"TEACHING PEOPLE TO DOCTOR - Simple Strategies for Success" - Rachel Osborn, MD, M.A.T.
September 18, 2023Information
"TEACHING PEOPLE TO DOCTOR - Simple Strategies for Success" - Rachel Osborn, MD, M.A.T.
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- 00:00An educator series called Yes
- 00:03and that is I believe Fridays.
- 00:07So there is there is basically about
- 00:11every week or every other week a session
- 00:15that is geared towards enhancing
- 00:18your skills as educators and so very
- 00:21excited about this upcoming year.
- 00:24So wanted to introduce our first
- 00:27speaker of the year and it's really
- 00:30an honor to introduce Rachel Osborne,
- 00:34who I personally recruited back to Yale.
- 00:39I know there were many other voices,
- 00:41but particularly proud of this achievement.
- 00:46As you all know, Rachel,
- 00:47she's presently the residency
- 00:48director and as of July 1st,
- 00:51Associate professor of
- 00:54Pediatrics and hospital Medicine.
- 00:57And for those of you who might not have
- 00:59known Rachel for that long or her history,
- 01:02Rachel did her undergrad at
- 01:04Stanford and then got her Masters
- 01:06in Arts and teaching also,
- 01:10and that was at National
- 01:12Lewis University. It's a teachers
- 01:14college when I was a high school teacher.
- 01:17And so Rachel's kind of
- 01:21understanding education certainly
- 01:24far preceded this present position.
- 01:28She was a residence here,
- 01:32a chief resident in Med Pete's,
- 01:35and then was an instructor in
- 01:39Pediatrics as well as, let's see,
- 01:41an assistant professor before
- 01:43leaving us to go to University
- 01:47of Michigan for two years.
- 01:49At which point we recruited her back in
- 01:53order to become our residency director.
- 01:57Certainly Rachel has a strong history
- 02:02in Qi and her understanding of how
- 02:06to first of all problem solve,
- 02:11her adherence to critical thinking and
- 02:16her support for critical thinking in
- 02:19the residency program and her approach
- 02:22in terms of education as a systems
- 02:25process to me is just unparalleled.
- 02:29Rachel has done work in the
- 02:32X&Y scheduling for clinic.
- 02:34She's also done work in addressing
- 02:38bias and discrimination in the
- 02:41recruitment process and most recently
- 02:44is really I would say a pioneer
- 02:47in the ambulatory core rotations
- 02:50and that's just to name a few.
- 02:52And of course Rachel has every year the,
- 02:56regardless of which institution she's
- 03:00in has received honors in teaching,
- 03:03whether it's the honor roll here
- 03:06or University of Michigan.
- 03:07So I'm extremely,
- 03:09extremely honored to have Rachel as
- 03:12one of our educational leaders and
- 03:14certainly as our first speaker to
- 03:16kick off is year into the pediatric
- 03:20education learning community.
- 03:21So thank you,
- 03:22Rachel.
- 03:24Thank you so much, Panina,
- 03:25and thanks everybody for coming.
- 03:27It's actually really exciting to see
- 03:28this many people sort of excited to,
- 03:31to spend lunch with me today.
- 03:34This session is going to be interactive.
- 03:35I'm not going to do the thing
- 03:37with my residents where I make
- 03:39everybody turn on their cameras,
- 03:40but at some point I probably will
- 03:42ask folks to turn on cameras because
- 03:43we're going to go into breakout rooms.
- 03:45And talking to yourself on Zoom
- 03:47is always a little disconcerting.
- 03:49So if you're eating lunch or whatever,
- 03:51just be prepared that we are
- 03:52going to go into some breakout
- 03:54rooms a couple of times today.
- 03:56And this is really meant to be quite
- 03:59informal and sort of give you a little
- 04:01bit of an overview of how learning
- 04:04theory can inform the decisions
- 04:06we make when teaching residents.
- 04:09I will add. Medical students, I will.
- 04:11I will just offer a quick
- 04:14disclaimer before I begin.
- 04:15I'm in my office and my Wi-Fi is
- 04:17sometimes a little challenging here.
- 04:18So if I freeze for just a moment,
- 04:20know that I'm going to come back.
- 04:21But I turned off the blur,
- 04:23my background to save all my
- 04:25processor speed that I can.
- 04:27So to start, I have no disclosures.
- 04:28As I always say,
- 04:29if anyone has a lead on any way that I
- 04:31can get something that someone will pay
- 04:32me to do that I would have to disclose,
- 04:34just let me know.
- 04:35But until such time arises,
- 04:37I have no disclosures.
- 04:38And I'm going to start.
- 04:40I just came off a very busy week of
- 04:42service on the Blue Orange team.
- 04:43And I'm going to start by sort
- 04:45of talking a little bit about an
- 04:46actual case from this past week to
- 04:48give you a sense of how complex
- 04:50the task is that we're actually
- 04:52asking people to learn how to do
- 04:54in a really short period of time.
- 04:56So we have an 11.
- 04:58I I came into morning bolus my first
- 04:59day of service and heard from my from
- 05:02my night senior and my night intern
- 05:03in a little 30 minute conference in
- 05:05the morning that we had an 11 year old,
- 05:08previously healthy boy admitted with four
- 05:10days of progressive neck and back pain.
- 05:13And they went through and sort of told
- 05:15me different different facts about
- 05:17him including that he'd had a fever,
- 05:19had been in the emergency department
- 05:21and had had an unsuccessful LP
- 05:24attempted times two while he was in
- 05:27the while he was in the emergency
- 05:29room and was sort of admitted for
- 05:31this idea that he was going to be re
- 05:34LPD with interventional radiology.
- 05:38And so that was the,
- 05:39the handoff that I received and then
- 05:41asking some questions in conference,
- 05:44I learned a number of things.
- 05:46So I was very specific to ask,
- 05:47did they do a dedicated neurologic exam?
- 05:50And in fact they did do a dedicated
- 05:52neurologic exam and found that
- 05:54he had left upper extremity,
- 05:55numbness and weakness only in
- 05:57the Palmer aspect of his hand and
- 05:59sort of this part of his forearm.
- 06:02And I asked some other questions,
- 06:03including did he have any history of trauma?
- 06:05He did not. And I asked importantly
- 06:07if he'd had any altered mental status,
- 06:09been tired or cranky at all.
- 06:11And the answer was no.
- 06:13And it was, it was interesting because this
- 06:16patient was sort of presented to us as a,
- 06:18this is a kid who might have bacterial
- 06:21meningitis and we need to tell P him again.
- 06:23And the ultimate answer of what he
- 06:25had was cervical osteomyelitis with
- 06:26an Abscess that was compressing
- 06:28part of his upper spinal cord.
- 06:29We were able to sort of come to
- 06:32that decision that he needed an
- 06:33urgent MRI within about 6 minutes
- 06:36of discussion in the morning.
- 06:37But when you actually think about this case,
- 06:40it's incredibly complicated, right?
- 06:43It is an incredibly complex process by
- 06:46which we're asking brand new doctors to
- 06:49ascertain a differential diagnosis for
- 06:51things that don't always fit into a nice box.
- 06:55And So what I have here on the slide is,
- 06:59is Bloom's Taxonomy.
- 07:00Mine is the very top.
- 07:01I always leave Create off.
- 07:03I was a creative writing major.
- 07:04I'm allowed to be to be
- 07:06dismissive of the create,
- 07:07although that's that's an
- 07:08important thing at the end,
- 07:09but I like to end it evaluate when
- 07:11I'm talking about clinical reasoning.
- 07:14And so you can imagine that any
- 07:16resident or medical student who's
- 07:18going to ultimately arrive at
- 07:20this correct diagnosis first has
- 07:21to remember a number of facts.
- 07:23They have to remember how the
- 07:25dermatones work.
- 07:26They have to remember where
- 07:27people can get infections.
- 07:28They have to remember the types
- 07:30of of bugs and presentation
- 07:31that that might present with.
- 07:33They have to understand a little bit of
- 07:36how those facts apply to this current kid,
- 07:39right.
- 07:39They have to understand that not every
- 07:42single patient will will ultimately
- 07:44have a perfect presentation of spinal,
- 07:46of spinal root compression and
- 07:48they have to apply that knowledge
- 07:50to the kid in front of us.
- 07:52They have to think about what
- 07:53questions they're going to ask,
- 07:54how are they going to do a hypothesis
- 07:57driven history and physical.
- 07:58Then they have to analyze the
- 08:00data that they receive.
- 08:02So for example,
- 08:03this patient had a CRP of 180, right?
- 08:05They need to analyze that particular
- 08:08piece of information in order to
- 08:11create and evaluate a diagnostic
- 08:13plan or therapeutic plan.
- 08:15And so much of how we teach people
- 08:17in medical school and in residency
- 08:19in didactic sessions really focuses
- 08:21on these bottom parts.
- 08:23We're really trying to get people
- 08:25to remember facts and sort of have a
- 08:27have a surface understanding of how
- 08:29of how those facts impact patient care.
- 08:31So I'm guilty of this.
- 08:33You know, it's like the,
- 08:33the leading question,
- 08:34you know,
- 08:35what bacteria are you most worried about
- 08:37in a patient who has a bone infection?
- 08:39That's a fact, right?
- 08:40That's a fact that we want them to
- 08:43remember and they need to remember that
- 08:46fact in order to apply an antibiotic
- 08:48regimen for for a given patient.
- 08:50But we often end up stopping right
- 08:53here at those remember and those
- 08:55understand and sort of spoon feeding
- 08:57our residents or our students.
- 08:59The rest of this we say you're right,
- 09:01it's staff or strep.
- 09:02And so we're going to give
- 09:03Oxicillin and there's there's some
- 09:05opportunities here to think about
- 09:07these higher order objectives.
- 09:08When we go through our process
- 09:11today and think about how we're
- 09:13actually teaching people to do the
- 09:15complex task of being a doctor.
- 09:17Because it's not just knowing the facts.
- 09:19It's also things like how am I going to
- 09:21elicit this history from a child who's
- 09:23pretty afraid and in a lot of pain?
- 09:25This particular family spoke Spanish.
- 09:27How am I going to utilize an interpreter
- 09:30to adequately ascertain this history?
- 09:32There are so many pieces that go into
- 09:35teaching someone how to actually be an
- 09:38effective clinician in in an environment,
- 09:41whatever that environment is,
- 09:42be it an acute care environment,
- 09:44a hospital, a clinic and outpatient setting.
- 09:47We really need to be thinking about
- 09:49how are we using our learners at
- 09:52all stages of Bloom's Taxonomy.
- 09:55And I'd like to take just a moment
- 09:57to think about how we can engage
- 09:58our learners in this.
- 09:59I hear the phrase,
- 10:01quote UN quote adult learners a lot.
- 10:03When I talk about residents and
- 10:05medical students, I hear the phrase,
- 10:06well, they're adult learners,
- 10:07so they'll read on their own, right?
- 10:09Or they're adult learners,
- 10:10so they're going to choose if they
- 10:11want to come to noon conference or not.
- 10:13And I think we use this phrase to imply
- 10:17something that it doesn't necessarily.
- 10:19That's not actually what adult learners are.
- 10:22So adult learners refers to a
- 10:24very specific learning theory,
- 10:25sort of within the humanistic
- 10:27lens of learning theory that talks
- 10:29about how adults approach learning
- 10:31slightly differently, right,
- 10:32than a first or a second grader.
- 10:33So they tend to be problem oriented.
- 10:35They like to apply their previous
- 10:37life experience to that problem.
- 10:39They're theoretically internally
- 10:40motivated to learn certain things
- 10:42and are more ready to learn,
- 10:43and they're they therefore they
- 10:45can be more self-directed.
- 10:47But that doesn't simply mean
- 10:48that we say to an adult learner,
- 10:50hey, you want to be a doctor,
- 10:51go read up to date and pub bed
- 10:53and come back to me in a week.
- 10:54There's still an argument to be made
- 10:57for really significant scaffolding,
- 10:59and I think it's also a misunderstanding
- 11:01to assume that everyone who is an adult
- 11:04who is also learning is by definition
- 11:07an adult learner in that setting.
- 11:09So I was joking before I began
- 11:11that I was trying to figure out
- 11:13how to rewire the the lights in my
- 11:15house this past weekend.
- 11:17The lights in my children's rooms
- 11:18have been wonky for some time,
- 11:20right? So yes, that's been
- 11:22true for two years, right?
- 11:24You can make an argument that
- 11:25I should have been an adult
- 11:27learner for two years, right?
- 11:28I had a problem,
- 11:29Don't have a lot of experience,
- 11:30but theoretically I'm internally motivated.
- 11:32I should be self-directed, right?
- 11:34And ultimately one day decided that
- 11:36I was going to be an adult learner
- 11:38in this setting and I was going
- 11:39to figure out how to fix this.
- 11:41But it took a little while and
- 11:43there were a lot of things that
- 11:44sort of entered into my decision to
- 11:47eventually decide to rewire my house.
- 11:48And that's true for everyone who's
- 11:51learning these very complex clinical
- 11:52structures that we're asking them
- 11:54to learn in residency as well.
- 11:56So self motivated does not
- 11:59necessarily mean fully independent.
- 12:01And I bring up Maslow's hierarchy
- 12:02within this as well because I think
- 12:04it's important to remember that
- 12:06residents are human beings and adult
- 12:08learners and that certain things
- 12:09need to be met in order for them to
- 12:12actually do the hard work of being a learner.
- 12:15So self,
- 12:16self motivated learners are often within
- 12:18this sort of top tier on Maslow's hierarchy,
- 12:21right?
- 12:21They're realizing their potential.
- 12:23They have self actualization.
- 12:24But in order to achieve that,
- 12:26we have to make sure that they have
- 12:27at least some baseline functioning
- 12:28of these things below them, right?
- 12:30So food, shelter, warmth.
- 12:32I don't know if you guys have
- 12:34noticed if any of you are ever
- 12:35in the inpatient setting,
- 12:36but our residents have a how much
- 12:39water did I drink board on their
- 12:41walls in all of these rooms?
- 12:42So they're actually calculating how
- 12:44many times they drink water in a day.
- 12:46And I have yet to see a single
- 12:48team actually meet their goal.
- 12:50Right. So did they get to pee?
- 12:51If they're a nursing mom,
- 12:52do they have time to go express breast milk?
- 12:54Right.
- 12:54Like,
- 12:55what are we actually needing
- 12:56their physiologic needs?
- 12:57The answer is often no, right?
- 13:00And then there's this question
- 13:01I'm so happy Panina brought up,
- 13:03you know,
- 13:03our upcoming session on sort of safety,
- 13:05right.
- 13:05And the idea of safety that
- 13:07do people feel protected?
- 13:09So we had an incident last year
- 13:11in which a resident was sort of
- 13:14verbally and nearly physically
- 13:15threatened by a parent who was
- 13:18secretly filming the entire encounter.
- 13:20And that resident really wanted
- 13:22there to be some support from from
- 13:24faculty and from hospital leadership
- 13:26to make sure that she knew she was
- 13:28still safe in this environment.
- 13:30And until we were able to sort
- 13:32of demonstrate that in fact
- 13:34that learner is protected here,
- 13:35they aren't going to be able
- 13:38to be self actualized and it's
- 13:40foolish to think they can.
- 13:42I think it's also important to realize
- 13:43that people want to feel connected.
- 13:45One of the reasons why we as a
- 13:47residency program spend so much time
- 13:49and energy forming peer-to-peer
- 13:50connections is because that's
- 13:52crucial for people to becoming
- 13:53self actualized as
- 13:54doctors do. People care who they are, right?
- 13:58So one of the examples that I sometimes give,
- 14:00and this isn't meant to throw shade
- 14:02at the University of Michigan,
- 14:03I was very happy there.
- 14:04But when I won their teaching award,
- 14:07the quote that was read out loud about
- 14:08me at the banquet that started the
- 14:10the session in which they gave me this
- 14:12award was from a thirdyear resident
- 14:14who said Doctor Osborne is unique and
- 14:16that she treats us like actual human
- 14:19beings with names that she remembers.
- 14:21And I think we all have to sort of let
- 14:24that sink in for a second because I I
- 14:26think I have personally encountered many,
- 14:28many times in which someone has
- 14:29wanted to give me constructive
- 14:31feedback about a learner.
- 14:32And I say, well, who was the learner?
- 14:34And the faculty doesn't
- 14:36know that learner's name.
- 14:37And so this is they they aren't going
- 14:39to be able to achieve what we want
- 14:41them to achieve if we don't take the
- 14:43time to sort of know who they are,
- 14:45at least on a very surface level.
- 14:49And then residents and students want
- 14:50to feel like their value added.
- 14:52They want to feel like the process and
- 14:54the work that they're doing is important
- 14:56to the ultimate care of the patient.
- 14:58They want to feel respected.
- 15:00Now that doesn't mean that we just tell
- 15:02them that their ideas are always right,
- 15:04but listening to their ideas and asking
- 15:06probing questions about those ideas,
- 15:08those are things that help
- 15:09residents and students become
- 15:11sort of self actualized learners.
- 15:13And then we get to this question right.
- 15:14I I love when my third years are
- 15:17starting to panic because they
- 15:18realize that in fact they're going to
- 15:20be in charge next year or at least
- 15:22partially in charge in many settings.
- 15:24And that's when you're starting to to
- 15:26develop that self actualization, right?
- 15:27Am I ready to know what I know?
- 15:29What I don't know?
- 15:30Am I ready to access the resources
- 15:32that I need to access?
- 15:34But in order to get there,
- 15:35we really need to be thoughtful about
- 15:37these things below it or else we're
- 15:40never going to have a learner who
- 15:42ultimately becomes self actualized.
- 15:44So Adult learner Theory is really
- 15:46based in the same idea of Self
- 15:48Determination Theory.
- 15:49I use a lot of Liz and Molly cartoons.
- 15:51I love Liz and Molly.
- 15:52If you guys don't follow them on Instagram,
- 15:54I highly suggest it.
- 15:55But the idea here is that residents
- 15:57and students need to feel like
- 15:59they're always sort of moving and
- 16:01that they can reach the top.
- 16:03And this is based in in
- 16:06psychological learning theory,
- 16:07that this doesn't just happen
- 16:08because you turn 20 and all of
- 16:10a sudden you're adult learner.
- 16:12And it doesn't just happen because
- 16:13you become to medical do you go
- 16:15to medical school?
- 16:16There are three components of helping
- 16:18people be effective adult learners
- 16:21with effective self determination.
- 16:23And those 3 components are connection,
- 16:26competence and autonomy.
- 16:27So people have to feel
- 16:29like they've got a buddy,
- 16:31that they have someone who cares
- 16:32about them and that they're part of a
- 16:34system that cares about who they are.
- 16:36They have to feel like they're
- 16:37learning what they're doing.
- 16:38Like they kind of know what they're doing
- 16:40and have the opportunity to continue to
- 16:42grow because they have baseline competence.
- 16:44And then they have to have
- 16:46some degree of autonomy.
- 16:47And we're going to talk a little bit about
- 16:49that autonomy at the end of the session.
- 16:53So I'm going to ask us all to be
- 16:55a little bit vulnerable here,
- 16:57and we're going to go into
- 16:58some breakout rooms.
- 16:59But I will role model this first.
- 17:02I think one of the things that's very
- 17:05challenging for residents in training,
- 17:07and one of the reasons why medical
- 17:09trainees have probably the highest
- 17:11rates of burnout and depression of any
- 17:14profession in in the United States is
- 17:16because they can feel incredibly isolated,
- 17:19right?
- 17:19We we have an unwritten curriculum
- 17:22that you repress and ignore,
- 17:24repress and ignore,
- 17:25repress and ignore and that actually
- 17:27having any kind of emotional
- 17:29response to something that happens
- 17:30at work is a sign of weakness.
- 17:33And I can tell you one of the
- 17:35things that's been sort of most
- 17:36powerful for me in creating a little
- 17:37bit of a learning and creating a
- 17:39positive learning climate is being
- 17:41willing to admit when I have an
- 17:43emotional response to something or
- 17:45when I regret a decision that was
- 17:48made or a mistake that I made.
- 17:50So I've led a noon conference in which I
- 17:52talk about as a as a second year resident,
- 17:54a patient was admitted with
- 17:56increased work of breathing who I was
- 17:58pretty sure had a cardiomyopathy,
- 18:00but I thought it could wait until
- 18:01the morning and that patient
- 18:03coded at 5:30 in the morning.
- 18:05And I still think about that case
- 18:08and being able to share that with
- 18:10with residents and talk about
- 18:11how difficult it was for me to
- 18:13go through that as a learner.
- 18:14But also what I learned from and how
- 18:17I moved forward is it it allows our
- 18:20residents to feel connected and to feel seen.
- 18:24I also talk a lot about my and I'm I'm,
- 18:26I'm like this bonus.
- 18:27I'm not asking anyone to be quite
- 18:29this vulnerable today guys.
- 18:30I'm leading the session.
- 18:31So don't worry.
- 18:32You don't have to bury your your
- 18:34deepest most personal secrets.
- 18:35But many of you have probably
- 18:37heard me talk about this,
- 18:39that I had a very difficult time
- 18:40with nursing, with my first child.
- 18:42And really it was, it was sort of in in.
- 18:45It was all wrapped up in what is,
- 18:47in hindsight,
- 18:48very obviously recognized as
- 18:49severe postpartum depression.
- 18:50And I wrote about this and
- 18:52it was published in a jam,
- 18:53a piece that residents have read and
- 18:55have approached me and talked to me about it.
- 18:57And I think being willing to
- 18:59admit that I am
- 19:00a person who is also a physician has
- 19:02been really, really helpful for our
- 19:05residents and for learners overall.
- 19:07I have never had a learner
- 19:08come to me and say, man,
- 19:09I wish I didn't know that about you.
- 19:12They've always come to me and said
- 19:13that they really appreciate that.
- 19:15I make it a little more normal for
- 19:17them to be going through some of these
- 19:19feelings that they might be going through.
- 19:21So we're I'm not going to make
- 19:22anyone do it in a big group.
- 19:24But Karina,
- 19:24we're going to put people in breakout
- 19:27rooms and I want everybody for
- 19:295 minutes to think about a case.
- 19:32Everyone's going to take two or
- 19:34three minutes each.
- 19:34You're going to think about a day that
- 19:37you had an actual emotional response
- 19:39to something at work and you're
- 19:41going to authentically validate it
- 19:43to one another in your small group.
- 19:46It's Vegas rules.
- 19:47What happens in the breakout rooms
- 19:49stays in the breakout rooms.
- 19:50People are only allowed to share
- 19:52their own story, Okay.
- 19:53So Karina,
- 19:53can we put people in in the
- 19:55rooms and we'll come back here in
- 19:57about 5 or 6 minutes guys?
- 20:11And I sent you instructions,
- 20:12Rachel, for how to share in the
- 20:14breakout rooms if you want to. OK,
- 20:16perfect. I need it for the last
- 20:17one, but not for this one.
- 20:24All right. Looks like
- 20:26everybody's in. OK. Perfect.
- 20:32Gives me a little break.
- 20:44There's one room ended up
- 20:45with only two people. I think
- 20:47a few people. As long as they're
- 20:48both active in it, it'll be fine.
- 21:02I'm going to try to do this real
- 21:03quick and see if it lets me.
- 21:04I'm going to stop, share, and reshare
- 21:06while they're in the breakout rooms.
- 21:11There we go. Perfect.
- 21:15It does work. I've never done it before,
- 21:17but I just googled how to do it
- 21:27for the next breakout. Do we want
- 21:28to keep the same people together?
- 21:31It's a completely different vibe.
- 21:33Then I'll probably change it up just
- 21:36to for the sake of changing it up.
- 21:46You
- 21:50need to speak more often. This is
- 21:52the best attended health yet. Well,
- 21:55we'll see how it goes.
- 21:56I don't know that I've got
- 21:58anything that amazing to say.
- 22:00I'm just like, let's all talk
- 22:01about our feelings, guys.
- 22:02We and I had a couple of robots
- 22:05and I had a couple people ask music
- 22:08recorded. So people are interested.
- 22:18I'm going to send a broadcast.
- 22:25Do
- 22:36you know if we have a timer
- 22:38on these breakout rooms?
- 22:38We probably can't tell, can we?
- 22:40We usually do like a 62nd timer.
- 22:44I'm going to assume we do.
- 22:50I'm sorry, I have myself on mute.
- 22:52When you hit closed rooms,
- 22:54it starts a sticky 62nd timer.
- 22:58So just let me know when you're ready
- 23:00for me or if you want. You said you
- 23:02sent a message already out, right?
- 23:03I sent a broadcast to people that said
- 23:05two minutes, so I'll tell you when
- 23:06we should actually try to close them.
- 23:23It's Betty. I'm not sure
- 23:24when you say close all rooms,
- 23:26you may have to recreate them
- 23:27again. I'm not sure. Yeah,
- 23:29I'll recreate them again.
- 23:31Thank you. Sorry guys.
- 23:44Okay, we can hit close all rooms.
- 23:59Hi, Jim. Hi Rachel.
- 24:01Sorry, accidentally clicked
- 24:02leave the room a little early.
- 24:04That's Okay. I do that all the time.
- 24:07Thanks for joining today.
- 24:08This is great.
- 24:17I
- 24:51Hi, boss.
- 25:00Right, So it looks like
- 25:02people have made it back.
- 25:03I I don't see anyone in hives
- 25:05or tears so I'm assuming that
- 25:08that that process was okay.
- 25:10But I I just really want to
- 25:12tell you it it takes it.
- 25:13The first time I ever did this
- 25:15right really talked about something
- 25:17that really was hard for me.
- 25:18I was so nervous.
- 25:19I thought I was going to
- 25:21make the residents afraid.
- 25:22I thought they were going
- 25:24to lose respect for me.
- 25:25I was a relatively junior attending
- 25:27when I did this the first time and
- 25:29and I just have to tell you that
- 25:31it it pays dividends and their
- 25:33willingness to engage with you in the future.
- 25:36So you don't have to do that every day.
- 25:38Other strategies that are really
- 25:40important for sort of connection,
- 25:42what I call connection light, right,
- 25:44is ask their names and then use them.
- 25:47So I'm not good with names.
- 25:49I'm really not.
- 25:49I've learned a lot of skills over
- 25:51the years to get better at it,
- 25:53partially from when I was a teacher
- 25:55and partially from just having
- 25:56sort of this job that I have.
- 25:58But I write their names down on
- 25:59the back of my patient list.
- 26:01And at the end of the day,
- 26:02when I'm done writing my notes,
- 26:03I refresh and I remind myself
- 26:05I've put them in my phone before,
- 26:07right, so you can cheat.
- 26:08No one is saying you can't have
- 26:10a cheat cheat,
- 26:11but ask their names and use
- 26:12them on a consistent basis.
- 26:14Small gestures of appreciation go a long way,
- 26:17right?
- 26:18Saying thank you can be really,
- 26:21really important.
- 26:21I remember when I was a trainee one
- 26:25day I spent two hours organizing
- 26:27A sedated lymph node biopsy and
- 26:30MRI for a patient only to have the
- 26:33attending tell me it was going to be
- 26:35cancelled 3 minutes after I did it.
- 26:37And I was like,
- 26:39and then the fellow looked at me and said,
- 26:41thank you so much for your hard work.
- 26:42I know that that was really unfortunate
- 26:44that you did all that for nothing.
- 26:45And I remember it now as a positive
- 26:47thing instead of as a negative thing.
- 26:49And so small gestures of appreciation
- 26:52really can help those connections form.
- 26:55And I just like to make a little,
- 26:56a little reminder that we can all
- 26:58be part of ending generational
- 27:00trauma and medical training.
- 27:02Yes, we all have horror stories,
- 27:04and the vast majority of us will
- 27:06have trained in a time that was
- 27:08empirically more challenging than
- 27:09the residents who are training today.
- 27:11But that doesn't mean that that's
- 27:12the right way to have done it.
- 27:14So the picture here is my daughter
- 27:16wrote this book about feelings
- 27:18that she published and like,
- 27:19sold a bunch of copies of.
- 27:21And this is her.
- 27:22This is like her, her,
- 27:23her essential representation of
- 27:25what it is to sort of heal,
- 27:28right.
- 27:28And so really thinking a
- 27:29little bit about how
- 27:30we can be part of that,
- 27:31acknowledging things that
- 27:32happened to us that were hard,
- 27:34but not necessarily leveraging that
- 27:36misery on someone else because we think
- 27:38that's the only way to teach them.
- 27:42All right, let's move on
- 27:43to the next one. I promise.
- 27:45All the feelings are done now, guys.
- 27:46So the next one really has to do with,
- 27:49with competence, right?
- 27:51So we talked that residents need connection.
- 27:53Residents also need to feel like they
- 27:56are becoming increasingly competent,
- 27:58and one of the ways in which
- 27:59residents can feel that the most is
- 28:01in helping them develop their skill
- 28:03set and clinical reasoning, right?
- 28:05So this takes a whole different
- 28:06learning theory.
- 28:07This really is moving away from the
- 28:09humanistic learning theory and moving
- 28:10much more into into some sort of
- 28:12social cognitive learning theories.
- 28:14But the idea behind this is teaching
- 28:17people to recognize how they are
- 28:20thinking and that can be an incredibly
- 28:22useful tool in helping residents and
- 28:24medical students learn a little bit
- 28:26more of how to be sort of effective
- 28:28clinicians in different in different arenas.
- 28:31So who just I know, Not everyone.
- 28:33I wouldn't even ask.
- 28:34Show of hands Zoom is the worst.
- 28:36Anyhow,
- 28:36I'm assuming many people have
- 28:38heard of type one thinking,
- 28:39which is sort of heuristic thinking.
- 28:41So it's like that knee jerk reaction.
- 28:43This is the kid who has a history of eczema
- 28:47and a strong family history of asthma,
- 28:49who's presenting at age 3 with
- 28:52whee's right and and it's natural for
- 28:54physicians to use a little bit of knee
- 28:56jerk thinking when we hear that right,
- 28:57like okay, let's give that's asthma,
- 28:59right?
- 28:59Let's give that kid treatment for asthma.
- 29:02Whereas type 2 thinking is really forcing
- 29:04yourself to slow down and be like,
- 29:06are there components of this
- 29:08particular history and physical that
- 29:10don't fit with what I think, right.
- 29:12And so or what is the differential
- 29:14that I could actually generate that
- 29:16might be relevant for this patient.
- 29:18So a few weeks ago,
- 29:20I had a patient admitted on service
- 29:22who had had recurrent wheeze for his
- 29:24whole life but had no personal family
- 29:27history of A to P and no no personal
- 29:29or family history of A to P including
- 29:31like an IGE of nothing and EO's of nothing.
- 29:34And my team just had a conversation
- 29:36that that's interesting,
- 29:37right.
- 29:38That's puzzling.
- 29:38That makes us wonder,
- 29:39is it possible that this kid could
- 29:42have ciliary dyskinesia or another
- 29:44reason for his ongoing we use that
- 29:46isn't necessarily traditional asthma.
- 29:48And so helping people recognize
- 29:50when they're using sort of quick
- 29:52thinking and when it's important
- 29:54to slow down is really crucial.
- 29:56This is something most advanced physicians,
- 29:58right,
- 29:59which I'm calling us all advanced physicians.
- 30:02A medical student the other day
- 30:03called me an expired millennial.
- 30:04So I'm going to call us all
- 30:07advanced physicians.
- 30:07And so thinking a little bit about
- 30:10those that that idea of like when we
- 30:13recognize that something doesn't fit,
- 30:15but saying that out loud and role
- 30:17modeling that for learners is
- 30:19incredibly important rather than
- 30:20just saying this is an asthma,
- 30:22this is ciliary dyskinesia.
- 30:23Saying the reason why I think
- 30:25this is an asthma is because XYZ and being
- 30:28really explicit and role modeling that
- 30:31the other really important thing that
- 30:34can be helpful is creating a skill set
- 30:37and developing an illness script, right.
- 30:39And so one of the things,
- 30:41one of the concrete takeaways
- 30:42I really want you guys to,
- 30:44to learn from today's talk is how easy
- 30:46it is to teach residents and students
- 30:48to create an illness script for a given
- 30:51presentation and how useful that is for
- 30:53them in widening their diagnostic library.
- 30:57So I have a whole bunch
- 30:59of illness scripts here.
- 31:00I tried to sort of spread out Outside
- 31:02of just the hospitalist world though
- 31:05you'll notice that I I'm bad,
- 31:07I don't know,
- 31:07a lot of clinical medicine outside
- 31:09my own purview, but that's okay.
- 31:11So you know, you,
- 31:12you might say that we have a four
- 31:14day old X30 X 36 week infant
- 31:17with hypoglycemia to 40, right.
- 31:18That is an illness script.
- 31:20That's a pretty straightforward
- 31:21illness script, right,
- 31:23a 17 month old admitted with
- 31:25recurrent wheeze.
- 31:26So things we might add to that.
- 31:28So you can say things like is this acute,
- 31:31subacute or chronic,
- 31:32making sure every presentation the
- 31:34residents are recognizing acute,
- 31:36subacute or chronic recognizing
- 31:37criteria that might come along with
- 31:40that particular patient, right.
- 31:42So a 17 month old with no past medical
- 31:44history of any kind is different than
- 31:46a 17 month old who has a history of peanut,
- 31:49an egg allergy as well as
- 31:51severe refractory eczema,
- 31:52right.
- 31:52And so adding those small details
- 31:55can be incredibly helpful.
- 31:57I'll say,
- 31:57like a 10 year old who presents with
- 31:59unilateral pain and swell knees,
- 32:01pain and swelling and mild anemia.
- 32:03So that would be one we're really knowing,
- 32:04like is this acute?
- 32:05Did the kid wake up that way or
- 32:07was this subacute,
- 32:08did this happen over a period of weeks?
- 32:10Is it recurrent?
- 32:11Is it the only time it's ever happened?
- 32:13So adding those qualifiers is really,
- 32:16really crucial because I find
- 32:18that many residents and students
- 32:20present a summary statement when
- 32:22they tell me their assessment.
- 32:23So they say things like,
- 32:25oh, well,
- 32:25this is an 8 year old with refusal to
- 32:28to take solid PO for a week, right.
- 32:30I'm like, OK, well,
- 32:30I remember that from when you
- 32:32actually presented the kid, right.
- 32:33So let's add a few more qualifiers.
- 32:35Right.
- 32:36So it's an 8 year old with subacute
- 32:39decrease in oral intake and an acute
- 32:41refusal to take PO to solids with
- 32:44maintained hydration status, right.
- 32:45So really forcing them to add as
- 32:48many qualifiers as they can that
- 32:51we think are relevant.
- 32:52So I tell people this is the,
- 32:55this is the, the rhythm to follow, right.
- 32:57So age and comorbidities, who is the kid?
- 33:00Is this a kid who has chronic?
- 33:02Is this a kid who's technology
- 33:04dependent or not?
- 33:05Is this, you know,
- 33:06to use a neonatology example,
- 33:08right?
- 33:08Is this a kid who was born at term
- 33:09or is this a kid who was born at 26 weeks?
- 33:11Those are very different posts, right.
- 33:14So those those types of things, you know,
- 33:16all three month olds are not created,
- 33:17the equal and so age and comorbidities
- 33:20is important, Acute, subacute,
- 33:22chronic, recurrent or or non
- 33:24recurrent are important things.
- 33:26And then I force learners to pick
- 33:283 words to describe what they have
- 33:30because otherwise you'll find that they
- 33:32just want to pick everything, right.
- 33:34They'll say, well,
- 33:34this is a 10 year old,
- 33:36previously healthy child with
- 33:38acute right sided knee pain who's
- 33:40presenting with a normal CRP and a
- 33:43normal white count and a little bit
- 33:45of anemia and a rash on their belly
- 33:47and had a headache three days ago.
- 33:49And they find themselves just
- 33:51repeating everything that they
- 33:52originally said in their presentation.
- 33:54So forcing them to sort of nickel
- 33:56down to three will help them to
- 33:59develop this illness script.
- 34:01This is a habit that I've taken to for
- 34:02all of our when we do morning boluses,
- 34:04which is when we have the night
- 34:07team present their day admissions.
- 34:08I force the night team when they get
- 34:11to their assessment to say stop,
- 34:13give me this kind of assessment
- 34:15every single time.
- 34:16And in doing that,
- 34:18you will find that they're better
- 34:19able to elucidate why they might want
- 34:21to do the next step that they want
- 34:23to do or if the next step that they
- 34:25presented is in fact not the right next step.
- 34:28So with that case that I presented, I said,
- 34:30I said so now we've got a 10 year old,
- 34:31previously healthy kid with acute fever,
- 34:35neck pain and upper extremity symptoms
- 34:39and unilateral upper extremity symptoms.
- 34:40Do you really think an LP is the next step?
- 34:43And the first thing out of their
- 34:44mouth was no,
- 34:45we need an urgent MRI of the neck.
- 34:47And I said great,
- 34:48let's do an urgent MRI of the neck.
- 34:49And so really pushing them to
- 34:51think about that illness script
- 34:53can be incredibly useful.
- 34:56So I was going to pick.
- 34:59I was going to pick on some people,
- 35:00but I feel like there's a lot of people here,
- 35:02and that will be mean.
- 35:03Unless anyone wants to.
- 35:05I'll just do it. Sorry.
- 35:06Well, I'll just listen to my own
- 35:08sound of my voice a little more.
- 35:10So really thinking about how to flush out
- 35:12these illness scripts a little more, right?
- 35:14So another case from last week,
- 35:16a four month old who
- 35:17presented with a diaper rash.
- 35:19So this is a better illness
- 35:20script for it right?
- 35:22A four month old,
- 35:23otherwise healthy child who presented with
- 35:25an acute on chronic non blanching violations,
- 35:27papular diaper rash.
- 35:28The actual diagnosis there?
- 35:30Langerhans cell histeocytosis.
- 35:32Thank you Adam Burke for picking
- 35:34that up from just Googling it.
- 35:36But you can really see that forcing
- 35:38people to be thoughtful about that
- 35:41very specific illness script is,
- 35:43is crucial.
- 35:47And so, you know, another example here,
- 35:50right, is that this is a 7.
- 35:52You know, instead of just saying
- 35:53a 17 month old who was wheezing,
- 35:54a 17 month old with significant
- 35:56atopic history, who presented with
- 35:58subacute wheezing times 3 weeks
- 36:00without fever or rhinorrhea, right.
- 36:02And so that starts to be like,
- 36:04OK, so maybe this kid actually
- 36:05has a foreign body, right?
- 36:07Or maybe this kid has some kind of
- 36:09airway anomaly and not asthma because
- 36:11the illness script no longer fits
- 36:13with necessarily a presentation of
- 36:16asthma or recurrent preschool weeks.
- 36:19All right,
- 36:19so we're going to move on to the last,
- 36:21the last criteria.
- 36:23So we talked about methods to
- 36:25create connection.
- 36:26We talked about methods to increase their
- 36:29subjective feeling of competence and
- 36:31making diagnosis and developing plans.
- 36:33So now I want to talk about the one that's,
- 36:34you know,
- 36:35traditionally thought of as the most floated,
- 36:37which is autonomy.
- 36:38I have learned over the years that pediatric
- 36:41attendings hate when I talk about autonomy,
- 36:44right.
- 36:44And that our brains all start to move
- 36:46towards this thing that's like, yeah,
- 36:48but they don't know what they're doing.
- 36:49Or.
- 36:49Yeah, but not in my clinical arena, right.
- 36:52Or. Yeah, but but not yet.
- 36:54And I want us to just turn off those,
- 36:56yeah,
- 36:56butts for a second and hear me
- 36:59out about ways in which we can
- 37:01actually promote autonomy and
- 37:03really help you understand how
- 37:05crucial it is to promote some
- 37:07autonomy if we want our learners to
- 37:10become self actualized physicians.
- 37:13So I defined, I Googled this,
- 37:15I defined autonomy.
- 37:15Me and Google were like this lately.
- 37:18So having the authority to make one's own
- 37:21decisions and the freedom to act right.
- 37:23So in the clinical arena,
- 37:24right.
- 37:25It's the idea that like our
- 37:26residents able to make a decision
- 37:28and implement that decision without
- 37:30betting every single component of
- 37:32that decision with someone else.
- 37:34Because if they have to vet every
- 37:35component of the decision over time
- 37:37they're going to stop making those decisions.
- 37:39In their mind they're going to
- 37:41just wait to be told what to do.
- 37:43And and this is a crucial piece of them
- 37:46becoming self actualized physicians.
- 37:48So we want to think about how can we,
- 37:49how can we promote autonomy safely
- 37:52in a variety of clinical spheres.
- 37:55So I also will just tie this back
- 37:58to to Maslow's hierarchy, right.
- 38:01And the idea of respect.
- 38:03So I'll be honest,
- 38:05I have had learners catch things
- 38:07that I haven't caught.
- 38:09I suspect that's true for nearly
- 38:11everyone on this call, right.
- 38:13I've said something and a
- 38:14resident has been like, yeah,
- 38:16but they actually had a fever to 103.
- 38:18So don't you want to do this?
- 38:19I'm like, oh, yes, I do, right.
- 38:22And so if I haven't made an
- 38:25environment in which it's clear
- 38:26that I care what they have to say,
- 38:29I'm actually way more dangerous
- 38:31as a physician than I would be
- 38:33if I just told them everything.
- 38:35You know, like if I just tell them
- 38:37everything and they never bring up a thought,
- 38:39I'm way more dangerous than I am if
- 38:41I'm making some space for them to
- 38:43offer their perspectives and ideas.
- 38:45Because eventually you will
- 38:46create this this world, right,
- 38:48in which people feel like their
- 38:50voice doesn't have a space,
- 38:51so why would they share anything?
- 38:53And that's bad for patients
- 38:55and it's bad for education.
- 38:58So we're going to use a strategy
- 39:00called the One minute Preceptor.
- 39:03And I talk about this strategy as a way
- 39:06to it's it's autonomy light, right.
- 39:08It's it's,
- 39:09it's a way to make residents feel
- 39:11that they're growing into an
- 39:13autonomous physician without having
- 39:14to give them so much autonomy that
- 39:16we're all wringing our hands and
- 39:18developing ulcers about the decisions
- 39:19that are being made overnight.
- 39:21So this is the these are the components
- 39:24of the one minute preceptor.
- 39:26A resident presents something to you.
- 39:27It can be a full HMP, it can be a blood gas,
- 39:30it can be anything, right?
- 39:32It can be a new lab.
- 39:33This, this CRP went from 180 to 80
- 39:36and I asked the learner for a commitment.
- 39:39It can be any commitment.
- 39:41I'm going to pick on Lubena because
- 39:42she's a hospital medicine fellow.
- 39:43I'm not actually going to make
- 39:44you say anything,
- 39:45Lubena, don't worry.
- 39:45But I would say to Lubena,
- 39:47so when do you want to check another CRP?
- 39:50And Lubena is going to answer me
- 39:52and then I'm going to say why.
- 39:54So if Lubina says I want to check
- 39:56another CRP because I think we
- 39:57might be able to transition off
- 39:59IV antibiotics tomorrow,
- 40:00I'm like this is not going to happen.
- 40:01You're not going to go from 80
- 40:03to 3:00 tomorrow, right?
- 40:03So I can give her some feedback
- 40:06about her thought process.
- 40:08But if Lubina says I want to check
- 40:10another CRP in four days because
- 40:11I think she's is down trending,
- 40:13we don't need to check it as long
- 40:15as he's staying clinically well.
- 40:17And I think that might be a time
- 40:18in which we can push infectious
- 40:20disease to come up with a final
- 40:22duration of treatment.
- 40:23Well, all of a sudden,
- 40:24two things have happened.
- 40:25One, Lubina's been able to demonstrate that,
- 40:27in fact, she does know what she's doing,
- 40:30right?
- 40:31And two,
- 40:32I now trust Lubina more because I now
- 40:35know that in fact she has thought
- 40:37this through and has made a great decision,
- 40:40right?
- 40:40And so either the resident learned
- 40:42something that they didn't know
- 40:44before or we learned something
- 40:46about that resident that allows
- 40:48us to give them more autonomy and
- 40:51similar situations in the future.
- 40:52And so the the criteria of of the
- 40:54of the one minute researchers,
- 40:56you ask for a learner,
- 40:57you ask them why you provide feedback.
- 40:58And then if there's a general learning point,
- 41:00particularly if you're in a room, right.
- 41:02If you're in a group of people,
- 41:03you can say, yeah, that sounds great.
- 41:05This is why this is the right answer here.
- 41:07Right. You know,
- 41:08we generally can transition to oral
- 41:11antibiotics when the CRP is nothing
- 41:13for uncomplicated osteomyelitis,
- 41:14whatever that general rule might be.
- 41:16So everyone has learned,
- 41:18but Lubene has been able to utilize
- 41:20some autonomy and I have demonstrated
- 41:22that I respect her opinion by asking
- 41:25it and listening to it before I just
- 41:27tell everybody what we're going to do.
- 41:30So I don't know I I've messed up my
- 41:34my animations they're clearly anyhow,
- 41:36moving on someone can do a how
- 41:38to do PowerPoint for me at some
- 41:39point in the future.
- 41:40So I'm going to do can I
- 41:43actually a bridge party.
- 41:45Will you come off mute
- 41:46and be my learner For me?
- 41:48Once, once my chief resident.
- 41:50Always my chief resident.
- 41:52I'm ready. All right.
- 41:54So I'm going to you're going to be
- 41:56my learner here, Okay. And I'm.
- 41:57I'm the. I'm the preceptor.
- 41:59So I have a three.
- 42:00You've presented this to me.
- 42:02You want to read it out loud for us,
- 42:04Lavina.
- 42:05So this is a three-year old boy who
- 42:07presents with a cute Shigala gastroenteritis
- 42:10complicated by severe dehydration.
- 42:12He is not yet taking oral intake.
- 42:16And then they go so, right.
- 42:18And they're often waiting for us to jump in,
- 42:20right. There's this like pause that
- 42:22many of you have probably noticed
- 42:23in which the learners like, are they
- 42:25just going to tell me what to do here?
- 42:27Am I expected to come up with a plan?
- 42:29And so when you come to that pause,
- 42:31you can ask any question you want, right?
- 42:33Maybe I ask Lubena, So what do you want?
- 42:36What did I say? What do you want
- 42:38to do with this fluids today?
- 42:39Or maybe I ask,
- 42:40do you want to give him antibiotics, right.
- 42:43Or maybe I ask,
- 42:45when do you want to check labs again?
- 42:47So we'll be going to pick one
- 42:48of those two to answer.
- 42:50What do you want to do today?
- 42:51Or do you want to start antibiotics?
- 42:54I would like to resuscitate him first
- 42:57with simple horses and then start him
- 43:00on continued continuous fluids as well.
- 43:02OK. So why do you want,
- 43:03why do you want to do that?
- 43:06I think that he's already very behind.
- 43:08So I think that we have to catch him
- 43:10up first before we can support him
- 43:12with what his maintenance needs are.
- 43:15Yeah. And you know what?
- 43:15If I'm really in the clinical environment,
- 43:17I can push her further
- 43:18using these same things.
- 43:18I won't make her do this because she
- 43:20doesn't actually have the kids labs, right.
- 43:21But saying like,
- 43:22what fluid do you want to use?
- 43:24How much of it do you want to use, right.
- 43:25And providing feedback about that.
- 43:27You guys saw that took 30 seconds
- 43:30for me to ask Lubina those
- 43:31questions instead of just saying.
- 43:33So we're still way behind and we need
- 43:35to give them some boluses today, right?
- 43:36Or if I said what do you
- 43:38want in his case 2.7,
- 43:39what do you want to do about that, right.
- 43:40And have Lubina say,
- 43:41I want to give oral K I'm like good luck,
- 43:43he'll puke that up in a second, right.
- 43:45And so those are opportunities
- 43:46to really engage.
- 43:47But you're you're you have
- 43:49to ask them a question.
- 43:50Do you actually want to hear the answer
- 43:52to And it's A-frame shift from from that,
- 43:54like guess what I'm thinking question, right.
- 43:56So often on rounds I might be tempted to say,
- 43:59So what are the criteria for starting
- 44:01antibiotics in a patient with Shigella?
- 44:03And I'm waiting for people
- 44:05to spit out those criteria.
- 44:06That's a knowledge level.
- 44:07That's the bottom of the pyramid, right?
- 44:10By saying what do you want to do?
- 44:11You want to start antibiotics, right?
- 44:13Or what do you want to do
- 44:14with this fluids today?
- 44:14That's an application that's a higher level.
- 44:16So I'm,
- 44:17I'm both encouraging higher level thinking.
- 44:20I'm teaching myself how much
- 44:21autonomy I can give my learner.
- 44:23And I'm giving my learner
- 44:25the illusion at least,
- 44:26of autonomy by asking those questions.
- 44:29So let's practice again.
- 44:30Who else can I pick on?
- 44:35Doctor Loyal. Do you want
- 44:37to be a learner for me?
- 44:41Once my boss. Always
- 44:42my boss. Okay, you're going to be my learner.
- 44:45Can you read the the, the, the case there?
- 44:48Yes. This is an 18 month old here for
- 44:51a well child check who presents with
- 44:53poor weight gain and decreased oral
- 44:55intake for the past seven months.
- 44:58So I could ask any of these questions.
- 44:59You don't have to ask all of them, right?
- 45:01Maybe I say to Jespree, what workup
- 45:03do you want to start for him today?
- 45:04Or I'm going to ask you the second question.
- 45:06So Jespree, when do you think is the
- 45:08threshold to admit him to the hospital?
- 45:10Do you think we need to admit
- 45:11him or what's the threshold?
- 45:17Okay, I'm overthinking this. If you want,
- 45:19I was going to say, do
- 45:20we have to admit, right.
- 45:22So you could say we might not have to.
- 45:24So that might be your answer, Right.
- 45:25And like, what would be your reasoning
- 45:27for why you might not admit?
- 45:29Because we're hospitalists and we try
- 45:31to avoid these admissions at all costs.
- 45:33well-being, I think being in a
- 45:35hospital is a stressful environment.
- 45:36So I don't know, you know,
- 45:39sometimes like that can be
- 45:41worse for the family dynamic,
- 45:43right. And so I hear that from Jess Free,
- 45:45right. And I say to her,
- 45:46like, absolutely right.
- 45:46And I think we want to avoid that
- 45:49hospitalization at all costs, right.
- 45:51And so for me, I would only want
- 45:52to admit this kid to the hospital
- 45:54if I think we really, truly cannot.
- 45:55We've tried a lot of things to get
- 45:57him to gain weight in the outpatient
- 45:59setting or I think he's at risk of
- 46:01acute refeeding syndrome, right.
- 46:02And those are kind of the two reasons why
- 46:04I might admit a kid to the hospital, right.
- 46:06And so I've asked Jaspreet her opinion.
- 46:08I've heard where she's at and
- 46:10thinking about this patient,
- 46:11and I'm able to sort of continue
- 46:13the conversation moving forward.
- 46:14But
- 46:15what if I tell you the PCP
- 46:16wants him admitted? Then what?
- 46:19Well, then I would say, but do you agree?
- 46:20Right. So if I'm using this method,
- 46:22I would say, but do you agree?
- 46:24Right. And. And maybe maybe the
- 46:25resident says I don't agree, right.
- 46:27And I and that's an opportunity
- 46:28for us to connect. Right.
- 46:29I I share that opinion, right.
- 46:31Then I can share,
- 46:32go back to that connection piece,
- 46:33right where I can say, you know,
- 46:35as a hospitalist who sees the stressfulness
- 46:37of this for families, I agree.
- 46:38It's lousy to admit a kid for failure
- 46:40to thrive to the hospital when I feel
- 46:42like I can't do very much for them.
- 46:44Sometimes we exist in this reality, right.
- 46:46And so you're able to sort of
- 46:48offer that connection, right.
- 46:49So there's don't be afraid of
- 46:51asking them this question.
- 46:53Nothing bad can happen from it.
- 46:55Either they learn or we learn that
- 46:57they didn't need to learn that
- 46:59particular piece of information
- 47:00and both are incredibly useful.
- 47:03So we're going to go and break out rooms
- 47:04one more time for five more minutes.
- 47:06I'm going to stop my share for
- 47:07a second because I'm going to
- 47:08reshare with my breakout rooms,
- 47:09being allowed to share,
- 47:13share the breakout rooms.
- 47:15And you guys are going to go into a
- 47:18breakout room and pick one of these
- 47:20cases that you want to practice.
- 47:23So be a learner, Be an educator.
- 47:25Ractice the the oneminute preceptor.
- 50:17I'm going to close the rooms.
- 50:18OK, Karina, but I have it here, so,
- 51:28OK oh, look, we've got a baby guest.
- 51:33So I think so I hope you guys got
- 51:35a chance to sort of practice that.
- 51:37I find a lot of people want to jump into,
- 51:39like asking more questions and
- 51:40doing more didactic learning.
- 51:42And when you use the strategy,
- 51:43it's important that you stick to what
- 51:45do you want to do and why and then teach
- 51:48from that moment, very limited, right.
- 51:49And it's meant to be something you can do
- 51:52in all sorts of busy and busy environments.
- 51:55So I will, I will wrap up today with
- 51:58just a few important takeaways, right.
- 52:01So, one, I think we know this,
- 52:03but I think sometimes we forget this.
- 52:05Learning to be a doctor is an
- 52:09incredibly complex task that
- 52:11requires tremendous scaffolding,
- 52:13and the idea that we're going to teach
- 52:16people to do it by just harping on
- 52:19knowledge is really fundamentally unsound.
- 52:22I also want to to really impress
- 52:24upon you guys that adults are not
- 52:27inherently selfmotivated learners.
- 52:29They're not inherently selfdetermined.
- 52:31We build selfdetermined learners by
- 52:34creating environments that allow for
- 52:37that connection for like recognized
- 52:39improved competence and for autonomy
- 52:41in in certain settings that are safe,
- 52:44right.
- 52:45And those are all crucial towards the clip,
- 52:47towards developing a healthy and
- 52:50happy clinical learning environment.
- 52:52And when you do this right and you
- 52:54do this well,
- 52:54I assure you that you can give residents
- 52:57and students a lot of feedback.
- 52:59You can tell them all sorts of things
- 53:02that you want them to do better
- 53:04because they believe you that you
- 53:06are in fact invested in helping
- 53:08them be self actualized learners.
- 53:10When you've done these things to sort
- 53:12of lay the groundwork to demonstrate
- 53:14that you were in fact invested in them
- 53:17becoming self actualized learners.
- 53:18This is my daughter becoming a self
- 53:21actualized learner in Harry Potter
- 53:23world where these little magic
- 53:25wands are actually way harder to
- 53:27to to work than you think.
- 53:28Right.
- 53:29And she's up there like trying to make
- 53:31this stupid umbrella rain and you know,
- 53:33but she she wanted to do this.
- 53:35She was surrounded by other kids,
- 53:37you know, she felt that connection.
- 53:38She got better at as time went on.
- 53:41Right.
- 53:41And I let her pick which one
- 53:42she wanted to do next.
- 53:43It was a great three hour activity
- 53:45that only cost me $55 per wand.
- 53:47We'll talk about that another day.
- 53:49But it was it, you know,
- 53:51I think that that mentality that can exist
- 53:53in the clinical learning environment,
- 53:56it can kid residents can be like
- 53:58kids at Harry Potter World,
- 54:00but you have to build the
- 54:01right setting for them.
- 54:02And so I know we're running low on time,
- 54:05but I will end by asking
- 54:07if anybody has questions,
- 54:08thoughts they'd like to share.
- 54:10I'm open to be taken in the jaws.
- 54:13And if anyone has something
- 54:14negative but wants to pretend to
- 54:16radiate positive energy,
- 54:18my six year old's here for it.
- 54:20So any questions or comments that people
- 54:22want to share in our last minute or two,
- 54:29Rachel, how do you pick just one thing
- 54:31to focus on for one minute preceptor like
- 54:34you're going to learn something new
- 54:36the next time, right? And so remember,
- 54:38if you do it for every patient,
- 54:40then you'd pick something different, right?
- 54:41So in bronchiolitis, I try to vary, right?
- 54:43What do you want to do
- 54:44with their high flow today?
- 54:45You want to give that one albuterol, right?
- 54:47And so you can sort of pick
- 54:49different questions or if it's a
- 54:51really interesting and complex kid,
- 54:52you can ask different learners
- 54:53different questions.
- 54:54So you can say what do you want
- 54:55to do next diagnostically what
- 54:57antibiotics you want to give.
- 54:58And so you can sort of walk around the
- 55:00room that way and that can be a way to do it.
- 55:02But just realize this isn't the
- 55:04last time they're going to learn
- 55:05about whatever topic it is.
- 55:07So why pick whatever I want to talk about,
- 55:08which is you guys can tell is quite a lot.
- 55:10So
- 55:19okay. Thank you, Rachel,
- 55:21so much. Really, this was a great
- 55:24kickoff and so appreciate you sharing
- 55:27your experience as well as you know,
- 55:30certainly the expertise that you have.
- 55:34All right, thanks guys. Take care, everyone.
- 55:38Great. Thank you.