecting the attending
- 30:13and not recognizing or empathizing
- 30:16with the team that worked up
- 30:18all these admissions overnight.
- 30:20Nor did the he or she introduced themselves
- 30:24or the OR the team members okay.
- 30:27And then how about we
- 30:29also talked about boundaries issues.
- 30:32You know, there's the cliche of I'm
- 30:34working on my phone, I'm not, you know,
- 30:36you're telling me about patience,
- 30:37but I'm not really present
- 30:40or available to you.
- 30:42So, you know, it's that culture of
- 30:46apathy and the abdicator role and the
- 30:50importance of setting boundaries around
- 30:52something you consider important.
- 30:53If it's not important,
- 30:55then it doesn't really matter.
- 30:58Sure. So the fact that the attendee
- 31:00is responding to a text message
- 31:02during the presentation by the by
- 31:05the team shows not only disrespect,
- 31:07but again no empathy for the team and
- 31:10the and the needs for them as learners.
- 31:13It it sends a lot of messages
- 31:14that this is not important,
- 31:15as important as what the text message is.
- 31:18And this is picked up on by teams
- 31:21all the time when this happens.
- 31:23Okay. Anything else
- 31:27that anyone noted that the attending
- 31:28did or that the attending didn't
- 31:30do that they should have done.
- 31:37One of the things that came up in
- 31:39our small group was just kind of
- 31:43role modeling behavior that you know,
- 31:46that they just weren't prioritizing
- 31:48patient care or learning.
- 31:50I have a meeting at 9:00 and you
- 31:53know answering the text message and
- 31:56you know the the, the flip side of
- 31:58that which I really appreciated.
- 32:00One of our one of our participants
- 32:01was saying, well there's nothing wrong
- 32:03with modeling that you have a lot going on.
- 32:06It's just how you set the priorities,
- 32:08how you inquire what what does
- 32:09the team have to do this morning,
- 32:11when is morning report,
- 32:12when are these other things,
- 32:13do they have to get their 11:00
- 32:15AM discharges done?
- 32:16I have these meetings let's,
- 32:17you know come up with a plan together
- 32:19would have been a way that could have
- 32:21been done in a more productive way.
- 32:24Karen Hutchinson made a very
- 32:26good point about, you know,
- 32:29how you mentor and how you model and what
- 32:33that means down the line to learners.
- 32:36Karen, I don't want to steal your Thunder,
- 32:41absolutely limited Thunder,
- 32:44but simply I'm just
- 32:46but for the little bit of Thunder,
- 32:47I was just referencing the
- 32:49clear program from the A/C GME
- 32:51and how that that was founded.
- 32:53Basically in recognition of the
- 32:56fact that our trainees behave
- 32:59as they were trained to behave.
- 33:02And if 15 years out they they imitate
- 33:05as you know like we imitate our parents,
- 33:07they imitate their attending.
- 33:08So this is not a medical knowledge
- 33:10or patient care issue.
- 33:11This is just how they were treated,
- 33:13is how they treat others and we know this,
- 33:15but it's a huge focus for the A/C GME well
- 33:19and you know how important because you
- 33:22you throw a Pebble in the pond and
- 33:25the ripples go out quite a distance.
- 33:28So if you're trying to change
- 33:30culture and it doesn't start with
- 33:31you as an individual modeling,
- 33:33setting the environment,
- 33:34modeling the things you want people to see,
- 33:37how many years is this going to take until
- 33:40the environment can substantially change?
- 33:45Absolutely all, all excellent points,
- 33:48not only the concrete issues,
- 33:51but the impact of those issues
- 33:54lasting years and generations. So.
- 33:56So if we were just kind of like
- 33:58summarize what people were saying,
- 33:59that the behavioral limitations of
- 34:02the faculty member was that they
- 34:05never introduced his or her name,
- 34:07never asked the learners their names,
- 34:09didn't ask the learners their learning goals.
- 34:12There was a lack of enthusiasm for patient
- 34:14care with divided attention, right?
- 34:16Was worried about their own research
- 34:17meeting and the text messages they
- 34:19were receiving during the presentation.
- 34:21They were unfriendly and questioning and
- 34:24refer to learners as interns and students
- 34:27and not by their individual names.
- 34:30So the session overall was not
- 34:33learner focused and was disease
- 34:35focused and not patient oriented.
- 34:37So these are concrete things that we
- 34:40can identify in this setting that were
- 34:44limitations in the behavior exactly number.
- 34:48Thank you. I'm going to
- 34:49move on to case two just in
- 34:51the interest of time,
- 34:51I want to make sure we have time
- 34:53to discuss this one as well.
- 34:55So again, please, you'll pay attention,
- 34:58take notes during the reading of the
- 35:01case and then we'll break you out into
- 35:03breakout readings again to discuss
- 35:05what you see is both the good and bad
- 35:08learning climate strategies displayed.
- 35:10So, same situation.
- 35:12Faculty says good morning team,
- 35:15my name is Joanna Brown.
- 35:16I'm excited to start as you're
- 35:18attending today.
- 35:19I know you must have had a busy night,
- 35:20but before we begin,
- 35:21I was wondering if we could take
- 35:235 to 10 minutes to gather our
- 35:25thoughts together about how we best
- 35:27do work rounds and teaching rounds,
- 35:29the resident says. Okay.
- 35:31Sure.
- 35:32First,
- 35:32I'd like to each I'd like each of you to
- 35:35know that I've been attending several years,
- 35:36but I still learn medicine every day
- 35:39from our patients, our residents,
- 35:40our interns, and our students.
- 35:41We all have gaps in our knowledge,
- 35:43but we can learn from each other and as a
- 35:45team, give the best care to our patients.
- 35:48I'd like each of you to tell us your
- 35:49name and something important about you.
- 35:51I'll start.
- 35:51I'm Joanna.
- 35:52I'm a proud mother of two boys,
- 35:53and I was a former Yale intern.
- 35:56The residents, interns,
- 35:57and students introduce themselves with a
- 35:59brief personal feature about themselves,
- 36:02Faculty okay.
- 36:03I'd like the most junior member of the
- 36:04team to present the patients each day.
- 36:06The students get the first opportunity,
- 36:08then interns and residents.
- 36:09If possible,
- 36:10I'd like you to try to present
- 36:11at the bedside for each patient
- 36:12and mention only the key elements
- 36:14in the patient's story that are
- 36:16relevant to the submission.
- 36:17We can invite the patient to clarify
- 36:18any issues and describe our plan for the day.
- 36:21Residents, intern,
- 36:22Students not in agreement.
- 36:23Later in the day,
- 36:24we can all read about the key issues
- 36:26that arise in our patients and
- 36:27discuss them together at teaching rounds.
- 36:29I will try to identify original literature
- 36:31that illustrates important points,
- 36:33and at our first teaching rounds I'd
- 36:34like each of you to identify your
- 36:36learning goals for the rotation.
- 36:37We can meet at the end of the week
- 36:39to give each other feedback as to
- 36:40whether those goals were achieved
- 36:42and whether we need to change or
- 36:43workflow or teaching sessions.
- 36:45Residents. That sounds great.
- 36:47Does anyone have any questions
- 36:48or advice at this point?
- 36:49If not,
- 36:50why don't we go evaluate the
- 36:52first patient and we invite Lisa,
- 36:54our student,
- 36:54to please present at the bedside.
- 36:56All right.
- 36:57I'm going to put you back into
- 36:59your breakout rooms and we'll
- 37:02see you in about 7 minutes.
- 37:10Welcome
- 37:12back, don't talk about.
- 37:15Sorry. Welcome back, everybody.
- 37:18Let's give everyone a second to sort of
- 37:22come back just in the interest of time.
- 37:24We only have 5 more minutes.
- 37:26I'm just going to summarize what we see
- 37:30as the the aspects of this attendings,
- 37:37learning climate strategies that were
- 37:38good and then the few that were poor.
- 37:41Be very happy to hear if people
- 37:42have other thoughts about it.
- 37:43But if you go through, you know,
- 37:45the the five characteristics
- 37:47of a good learning climate,
- 37:48she really hits many of them, right?
- 37:50So right off the bat, she's friendly.
- 37:52She introduces herself.
- 37:53She's interested in learning
- 37:55about her learners,
- 37:56ask them questions about themselves.
- 38:00She's she seems to be
- 38:01organized and structured.
- 38:02We don't see how the actual
- 38:03teaching session goes,
- 38:04but she's being very organized and thoughtful
- 38:07about how their their rounds will go.
- 38:10She's very learner focused.
- 38:11She asks them to identify goals,
- 38:14asks what the things that they'll
- 38:17be wanting to learn about,
- 38:19and it included all levels of learners,
- 38:22right?
- 38:22She has having her students
- 38:24present 1st and then you know,
- 38:27having at the different levels
- 38:29present after the students.
- 38:31I mean then you know,
- 38:32we don't know how engaging she is,
- 38:33but she seemed to be, you know,
- 38:35warm and and outgoing and she certainly
- 38:38was engaged with her learners.
- 38:40So a very different feeling of a
- 38:42learning climate from the first case,
- 38:43however,
- 38:44not perfect.
- 38:44And so I think there are some
- 38:46things that she could maybe
- 38:48have done a little bit better.
- 38:50You know,
- 38:50she's seeking feedback on how things
- 38:52are going, but not for a week.
- 38:54And after they've been together,
- 38:57that seems like kind of a long time
- 38:58to be checking in to see if if things
- 39:01are working well for the team.
- 39:02And she doesn't ask sort of upfront
- 39:05for input about how how to run things.
- 39:09She sort of tells the team
- 39:11how it's going to go.
- 39:12Many of us really like our residents
- 39:15to be the ones running the service and
- 39:17running the team and and coming up with,
- 39:19you know, how rounds are going to run.
- 39:21And so she's a little bit, you know,
- 39:24not learner focused in that way.
- 39:26Many of us would again really invite our
- 39:29our residents to actually participate
- 39:31a lot more right up front about about
- 39:33how the service is going to run.
- 39:35So those are the big things
- 39:37that I've identified it.
- 39:38Does anybody have any quick thoughts?
- 39:40Just before we we move on
- 39:42and and take questions,
- 39:45one person in our group noticed that
- 39:49she tapped the student and thought it
- 39:51may have been more appropriate to say
- 39:54we'll have you presented the bedside.
- 39:56Are you comfortable with that? Yes.
- 39:59Before putting her into that position,
- 40:01Yes, that's a really good point. Thank you.
- 40:06All right. So with that.
- 40:14Hopefully you leave here understanding
- 40:16that learning climate is a miliere in
- 40:19which learning takes place per learning
- 40:21climate diminishes the effectiveness
- 40:23of the teaching that you do.
- 40:24A good learning climate enhances
- 40:26teaching and helps with team building,
- 40:28and it really is foundational to
- 40:30everything else that you do in education.
- 40:32But the good news is learning
- 40:34climate involves a set of skills
- 40:36which can be practiced and mastered.
- 40:38And hopefully you feel like you've
- 40:40learned something here today
- 40:42that that can help you with that.
- 40:44So this is the hopefully you
- 40:46can all see this,
- 40:47this is the evaluation form.
- 40:51I don't know if Linda can pop this
- 40:53into the Zoom chat for us.
- 40:55It's in the chat, so.
- 40:57Oh, thank you. Thanks, Janet.
- 40:58And there's the, the QR code you can use.
- 41:02And we're going to set a timer
- 41:04for a minute to give everybody
- 41:08a chance to give us evaluation.
- 41:10And again, we are very interested
- 41:12in your feedback on the session,
- 41:15what went well,
- 41:15what we could do to improve things
- 41:17And then we'll be open for questions.
- 41:22And feel free to ask questions now, I guess.
- 41:24Yeah, just to say that the QR
- 41:26code is taking us to a different
- 41:29session when we. Yeah, the 6th. No,
- 41:35Linda, any thoughts is how about
- 41:37the URL works to the right one. OK.
- 41:40Oh, thank you. Thanks, John. Yeah,
- 41:42the one in chat takes us to the correct one.
- 41:44OK. Thank you everybody for realizing that.
- 41:51Hello.
- 41:56Any questions while people are
- 41:58doing their evaluations and we're
- 42:00happy to answer them just because
- 42:02we're officially out of time.
- 42:06We appreciate having such a
- 42:08great diverse audience of people
- 42:10with such a broad expertise and
- 42:12different levels of of training.
- 42:14It's great to have all of you here.
- 42:16We appreciate any input you can give
- 42:18to us to constantly improve this.
- 42:21So the CMA code says sorry,
- 42:27there was a problem with it.
- 42:28Linda's taking everyone's name down
- 42:30and she will submit them that we.
- 42:33Yeah, let's see the the
- 42:35text code did not work. OK.
- 42:38But all your names been registered,
- 42:40so you'll receive the credit.
- 42:43Yeah. It's a great session.
- 42:44Thank you. Thank you.
- 42:46And again, any any comments,
- 42:48last thoughts or questions,
- 42:49we're I'm happy to stay on for a
- 42:51few minutes and and answer them.
- 42:53And thank you so much for,
- 42:54for participating and the upcoming
- 42:56sessions are going to be amazing.
- 42:59These are all wonderful educators,
- 43:00so I strongly encourage you to attend them.
- 43:03Thank you so much. Thank you.
- 43:07Thank you very much.
- 43:08Great session. Thank you.