Yale Psychiatry Grand Rounds: "Giving Feedback"

Transcript

• 00:00Thanks for the
• 00:01generous introduction. I actually
• 00:04almost forgot some of those
• 00:05things.
• 00:06Like like, the HIV work
• 00:07was so felt so long
• 00:09ago, but
• 00:10it's it's really fun to
• 00:11be part of.
• 00:13Maybe fun is not the
• 00:14word, but it was great
• 00:15to be part of.
• 00:17Thank you. Is there anything
• 00:19else I need to be
• 00:19doing, or am I good?
• 00:20Good. K.
• 00:22So,
• 00:24I'm gonna jump
• 00:25pretty much right into it
• 00:27because I have a lot
• 00:28to say, and I'm pretty
• 00:29much gonna stick to my
• 00:30script
• 00:31because it's not my usual
• 00:34style of teaching, Richard knows
• 00:35this,
• 00:36that,
• 00:37typically, I ad lib a
• 00:39lot when I'm teaching, but
• 00:41the ad libbing
• 00:42really eats up a lot
• 00:43of time. And I have
• 00:45lots to say, so I
• 00:46wanna make sure that it
• 00:47all fits in, and I
• 00:48wanna make sure we have
• 00:49some time for discussion as
• 00:50well.
• 00:52So I'm gonna jump in.
• 00:53We're talking about feedback as
• 00:54John has said, and feedback
• 00:57I see as being really
• 00:58important for,
• 01:01the development of all of
• 01:03us.
• 01:04I have no disclosures, by
• 01:05the way.
• 01:06I have no money.
• 01:09So
• 01:11I really want to think
• 01:13about feedback in the context
• 01:15of the report that we
• 01:16heard about two weeks ago,
• 01:18and think about some of
• 01:20those bigger issues
• 01:21and then how those issues
• 01:23impact on feedback. And I
• 01:25wanna make sure we're all
• 01:26on the same page by
• 01:27just saying that feedback is
• 01:29a process as it as
• 01:30it says here. By the
• 01:32way, welcome for those who
• 01:33are on Zoom. I was
• 01:34on Zoom two weeks ago,
• 01:36and I know there are
• 01:37many, many, many more people
• 01:38on Zoom. I think there
• 01:39were sixty six, and there
• 01:40was lots of chatter on
• 01:42the chat, which was really
• 01:43positive.
• 01:44So we're aware that you're
• 01:46with us.
• 01:48So I wanna make sure
• 01:50that we understand feedback as
• 01:51a process, not just as
• 01:53an evaluation process. Though, it
• 01:55is that, but it's really
• 01:57the way to improve
• 01:58our learning and our teaching,
• 02:01so that we, you know,
• 02:02so that we all develop
• 02:03into the best practitioners
• 02:05and so that we can
• 02:06give the best highest standards
• 02:08of patient care possible. So
• 02:10it's very crucial as a
• 02:12formative approach
• 02:14to learning. And I think
• 02:15we all need feedback in
• 02:16each of our professions, even
• 02:18those who are teachers. We
• 02:19need feedback about our teaching.
• 02:21Clinicians
• 02:22need continued feedback about clinical
• 02:24care.
• 02:25So that's how I think
• 02:27about feedback.
• 02:30So by the end of
• 02:31today, what I wanna do
• 02:33is to have us understand
• 02:35how issues like trust and
• 02:36decentralization,
• 02:37which we heard about two
• 02:38weeks ago, affect our feedback
• 02:40culture,
• 02:42to review a framework
• 02:44from the literature on on,
• 02:46feedback in medical education,
• 02:50and to explore models
• 02:52of structured faculty
• 02:54resident conversations
• 02:55aimed at mutual understanding. So
• 02:57when I get through those
• 02:58three things today, and hopefully,
• 03:00that's gonna spark conversation.
• 03:02I'm not going to provide
• 03:04the solutions today. I'm going
• 03:06to provide a framework
• 03:07for us to continue this
• 03:09conversation. I'm gonna show you
• 03:10some
• 03:11models, but I need your
• 03:12feedback in terms of whether
• 03:14you think those models are
• 03:15gonna work or not, or
• 03:16maybe there's others that are
• 03:18out there that we should
• 03:19consider. So this is all
• 03:20really about,
• 03:21framework setting.
• 03:23So with those issues in
• 03:25mind, wherein lies the problem?
• 03:27So I I really believe
• 03:28that the breakdown
• 03:30in effective feedback that John
• 03:32just referred to
• 03:33is not the problem,
• 03:36but the problem was stated
• 03:38in,
• 03:39the report two weeks ago.
• 03:41The the issue is the
• 03:43erosion of trust and psychological
• 03:44safety that I think all
• 03:46of us feel at some
• 03:47level. And I can tell
• 03:49you that it's not just
• 03:50us because I've been in
• 03:51conversations
• 03:52with other with other departments
• 03:54at Yale, but with other
• 03:55psychiatry departments and other institutions.
• 03:58And there's something happening
• 04:00within our broader culture, and
• 04:02I think you know the
• 04:03reasons why. I mean, it's
• 04:04completely dysfunctional right now. And
• 04:06some of that actually
• 04:08filters down to us. And,
• 04:09you know, I wanna talk
• 04:10about some ways that we
• 04:11can actually
• 04:12work against that too.
• 04:14So the report to get
• 04:16into the report,
• 04:18I guess I I guess
• 04:19what I really want us
• 04:19to understand is that
• 04:22we can address feedback, and
• 04:24we can even do some
• 04:25workshops around giving feedback, but
• 04:27that's not gonna solve the
• 04:28problem, and it's not gonna
• 04:30stick. But we have to
• 04:31really be about addressing some
• 04:33of those deeper issues. And
• 04:35then when we set that
• 04:37groundwork,
• 04:38then we can address feedback
• 04:40within that larger context.
• 04:42So none of this you
• 04:44know, the direction is in
• 04:45feedback, and then we make
• 04:46everything great. The the direction
• 04:48is make things better, and
• 04:50then let's see how we
• 04:50can address feedback. So I
• 04:52want that to be our
• 04:54mutual understanding.
• 04:56So the,
• 04:58review
• 04:59report
• 05:00talked about decentralization
• 05:02and variability,
• 05:04variability across clinical sites and
• 05:06the breakdown of communication,
• 05:08which in turn leads to
• 05:09variability
• 05:10in expectations,
• 05:12what's expected of people at
• 05:13those sites. So that's one
• 05:15thing we heard about. We
• 05:16also heard about the lack
• 05:18of,
• 05:18or maybe the underdeveloped because
• 05:20it's it's not to say
• 05:21that there's no faculty development,
• 05:22but underdeveloped
• 05:24systematic with the emphasis on
• 05:26that word, systematic faculty development.
• 05:29And then the third thing
• 05:30was a disconnect between classes
• 05:33of residents, between cohorts.
• 05:35Though I want to revise
• 05:37that a little bit because
• 05:38I don't think that it
• 05:39actually captures
• 05:41exactly what, is happening because
• 05:43I do believe
• 05:44from
• 05:46interaction with you, from talking
• 05:47with you, from talking with
• 05:49APDs,
• 05:50and the new program director,
• 05:52there is interaction
• 05:54going on. There's, you know,
• 05:55the resident association, there's the
• 05:57GEC,
• 05:58there's some social interaction that
• 06:00occurs. So I think it's
• 06:02wrong to say classes aren't
• 06:03interacting.
• 06:04I think where the issue
• 06:05is,
• 06:06and I have me and
• 06:07to think thanks thank for
• 06:09this,
• 06:10is that,
• 06:12it's really the educational
• 06:14knowledge and the clinical learning
• 06:16and the way in which
• 06:17we distribute that,
• 06:19where I think there's not
• 06:20as much interaction as there
• 06:22can be. So I wanna
• 06:23revise it to a disconnect
• 06:25in educational knowledge and clinical
• 06:27learning and the way it's
• 06:29shared,
• 06:30if we can do that.
• 06:30I know it's bold of
• 06:31me to do that, but
• 06:32I do think that,
• 06:34that that it's true.
• 06:36So let's look at how
• 06:38these three factors
• 06:40in my perception, affect
• 06:42feedback and the feedback culture.
• 06:44So decentralization
• 06:46across the clinical sites,
• 06:48expectations for giving and receiving
• 06:50feedback differ significantly,
• 06:53leading to a lack of
• 06:54uniformity in both how feedback
• 06:56is practiced
• 06:57and
• 06:58in effective communication skills.
• 07:01So I think that that's
• 07:02the effect on feedback.
• 07:04And, oftentimes, faculty
• 07:06rely on
• 07:07what's familiar, on approaches
• 07:09to feedback that you yourselves
• 07:12have experienced when you were
• 07:14residents.
• 07:15Which I want to make
• 07:16it clear that's not altogether
• 07:18bad. It's not that the
• 07:19way you've learned to give
• 07:21feedback, or that you've gotten
• 07:22it was a bad thing.
• 07:24But, I do also want
• 07:25to say that it doesn't
• 07:27always work in all circumstances.
• 07:30The resident needs, the training
• 07:32needs have grown
• 07:34exponentially
• 07:35over the years,
• 07:36and there are different dynamics.
• 07:38So that what's familiar
• 07:40doesn't always work. So I
• 07:41want us to to think
• 07:42about that as well.
• 07:46And additionally, there's a gap
• 07:48between, central leadership and site
• 07:50leadership in the way communication
• 07:52occurs, which you also heard
• 07:54about two weeks ago. And
• 07:55I think that that contributes
• 07:57to inconsistent messaging and hinders
• 07:59the development of an effective
• 08:01feedback loop.
• 08:02And why a loop is
• 08:03important is because that's the
• 08:05way that central leadership knows
• 08:08that there are some trends
• 08:10that are happening
• 08:11that's coming across through feedback.
• 08:13Not, you know, not just
• 08:14with individuals, but there may
• 08:16be some kind of aggregate,
• 08:17some collective trends.
• 08:19And it's important for central
• 08:21leadership to know that in
• 08:23order to address what may
• 08:24be a gap in the
• 08:25curriculum.
• 08:26And then it's important to
• 08:28know how feedback is given,
• 08:30and then if it's being
• 08:31effective, if it's making a
• 08:32difference in a collective way.
• 08:35So when that feedback loop
• 08:36breaks down, then there's no
• 08:38way to to monitor that
• 08:40whole process.
• 08:41So I think decentralization
• 08:43has probably the biggest role
• 08:45in what we're experiencing right
• 08:47now.
• 08:48The second,
• 08:49point was a lack of
• 08:51or underdevelopment
• 08:52of a systematic approach to
• 08:54faculty development, which affects the
• 08:56support and development of faculty
• 08:58in a number of skills
• 08:59in areas, but particularly around
• 09:01feedback as well.
• 09:03While we attempted to establish
• 09:06a feedback model that was
• 09:07shared and understood by all,
• 09:09and I actually was responsible
• 09:11for that,
• 09:12years ago in terms of
• 09:13doing feedback trainings
• 09:15in different clinical sites,
• 09:19These initiatives took place
• 09:21well before COVID, hit us.
• 09:23And, unfortunately, I think from
• 09:25the sounds of it, at
• 09:26least, the training efforts
• 09:28either didn't take hold strongly
• 09:30enough or they were insufficient
• 09:32in some ways that we
• 09:33should actually look at address,
• 09:35you know, what was the
• 09:36insufficiency.
• 09:37I think that there have
• 09:39been some I I don't
• 09:40know that it's necessarily the
• 09:41model that we use, but
• 09:43there have been some
• 09:45emerging issues, like the pandemic
• 09:47and other issues of things
• 09:48happening in the department that
• 09:50I think has
• 09:51sort of cut away. Again,
• 09:53you know, providing the model
• 09:54isn't gonna be the fix,
• 09:56but addressing trust, psychological safety,
• 09:58and then
• 10:00thinking about what model works
• 10:01within that context
• 10:03is probably the the better
• 10:04fix. So I want us
• 10:05to think about that, though
• 10:07I do take partial responsibility
• 10:08for not continuing to follow-up
• 10:10after the training and particularly
• 10:12after
• 10:13in the COVID pandemic, you
• 10:15know, when it really hit
• 10:16us hard, not following up
• 10:17after that, which we could
• 10:18have done.
• 10:21An additional reason why those
• 10:23trainings might have not gone
• 10:24deeply as they could have
• 10:26is because of the largely
• 10:28voluntary nature of the participation
• 10:30in the training,
• 10:31not completely voluntary, but mostly.
• 10:34And it could be that
• 10:35we just didn't reach everybody,
• 10:36and maybe the people who
• 10:38could most benefit from the
• 10:39training didn't receive it. So
• 10:41I want us to consider
• 10:42that as well.
• 10:45And then there's one more.
• 10:49Oh, so in the disconnect,
• 10:51in terms of educational knowledge,
• 10:54and clinical learning between
• 10:56classes,
• 10:57I think that, you know,
• 10:58there's a missed opportunity
• 11:00when we don't,
• 11:02try to
• 11:03build a structure in which
• 11:05that,
• 11:06information exchange can occur.
• 11:09And I think that, again,
• 11:10central leadership
• 11:12could provide a structure for
• 11:13that to think about, you
• 11:14know, how how do we
• 11:15roll our curriculum out and
• 11:17how does the curriculum allow
• 11:19people to interact. But I
• 11:21also think residents have a
• 11:22responsibility
• 11:23here too and,
• 11:25you know, senior residents in
• 11:27particular could within that structure,
• 11:30again, that might be created
• 11:31by the leadership
• 11:33to really build relationships,
• 11:35that
• 11:36give pure feedback and then
• 11:38also focus on mentoring. And
• 11:40all of that, like, if
• 11:41that
• 11:42dyad can be strengthened, then
• 11:44I think that that in
• 11:45itself goes a long way
• 11:46in addressing the psychological
• 11:48safety,
• 11:50and some of the bigger
• 11:51issues. It doesn't heal all
• 11:52of it, but it really
• 11:53goes away in actually
• 11:55addressing it. And and then
• 11:57there's one more
• 11:58that I'm not gonna get
• 12:00into in detail at all,
• 12:02but I do think that
• 12:03there's an effect on
• 12:05by the funding structure between
• 12:07the department and the hospital
• 12:08and how that relates to
• 12:10resident salaries.
• 12:12And I think the way
• 12:13that affects feedback
• 12:14is that,
• 12:16the sort of the unfortunate
• 12:17thing from that funding structure
• 12:19that we heard about,
• 12:21excuse me, is that,
• 12:23there's an uneven distribution of
• 12:25resident patient ratios,
• 12:28just by the way that
• 12:29rotations are set up. And
• 12:31in sites where there's heavy
• 12:33patient loads, there's a real
• 12:36possibility probability that feedback isn't
• 12:38gonna happen very frequently because
• 12:40there's just simply no time
• 12:42and everybody's,
• 12:43very, very busy. And then
• 12:45in the other sites where
• 12:46there's, you know, fewer patients,
• 12:48I think there's
• 12:50less opportunity for meaningful feedback
• 12:52because there aren't enough patients
• 12:54or there are not enough,
• 12:55you know, sort of differences
• 12:57among patients to see some
• 12:59of those differences and then
• 13:00how, you know, you can
• 13:02work therapeutically
• 13:03given those differences. So there
• 13:04there isn't enough there in
• 13:06some of the clinical sites
• 13:08where there are a few
• 13:08patients. So I think that
• 13:10needs to be addressed too
• 13:11and just wanted to bring
• 13:13that up in a bracketed
• 13:14way.
• 13:15So
• 13:17if I see these as
• 13:18the larger departmental issues, what
• 13:21might be some solutions?
• 13:23Which I think you wanna
• 13:24also hear today. So I
• 13:26think the one that we
• 13:27heard about several weeks ago
• 13:28and that we just could
• 13:29should continue to work on
• 13:31is to strengthen
• 13:32connections between central leadership and,
• 13:35clinical site leadership,
• 13:37so that both faculty and
• 13:39residents understand
• 13:40expectations
• 13:41particularly around feedback, but expectations
• 13:44overall around, you know, how
• 13:46teaching and learning
• 13:47can take place. So I
• 13:49think that's one thing that
• 13:50I know that I I
• 13:51was heartened last two weeks
• 13:53ago to hear John say
• 13:54that there was a commitment
• 13:55to work on that.
• 13:57I think increased
• 13:59transparency and accountability
• 14:00is also key.
• 14:02Feedback processes
• 14:03have to be transparent,
• 14:05and both faculty and residents,
• 14:08need to be accountable to
• 14:09the feedback process. It goes
• 14:11both ways,
• 14:12so that it's,
• 14:13constructive
• 14:14and psychologically safe for everybody
• 14:16involved.
• 14:18So this might actually involve
• 14:20training in a shared feedback
• 14:22model because to the extent
• 14:23that we all understand, yeah,
• 14:24this is how feedback is
• 14:26gonna occur or roughly how
• 14:27it's gonna occur, you know,
• 14:28in terms of this model,
• 14:30then that could go a
• 14:31long way in terms of
• 14:32building
• 14:32understanding and accountability.
• 14:35I think the
• 14:36new leadership positions that I'm
• 14:38really excited about I've talked
• 14:40with John. I've talked to
• 14:41the APDs before this grand
• 14:42rounds.
• 14:44I think, you know, that
• 14:45they will have a responsibility
• 14:47for ensuring,
• 14:49consistent feedback training, however we
• 14:52decide, whatever model we decide
• 14:53on to implement it,
• 14:55in the in the near
• 14:57future, hopefully.
• 14:59I also think standardizing or
• 15:01orientation across clinical sites can
• 15:03be very important. This was
• 15:05also addressed two weeks ago,
• 15:06and as I said, I
• 15:07was in chat. And on
• 15:09this point, people were,
• 15:11people were actually putting things
• 15:13in chat in a positive
• 15:14way saying, yes. That would
• 15:16really we really wanna see
• 15:17that happen. Now orientation,
• 15:21you know, can't be cookie
• 15:23cutter cutter across all the
• 15:24clinical sites because the sites
• 15:26are different with different kinds
• 15:27of patients,
• 15:28with different approaches to care.
• 15:31So they can't be completely
• 15:33uniform.
• 15:33But I do think there
• 15:35are areas that can be
• 15:36uniform, that can be standardized,
• 15:38and I do think that
• 15:39feedback expectations
• 15:41what we expect of this
• 15:43conversation
• 15:44can be,
• 15:45and should be part of
• 15:46the orientation and can be
• 15:47standardized across all the sites
• 15:49so there's some uniformity.
• 15:51And then
• 15:53structurally and personally fostering
• 15:56cross program year collaboration. As
• 15:58I said, you know, the
• 15:59the department can provide the
• 16:01structure for this to happen
• 16:03so that there's better educational
• 16:05flow between classes,
• 16:07but residents can also take
• 16:09responsibility for building these relationships.
• 16:11So I think those are
• 16:12four big things that we
• 16:14can think about think about
• 16:15how we're going to do
• 16:16this,
• 16:17and then in fact, you
• 16:18know, put some sort of
• 16:19strategy in place.
• 16:21I also wanna point out
• 16:23that
• 16:24the review team said some
• 16:26very, very specific things about
• 16:28feedback. They noticed some things
• 16:29about feedback and not necessarily,
• 16:31you know, these larger issues.
• 16:33And one was an observation
• 16:36or or more of an
• 16:37more of faculty telling the
• 16:38the team that they felt
• 16:40uncomfortable
• 16:41giving feedback sometimes because of
• 16:43the concerns for repercussions. That
• 16:45was something that was definitely
• 16:47part of the conversation. So
• 16:48I wanted to, acknowledge that.
• 16:52And then,
• 16:56they also said that residents
• 16:58said to to the team
• 17:00that,
• 17:02the way in which they
• 17:03get feedback very often is
• 17:04framed in terms of unprofessionalism.
• 17:08So I wanna, you know,
• 17:09talk for a minute about
• 17:10that. So that that kind
• 17:11of vague
• 17:12feedback can feel judgmental,
• 17:15unhelpful,
• 17:16and often racially and culturally
• 17:18discriminatory
• 17:19when framed with,
• 17:21minoritized residents.
• 17:22So it's essential that we
• 17:24move
• 17:25beyond
• 17:26this towards more specific,
• 17:29and I'm I'm slowing down
• 17:31purposefully,
• 17:32specific
• 17:33behavior based feedback
• 17:35that focuses on observable actions
• 17:38rather than generalized
• 17:40character judgments.
• 17:42I'm gonna say that again,
• 17:43actually, that we that we
• 17:44move towards more specific
• 17:47behavior based feedback that focuses
• 17:50more on observable actions
• 17:52rather than generalized character judgments.
• 17:55I think that that's crucial.
• 17:59So for a moment, I
• 18:00actually wanna step outside. Now
• 18:02if I was in the
• 18:03teaching situation, I was literally
• 18:05step outside. I'm aware of
• 18:06the Zoom audience.
• 18:08So I'll stay put, which
• 18:09is hard for me to
• 18:10do sometimes. But I wanna
• 18:12step outside of this conversation
• 18:14a little bit and step
• 18:15into the role of sociologist,
• 18:17which is my training background
• 18:18as as John said.
• 18:21So I think that this
• 18:23disconnect,
• 18:25in between residents and faculty
• 18:27around feedback
• 18:28is
• 18:29generationally
• 18:30based.
• 18:33I, myself,
• 18:34am a baby boomer
• 18:36and came up at a
• 18:37time when,
• 18:39things were, you know, were
• 18:41going fairly well post World
• 18:43War two.
• 18:45Not
• 18:46terrific for everybody,
• 18:48but there were more opportunities
• 18:49for more people than there
• 18:51had been before that period.
• 18:53And I certainly benefited from
• 18:54that. So I
• 18:57had educational opportunities open to
• 18:59me that were
• 19:01not even anywhere
• 19:03near, you know, the thinking
• 19:04of my parents when they
• 19:06were coming up. Not even
• 19:07possible.
• 19:08And then my parents had
• 19:11opportunities.
• 19:12They and their fourteen
• 19:14siblings
• 19:15had opportunities
• 19:16that their that their immigrant
• 19:18parents did not have,
• 19:20like buying brand new houses.
• 19:22My grandparents didn't have brand
• 19:24new house. They had, you
• 19:25know,
• 19:26small houses with big families
• 19:28is what they had.
• 19:29So so there were opportunities
• 19:31there. Now, again, I don't
• 19:33wanna say, you know, this
• 19:35was great for everybody because
• 19:36there were certainly
• 19:38inequities.
• 19:39But there were more opportunities
• 19:41for us who came up
• 19:42in that period of time,
• 19:44for the most part,
• 19:46than, I think maybe exist
• 19:48today or existed certainly existed
• 19:50before that time.
• 19:52So what are the consequences
• 19:54of coming up as a
• 19:55baby boomer? I mean, you
• 19:57know, economically, things were going
• 19:59pretty well. There were educational
• 20:01opportunities and job opportunities. There
• 20:03was the ability to move
• 20:05into the middle class for
• 20:06people who hadn't been middle
• 20:07class.
• 20:08But the
• 20:10unfortunate
• 20:11consequence
• 20:12is that rather than a
• 20:14work ethic,
• 20:15what was developed was an
• 20:17overwork ethic.
• 20:18And I think that we
• 20:20continue to experience that today,
• 20:22and I certainly do. True
• 20:24confessions.
• 20:25My partner says to me
• 20:27very often, now that I
• 20:28can work remotely,
• 20:30good part of the time,
• 20:32when are you gonna peel
• 20:34your way away from that
• 20:35desk chair at ten o'clock
• 20:36at night? So it's still
• 20:39an issue. It's still something
• 20:41that pulls me, but it's
• 20:42not healthy for us. I'm
• 20:43here to say it's not
• 20:44healthy.
• 20:45And I just said you
• 20:46know, I was talking to
• 20:47Richard and John just before
• 20:49we started that I need
• 20:50to get back to exercise,
• 20:52and that is the thing
• 20:53that's pushing the possibility of
• 20:54exercise out.
• 20:56Not healthy.
• 20:58In contrast, those of you
• 21:00who are residents
• 21:01are either
• 21:03millennials or Gen Z ers
• 21:05or somewhere on the cusp
• 21:06of something, who grew up
• 21:07in a vastly,
• 21:10vastly different social context and
• 21:13economic environment.
• 21:15I recently was watching a
• 21:16PBS special, and there was
• 21:17a younger millennial
• 21:19who were was giving us
• 21:21some warnings and saying that,
• 21:22you know, your generation
• 21:24needs to understand that the
• 21:26current generation of learners
• 21:28were born in the technical
• 21:29bubble,
• 21:30came of age during the
• 21:31great recession,
• 21:33and had their education interrupted
• 21:35by COVID.
• 21:36Now think of that context.
• 21:39Think of that context
• 21:40so
• 21:41vastly
• 21:42different from the context in
• 21:43which I was coming up.
• 21:44So what does it mean
• 21:45to be, you know, a
• 21:46learner and a teacher in
• 21:47that environment? It creates some
• 21:49differences.
• 21:50So for residents,
• 21:53technology, especially
• 21:54the rise of the Internet
• 21:55and mobile communication,
• 21:57sometimes not so good, but
• 21:59it really has shaped today's
• 22:01trainees approach to work.
• 22:04Emphasizing efficiency,
• 22:05accountability,
• 22:07instant access to information, great
• 22:09things actually.
• 22:10But residents, your social experience,
• 22:14was all has also built
• 22:16in a level of uncertainty.
• 22:18Like, is there another
• 22:20crisis coming around the corner?
• 22:22I think it's really present
• 22:24there for everybody. It's present
• 22:25for us too, but especially
• 22:27if you came up in
• 22:28the environment that I just
• 22:29talked about.
• 22:31So that affects the way
• 22:32in which you think about
• 22:33work
• 22:34and career, let alone, you
• 22:36know, possibilities for starting families,
• 22:39buying houses,
• 22:41you know, in short, just
• 22:42building a life in in
• 22:43the middle class for the
• 22:44most part.
• 22:46So that's the context in
• 22:47which you
• 22:49are involved in. And consequently,
• 22:51you know, I think that,
• 22:54for better or worse, I
• 22:55think for better, your central
• 22:57focus is we're really on
• 22:59achieving
• 23:00a work life balance,
• 23:01thinking about mental health. You
• 23:03think about work differently
• 23:05than the older people. I
• 23:06mean, that's just the way
• 23:07it is.
• 23:08So I realized that this
• 23:09is an oversimplification.
• 23:12Not everyone's
• 23:13generational experience is cookie cutter.
• 23:15I I do realize that,
• 23:18and it oversimplifies
• 23:19some of the deeper differences
• 23:21created by other demographic
• 23:23realities beyond age and beyond
• 23:25generation identity.
• 23:27I realize that some of
• 23:28these differences
• 23:30also are not just between
• 23:32residents and faculty,
• 23:33but they play out in
• 23:35interactions between younger faculty and
• 23:37older faculty. So there's some
• 23:39complexity there, and I want
• 23:41us to just be aware
• 23:42of that. So that's that's
• 23:43my sort of
• 23:44sociology, my sociological
• 23:46analysis of it.
• 23:48But even if it's oversimplified
• 23:50or if you don't find
• 23:51yourself
• 23:52in these descriptions,
• 23:54I think what the important
• 23:55point I wanna get across
• 23:56is is that we pay
• 23:58attention
• 23:59to what our differences are,
• 24:01and that we don't look
• 24:02at those as
• 24:04personal or personality
• 24:05differences,
• 24:06but look at them within
• 24:08the context of our social
• 24:10context. How we were socialized,
• 24:12how we came up, what
• 24:14those expectations
• 24:15were. And then I think
• 24:17if we
• 24:18internalize that, and that's the
• 24:20tricky part,
• 24:22if we internalize that as
• 24:24as many, many the members
• 24:26in the department can do,
• 24:28then I think it becomes
• 24:29different in the department. The
• 24:31department becomes different.
• 24:33So if we can internalize
• 24:35that those differences
• 24:37aren't personal,
• 24:38they're socially constructed,
• 24:40I think that we can
• 24:41then begin operating with empathy
• 24:45and with grace. So this
• 24:46is where I might slide
• 24:48from being a sociologist to
• 24:50a I'm not a preacher,
• 24:51but this is gonna sound
• 24:52preachy, but I think grace
• 24:55is vital.
• 24:56And it's the thing that's
• 24:58missing from our
• 25:00national,
• 25:01whatever it is. I don't
• 25:02even want to say that
• 25:03it's dialogue,
• 25:04but the dysfunctional
• 25:06things that are happening
• 25:07nationally.
• 25:09It's what's missing
• 25:10and what grace offers, why
• 25:12it's important.
• 25:15Treating each other with grace
• 25:16involves
• 25:17understanding that differences
• 25:18and attitudes and behaviors
• 25:21might come from different life
• 25:22experiences.
• 25:24It manifests as patience
• 25:26with when working with people
• 25:28who might approach tasks differently.
• 25:30It enables one to move
• 25:32past small errors or misunderstandings
• 25:35without holding grudges.
• 25:37It focuses on helping each
• 25:39other to grow
• 25:40even when mistakes are made
• 25:42and it frames feedback
• 25:43as something that can promote
• 25:45development
• 25:46rather than something that divides
• 25:47us. In essence, GRACE smooths
• 25:50the edges of generational and
• 25:52cultural differences,
• 25:53creating a workplace with respect,
• 25:55patience,
• 25:56and understanding to thrive.
• 25:58It makes space for growth,
• 26:00dialogue, and ongoing development of
• 26:02both individuals and teams.
• 26:04And if you wanna do
• 26:05this is where I really
• 26:06wanna step out. But if
• 26:07you wanna do
• 26:08something actionable, if we wanna
• 26:10do something actionable as a
• 26:12department,
• 26:13we can
• 26:15resist
• 26:16what's going on in the
• 26:17national dialogue and treat each
• 26:19other with grace.
• 26:20And when we do that,
• 26:22it may have some rippling
• 26:23effects. I don't think we're
• 26:24gonna change the nation or
• 26:25the world. But if for
• 26:27one thing, we can preserve
• 26:28ourselves
• 26:29instead of going down with
• 26:30that dialogue,
• 26:32but it may have some
• 26:33ripple effects to the extent
• 26:34that we can do this
• 26:35in in larger collective ways.
• 26:38So that's my sermon part
• 26:39of it.
• 26:41So to step back to,
• 26:43the review team's report,
• 26:45there were there was another
• 26:47finding that was specific to
• 26:48feedback. The team said that
• 26:50residents want,
• 26:51faculty to have faculty development
• 26:54around,
• 26:55constructive ways of offering feedback,
• 26:57and they also recommended
• 27:00joint resident faculty skill building
• 27:02sessions.
• 27:03So that helps me to
• 27:05segue into this next session
• 27:07section, which is about, okay,
• 27:08what are some tools that
• 27:09we can use in order
• 27:10to make that happen?
• 27:12So,
• 27:15where is there a clock?
• 27:15Can somebody tell me what
• 27:17oh, here it is. Ten
• 27:18fifty one. Good. I really
• 27:20wanna finish by eleven if
• 27:21we can. I don't know.
• 27:22Probably not now.
• 27:24So we have some time
• 27:25for discussion.
• 27:28So,
• 27:30so I wanna specifically
• 27:32consider three things. First, a
• 27:34paradigm
• 27:35for thinking about the different
• 27:37players within the feedback conversation
• 27:39and what factors affect each
• 27:41of those,
• 27:42individuals and entities
• 27:44to look at a possible
• 27:46model for fostering meaningful conversations,
• 27:49between faculty and residents around
• 27:52feedback in specific. And then
• 27:54to look at a feedback
• 27:55model that I have seen
• 27:56working
• 27:57in various contexts,
• 27:59for structuring those conversations.
• 28:01And all three emerged from
• 28:03the literature, though I'm not
• 28:04gonna be terribly scientific here,
• 28:07and layout, you know, the
• 28:08methodologies.
• 28:09I'll layout some of the
• 28:10findings, but I am gonna
• 28:12give you the links to
• 28:13each of the references that
• 28:15I'm going to,
• 28:18that I'm going to talk
• 28:19about or from which this
• 28:21information stems.
• 28:24So first, a framework for
• 28:26thinking about
• 28:28feedback and how it happens
• 28:30between learners, teachers, and within
• 28:32culture. So those are the
• 28:33three entities, learners, in our
• 28:35case, residents,
• 28:36teachers, attendings at clinical sites,
• 28:39and culture, which I'm really
• 28:41limiting to,
• 28:43department culture.
• 28:45Though I do realize that
• 28:46there are larger influences
• 28:49inside the institution as a
• 28:51whole and also the societal
• 28:53things that I have referred
• 28:54to that are happening that
• 28:56also bears down on the
• 28:58departmental culture. But for the
• 28:59moment, you know, in this
• 29:01large
• 29:02oval, I think I wanna
• 29:03focus on the the the
• 29:05culture in the department.
• 29:07So this framework,
• 29:09historically, in medical education has
• 29:09worked itself out with the
• 29:09with the backdrop of
• 29:11education
• 29:14has worked itself out with
• 29:14the with the backdrop of
• 29:14an apprentice model, which was
• 29:14largely teacher centered and driven
• 29:15mostly by what the teacher
• 29:15prescribed. So the conversations were
• 29:18pretty
• 29:19much
• 29:20one way as the arrow
• 29:22suggests.
• 29:28And what tended to happen
• 29:30in the conversations
• 29:31is that
• 29:32teachers seemed
• 29:34more psychologically
• 29:35big
• 29:36psychologically bigger to residents,
• 29:39when it was a one
• 29:40way conversation.
• 29:42So, of course, that all
• 29:43happens within the social context
• 29:45of this larger oval, the
• 29:46the culture, and the culture
• 29:48that allows those things to
• 29:49happen,
• 29:50or even may encourage those
• 29:52things to happen. But what
• 29:53we'd be we've been finding
• 29:55in medical education
• 29:57of late is that,
• 29:59this is a better model,
• 30:01that
• 30:02when teachers
• 30:04can sort of reduce their
• 30:06psychological
• 30:06size somewhat and put themselves
• 30:08at the level of learners
• 30:10and the conversations
• 30:11can be two ways
• 30:12two two way rather,
• 30:14then I think the feedback
• 30:15conversations go better. Now I
• 30:17wanna be clear
• 30:18by saying that this doesn't
• 30:21mean that you're equal in
• 30:23terms of information,
• 30:25expertise that you have.
• 30:27Of course,
• 30:29teachers, attendings have
• 30:31more years of experience, have
• 30:33seen many more things, have
• 30:34seen many more patients,
• 30:36have more information
• 30:38stored in our brains.
• 30:40So this putting oneself,
• 30:43in a level conversation
• 30:44doesn't mean
• 30:46compromising your expertise that needs
• 30:48to be there, and if
• 30:49we withhold it then that
• 30:50doesn't serve residents well.
• 30:53But it does mean creating
• 30:55the conversation in a level
• 30:56way, so that both the
• 30:58teacher and the learner have
• 31:00the possibility of talking, of
• 31:02sharing goals,
• 31:03of saying, you know, this
• 31:04is what this is something
• 31:05that I need that I've
• 31:06been working on as a
• 31:07resident.
• 31:08So this kind of two
• 31:09way, conversation,
• 31:12goes much better.
• 31:14So,
• 31:16what I wanna take a
• 31:18look at next is what
• 31:20factors
• 31:21are bearing down on each
• 31:22of these these actors or
• 31:24entities,
• 31:25starting with learners.
• 31:27What factors affect learners and,
• 31:30in the way in which
• 31:31they receive feedback?
• 31:33So,
• 31:34research by Watling and others,
• 31:36and that's the first reference
• 31:38here, shows that learner traits,
• 31:41significantly
• 31:42influence feedback on how feedback
• 31:44is received.
• 31:45A major factor is learner
• 31:47orientation,
• 31:48whether the learner adopts a
• 31:50performance mindset,
• 31:51which, you know, is I
• 31:53always have to do things
• 31:54perfectly because somebody's watching. I
• 31:55have to perform perfectly. Or
• 31:55a growth mindset focused on
• 31:57improvement. Performance oriented learners may
• 31:57resist feedback because it says
• 31:58something about, you know,
• 32:07my performance wasn't as great
• 32:08as I needed it to
• 32:09be. Whereas,
• 32:11those who are growth oriented
• 32:13tend to receive feedback,
• 32:15more openly.
• 32:18So though these orientations
• 32:20are not
• 32:21completely dichotomous, we can move
• 32:23between them.
• 32:25Some external pressures
• 32:26can bear down on residents
• 32:28so that say so that
• 32:29they actually you might actually
• 32:31come in with the growth
• 32:33orientation,
• 32:34but you may perceive expectations
• 32:36or there may be some
• 32:37other external
• 32:38factors
• 32:39that cause you to be
• 32:40more performance oriented.
• 32:42So I think that that
• 32:44model or that the economy
• 32:46is interesting for us to
• 32:47think about
• 32:49and think about how we
• 32:50can move residents more towards,
• 32:52a learner or growth orientation.
• 32:55So that's my first I'm
• 32:56doing bad with bullets here,
• 32:58but that's the first bullet.
• 33:01The second is self preservation
• 33:03and emotional response.
• 33:06So feedback can challenge
• 33:08the learner's self image,
• 33:10in a way that,
• 33:12you can become defensive,
• 33:14so that the consequences that
• 33:14you either
• 33:15no,
• 33:16that's
• 33:18not really me, or maybe
• 33:18even outright rejection of of
• 33:19listening to the feedback, which
• 33:19isn't good for learning. It
• 33:20just really blocks meaningful growth.
• 33:30And this closely ties to
• 33:32emotional responses,
• 33:33for both learners and teachers
• 33:36so that,
• 33:37it the emotions need to
• 33:39be recognized in the conversation.
• 33:41That's not to say that
• 33:42you need to always be
• 33:43talking about emotions,
• 33:45but you should be aware
• 33:46of emotional responses. And sometimes,
• 33:48I think it's better
• 33:50to just leave the feedback
• 33:52conversation, say, can we talk
• 33:53about this next week?
• 33:55While, you know, that gives
• 33:57time for self reflection and
• 33:59and emotions to settle in
• 34:01than actually having to keep,
• 34:02you know, bearing ahead. But
• 34:04I think that that needs
• 34:05to be recognized that that,
• 34:08feedback giving and receiving,
• 34:10involves emotions.
• 34:14And a another factor which,
• 34:17is actually positive
• 34:18is that learner perceptions of
• 34:20what work works makes a
• 34:22difference.
• 34:24So what's worked for your
• 34:25learning in the past as
• 34:26an undergrad or as
• 34:28a intern,
• 34:30can make a difference sharing
• 34:32that with the person who's
• 34:33giving you feedback so that
• 34:35they know that, you know,
• 34:36this is how you like
• 34:37to receive it or or
• 34:37this is the way that
• 34:38you've learned in the past
• 34:38so they have a little
• 34:38bit more information. So that
• 34:39makes a difference. And then
• 34:40the last one is, self
• 34:41assessment, which
• 34:42we all know that self
• 34:43assessment is,
• 34:52really crucial in medical education,
• 34:54and it's particularly crucial in
• 34:56in providing clinical clear care.
• 34:58We have to self reflect
• 34:59in terms of what what
• 35:00what our practice is.
• 35:02But the bad news is
• 35:03that we're not great at
• 35:05self reflection, and the literature,
• 35:07particularly Kevin Eva and Mann
• 35:09and his,
• 35:10colleagues
• 35:11tell us
• 35:12that, you know, we're all
• 35:14it's it's just not a
• 35:15natural. It's not an innate
• 35:16skill. And the biggest reason
• 35:18is because we're subjects in
• 35:20our performance that right now
• 35:22you're
• 35:23watching me. You're observing me.
• 35:25I'm not observing myself. I
• 35:27may look at the tape
• 35:27later. I may not. But
• 35:29as I'm performing,
• 35:32I don't you know, maybe
• 35:34I'm using my hands too
• 35:35much. Maybe I'm saying too
• 35:36many fillers. I don't know.
• 35:38Fillers. That's my Pittsburgh accent.
• 35:41I don't know. But,
• 35:44you do. You see what's
• 35:46going on, and you can
• 35:48tell me you can give
• 35:48me some advice about the
• 35:50next time I do grand
• 35:51rounds.
• 35:52So what this set of
• 35:53investigators
• 35:54says is that not just
• 35:56self assessment, but informed
• 35:58self assessment depending on some
• 36:00external observations,
• 36:02and then going and reflecting,
• 36:03you know, about what happened
• 36:04in performance
• 36:05is what tends to work
• 36:07best.
• 36:08So now let's turn to
• 36:10teachers.
• 36:12So from the research of
• 36:14Pilgrim and others, which is
• 36:16referenced here,
• 36:18we,
• 36:18they found that, a that
• 36:20having a task perception,
• 36:23it really affects positive feedback.
• 36:24And I've talked about about
• 36:26how neuroticism
• 36:27affects it in a positive
• 36:28way as well.
• 36:31So clinical teachers,
• 36:33who have residents and medical
• 36:35students and others in the
• 36:37clinical setting, and these are
• 36:38all,
• 36:39general practitioners
• 36:40in the study.
• 36:42Those who saw teaching as
• 36:44primary,
• 36:45along with patient care, of
• 36:47course, that's primary.
• 36:48But alongside of patient care,
• 36:50teaching is a primary task
• 36:52as opposed to a secondary
• 36:53task, you know, after we
• 36:55get through with the clinical
• 36:56stuff.
• 36:57Those teachers,
• 36:59tended to give feedback more
• 37:01frequently. So a positive
• 37:03relationship between,
• 37:05that task orientation and frequency
• 37:07and feedback. And then neuroticism,
• 37:11was found to have a
• 37:12positive correlation
• 37:13with higher quality feedback.
• 37:16So the investigators used a
• 37:18neuroticism
• 37:18scale,
• 37:20and those who scored higher
• 37:22in neuroticism, which is an
• 37:23emotional response,
• 37:25tended
• 37:26to give better feedback, feedback
• 37:29of higher quality according to
• 37:31the residents who are also
• 37:32or or the learners who
• 37:33are also,
• 37:34who are also surveyed.
• 37:36So that the the,
• 37:38you know, the story is
• 37:41that a bit of neuroticism
• 37:43might be okay. And then
• 37:44the hypothesis, this wasn't proven
• 37:46in the study, but their
• 37:47hypothesis was that that could
• 37:49be because
• 37:50the clinicians are really are
• 37:52concerned about patients. That's also
• 37:53primary. Right? And they wanna
• 37:55make sure that their residents
• 37:58understand
• 37:59everything that's going on with
• 38:00their patients.
• 38:02Therefore, they tend to give
• 38:03much more detailed
• 38:04feedback.
• 38:05So a little bit of
• 38:06neuroticism might work.
• 38:08And then
• 38:10last, teacher credibility makes a
• 38:12big difference.
• 38:14So credibility
• 38:15is fostered by deep understanding
• 38:18of what went on in
• 38:19a performance,
• 38:20you know, with a with
• 38:21a with a learner and
• 38:22a patient.
• 38:23But as we, you know,
• 38:25as we know that in
• 38:26the outpatient clinic, that's not
• 38:27always possible.
• 38:28Sometimes,
• 38:30teachers depend on residents
• 38:32saying this is what happened
• 38:33in the interaction.
• 38:35And,
• 38:36that could actually
• 38:38cut into credibility because the
• 38:41the the attending didn't actually
• 38:43observe, didn't really see what
• 38:45went on. So I I
• 38:46just offered that as,
• 38:48you know, something to think
• 38:50about, something we can work
• 38:51on, particularly in the outpatient
• 38:53setting. How can we increase
• 38:55the credibility
• 38:56of attendings when they're not
• 38:57seeing the performance?
• 39:03And last,
• 39:04and not surprising,
• 39:06this is more about the
• 39:07type of feedback or the
• 39:08quality of feedback given rather
• 39:10than a teacher trait. But
• 39:12feedback that was seen as
• 39:13constructive
• 39:14was,
• 39:15much more easily accepted by
• 39:17the learner. No big surprise.
• 39:19Right? But the study did
• 39:21show that,
• 39:24what tended to be visioned
• 39:26as as as constructive by
• 39:28the learners
• 39:29was,
• 39:30better accountability,
• 39:31specificity,
• 39:32again,
• 39:33manageability,
• 39:34not too many feedback points
• 39:35in any one setting,
• 39:37sitting, and feedback based on
• 39:39performance
• 39:40observed rather than assumptions about
• 39:42what might have occurred in
• 39:43the learner's performance.
• 39:45So, so some of the
• 39:47things that we talked about
• 39:48earlier also comes together in
• 39:50this.
• 39:51Because we're past eleven, now
• 39:53I wanna go through this
• 39:54fairly quickly, but not because
• 39:56I think it's unimportant,
• 39:57but because,
• 40:01I think it is crucially
• 40:02important. I think it's the
• 40:03most important thing actually in
• 40:04this whole mix,
• 40:06that there has to be
• 40:07some things that happen within
• 40:09the context of the culture
• 40:10in the department. So I
• 40:11wanna lay these out as
• 40:12things for us to think
• 40:13about and work on.
• 40:15Hierarchy
• 40:17is the first thing. The
• 40:18way in which the department
• 40:19perceives and structures hierarchy
• 40:22is crucial.
• 40:23It's essential that in certain
• 40:25contexts, actually, hierarchy does exist
• 40:28and works well. I mean,
• 40:29think about some clinical context.
• 40:31Somebody has to have the
• 40:32ultimate responsibility.
• 40:34However, if hierarchy dominates
• 40:37all of our interactions, it
• 40:38can create barriers and particularly
• 40:40barriers to helpful feedback conversations.
• 40:43Learners
• 40:43are likely to be hesitant,
• 40:46you know, because of the
• 40:47the, again, the bigger the
• 40:48bigger attending circle. And, also,
• 40:51faculty
• 40:52are can be inhibited by,
• 40:55always operating within a hierarchy.
• 40:58The second is autonomy.
• 41:00The question is how much
• 41:02autonomy do we give residents
• 41:03in their learning, and then
• 41:05how much guidance do we
• 41:06give? And that's the trick
• 41:07of residency. I mean, that's
• 41:08honestly,
• 41:09that's what's at the bottom
• 41:11of curriculum development for residency
• 41:13education.
• 41:14How do we balance that
• 41:15out?
• 41:17And it is a balancing
• 41:18act, and that is going
• 41:19on within the context of
• 41:21not only residents learning, you
• 41:23know, what is the right
• 41:24mix there to balance it
• 41:25out. But they're also thinking
• 41:27about patient autonomy because,
• 41:29you know, this is another
• 41:31thing that's different generationally is
• 41:33that residents today are constantly
• 41:36reminded that they have to
• 41:37be concerned about patient autonomy.
• 41:39So working out patient autonomy,
• 41:41how much guidance do I
• 41:42give at the same time
• 41:44in their learning, working out
• 41:46how much autonomy do I
• 41:47have, when do I need
• 41:48guidance.
• 41:49It's very complex, and what
• 41:50I'm pointing out is the
• 41:51complexity,
• 41:52again, not a solution.
• 41:54Something for us to think
• 41:55about.
• 41:57Evaluation culture and the role
• 41:59of critique is important.
• 42:00So building a positive evaluation
• 42:03culture hinges on whether the
• 42:04department
• 42:05at all levels,
• 42:07except critique is welcome and
• 42:09necessary for growth and excellence
• 42:11in,
• 42:13in all of our work.
• 42:13It should operate in a
• 42:15three sixty degree kind of
• 42:16way if we can get
• 42:17there.
• 42:18And on the contrary, if
• 42:20critique
• 42:21is seen primarily as a
• 42:22challenge to our credibility
• 42:24or a questioning of our
• 42:25skill level,
• 42:26then that's a stage for,
• 42:29feedback being viewed as mainly
• 42:31conflictual and as a weapon
• 42:33as some have, thought about
• 42:36it. So, there are two
• 42:38other
• 42:39culturally,
• 42:42two other aspects of culture
• 42:43that that I'll go over
• 42:44just very quickly. Department guided
• 42:46expectations for teacher learner relationships,
• 42:49and I wanna put the
• 42:50emphasis on department guided because,
• 42:52of course, teachers and learners
• 42:54work out the relationships between
• 42:56themselves.
• 42:57But if there's a structure
• 42:58for how that's supposed to
• 42:59work best, that's what works
• 43:01best. So there needs to
• 43:02be some sort of structure
• 43:04and expectations again there.
• 43:06And then department support for
• 43:08tools and resources for faculty
• 43:10is crucial.
• 43:11And to the extent that
• 43:12faculty feel supported and they're
• 43:14actually given good tools in
• 43:15order to teach well, to
• 43:16give feedback well, that also
• 43:19encourage or or enhances,
• 43:21credibility of the feedback givers.
• 43:23This is just a, thing
• 43:25that came out of the
• 43:26Watling
• 43:27study of,
• 43:29physicians
• 43:30who are also,
• 43:31pretty
• 43:32pretty well developed athletes and
• 43:34musicians sometime in their lives.
• 43:36And they asked them
• 43:38to think about how they
• 43:40learned as athletes or musicians,
• 43:42and how they learned,
• 43:44in medical school as physicians,
• 43:45and to compare and contrast.
• 43:47And what we know from
• 43:48this is that there are
• 43:49some things that they say
• 43:51in common, you know, that
• 43:52they learn best when there's
• 43:53credibility, constructiveness, the things that
• 43:55we talked about. But there
• 43:56were different styles between the
• 43:59two domains,
• 44:01with coaches
• 44:02being coaches. You know, that
• 44:04that that's the model, coaching
• 44:06rather than even necessarily teaching.
• 44:08Whereas physicians,
• 44:10in their medical school and
• 44:12even into residency,
• 44:13were taught in a different
• 44:14way, more from a top
• 44:16down type of approach. So
• 44:18I think that there's something
• 44:19in here. You know, it's
• 44:20I'm looking at it very
• 44:22quickly, but something in there
• 44:23for us to think about
• 44:24as well in terms of
• 44:25moving towards a coaching model.
• 44:28So I wanna say one
• 44:30now I'm shooting for eleven
• 44:32fifteen, but I wanna say
• 44:33one last thing about culture
• 44:35that I think would be
• 44:36remiss
• 44:37if I didn't say it.
• 44:40So it's no surprise to
• 44:41us
• 44:42that within our departmental culture
• 44:44that race
• 44:46and cultural differences has been
• 44:48an issue. It has really,
• 44:51affected the way in which
• 44:52we talk about each other
• 44:53and think about each other.
• 44:55So I'm not here to
• 44:57be the expert in working
• 44:58this out because I'm not
• 45:00the expert. Trust me. I
• 45:01wouldn't know how to structure
• 45:03that,
• 45:04development, but we do have
• 45:06resources
• 45:07for doing that. One that
• 45:08I just learned about from
• 45:09Ruby,
• 45:11just this week yesterday
• 45:12was the culturally aware mentorship
• 45:15program, and she may be
• 45:16able to talk to the
• 45:17department more about that.
• 45:20But the point is that
• 45:21there are tools for us
• 45:23to really begin to work
• 45:25on that or continue our
• 45:26work on that, and we
• 45:27should really pay attention to
• 45:28that. But what I do
• 45:29wanna do to just, you
• 45:31know, address the fact that
• 45:33race and culture make a
• 45:35difference in these feedback conversations
• 45:37is to read a passage,
• 45:39a narrative passage that,
• 45:41our beloved Terrence,
• 45:44wrote to me and said
• 45:45that I can share.
• 45:47So I'm gonna read it.
• 45:48Constant experiences of discrimination and
• 45:50prejudice can wear me down,
• 45:52leaving me unsure of whom
• 45:54I can trust for support
• 45:55or who will generally believe
• 45:57my concerns.
• 45:58It's been a game changer
• 45:59when a supervisor or colleague
• 46:01clearly sets the standard at
• 46:03the beginning of rotation stating
• 46:05that racism and discrimination
• 46:07are not tolerated.
• 46:09When they say, if you
• 46:10experience this, bring it to
• 46:11me and we'll handle it.
• 46:13It creates a sense of
• 46:14safety and reassurance.
• 46:16I found the faculty who
• 46:18share similar minoritized
• 46:20identities often provide the most
• 46:22comfort and understanding. They're usually
• 46:24the ones who offer me
• 46:25constructive feedback and help me
• 46:27to grow by sharing personal
• 46:28examples.
• 46:29Additionally,
• 46:30when faculty simply demonstrate awareness
• 46:33of how systems of oppression
• 46:36affect our experiences,
• 46:37I feel more comfortable giving
• 46:39them feedback.
• 46:41So while shared identities
• 46:43are important, it's equally crucial
• 46:45for mentors to show genuine
• 46:47knowledge and interest in how
• 46:49discrimination
• 46:50impacts our experiences.
• 46:52Creating an environment where all
• 46:53of this is acknowledged can
• 46:55make a significant difference in
• 46:57both trainee development
• 46:58and care we provide our
• 47:00patients.
• 47:01Training programs can benefit immensely
• 47:03from intentionally
• 47:05incorporating these elements into their
• 47:07curriculum
• 47:08and support systems.
• 47:10I don't think there's much
• 47:11more I can say than
• 47:12that, so I'm just going
• 47:13to move on.
• 47:16So let's think very quickly
• 47:18about two models that might
• 47:20be actionable.
• 47:21One is,
• 47:23something that was,
• 47:24developed at another medical school,
• 47:27and it involves creating a
• 47:29conversation
• 47:30between residents and faculty
• 47:33about feedback in particular.
• 47:35So there's a pre conference
• 47:37questionnaire
• 47:38that gathers information about what
• 47:40are your perceptions
• 47:41as residents of faculty, you
• 47:42know, what do you think
• 47:43their some of their
• 47:45the barriers might be to
• 47:46them giving feedback. And then,
• 47:48you know, the reverse is
• 47:49asked of of the of
• 47:50the faculty about residents. So
• 47:52that information is collected. And
• 47:54then in the activity, when
• 47:55they get together,
• 47:57that information is shared,
• 47:59you know, step back from,
• 48:01looked at. And then that
• 48:02creates a discussion
• 48:04about, you know, do we
• 48:05have some misperceptions?
• 48:07Are there things that we
• 48:08can be working on?
• 48:11And,
• 48:12it has had good results.
• 48:13In fact, I have used
• 48:14this model
• 48:16in,
• 48:17Alberta.
• 48:19So if you wanna if
• 48:20you wanna get a sense
• 48:21of does this work in
• 48:22other places, you can talk
• 48:23to David Ross about it.
• 48:24And I'm sure I I'm
• 48:26completely fine with you calling
• 48:27him and asking him. You
• 48:28know, how did it go
• 48:29when John did that?
• 48:30This I'm just gonna leave
• 48:32here because these are the
• 48:33results
• 48:34that were pretty positive, but
• 48:36I'm really trying to save
• 48:37time. So, again, I'm giving
• 48:39you the,
• 48:41the links
• 48:42for you to to look
• 48:43at, whether that model might
• 48:44work for us. And then
• 48:46the very last one that
• 48:47I wanna share with you
• 48:48is the,
• 48:50feedback model itself that I
• 48:52think can construct
• 48:53good conversations.
• 48:55It was developed at University
• 48:56of Washington,
• 48:58and I have used this
• 48:59in very many context actually.
• 49:02So the model is prepare.
• 49:04So it's the pre feedback
• 49:05conversation where you talk about
• 49:07goals, you talk about how
• 49:08I'm gonna observe your performance,
• 49:10if I'm gonna observe. But
• 49:11then in the feedback conversation,
• 49:13that starts with an ask
• 49:15so that the feedback giver
• 49:16asking for self reflection for,
• 49:19how they thought how the
• 49:20resident thought the performance went.
• 49:22And then the discuss is
• 49:24just a reaction to that,
• 49:26you know, to that reflection.
• 49:28Yeah. I agree totally with
• 49:29you. I saw the same
• 49:29thing. Or, no. I think
• 49:30you're being too hard on
• 49:31yourself. I saw this and,
• 49:33you know, there are something
• 49:34that you can work on,
• 49:35but this is what I
• 49:35saw. So that's the discuss.
• 49:37And then the final ask
• 49:39is after that happens maybe
• 49:40in an iterative way where
• 49:41there's several asks and discusses
• 49:44that
• 49:45it ends with the feedback
• 49:46giver asking a question again.
• 49:48So what are you taking
• 49:50away? What are you gonna
• 49:51do as next steps? Can
• 49:52we get together again? So
• 49:54this model is, very relation
• 49:56oh, the very last step
• 49:57is planning together. What what
• 49:58we are gonna do is
• 49:59follow-up.
• 50:00So the model is very
• 50:01relational,
• 50:03and
• 50:04this is the model in,
• 50:06shown in a more complex
• 50:08way. I can tell you
• 50:09that when I shared this
• 50:10at another institution,
• 50:12they made,
• 50:13pocket cards, laminated pocket cards,
• 50:16and carried this around and
• 50:17tried to really implement it.
• 50:18And what I like about
• 50:19it is it gives the
• 50:21feedback receiver, the learner, and
• 50:23the feedback giver both a
• 50:25role.
• 50:26So, again, these are materials
• 50:28for us to look at
• 50:29departmentally and ask ourselves, is
• 50:31this gonna work for us?
• 50:32So very quickly,
• 50:34we just wanna demonstrate this
• 50:36model for you.
• 50:37So Jada's gonna help me
• 50:39do this, and then we're
• 50:40gonna open it up. And
• 50:41we're close to eleven fifty.
• 50:44So
• 50:46you can stop.
• 50:49Thank you.
• 50:50So do you wanna set
• 50:51this up for us?
• 50:53Let
• 50:54me turn this on.
• 50:56I think I'm on. Okay.
• 50:56Cool. I told you I
• 50:57had a lot.
• 50:59I'm Jada,
• 51:01PGY two.
• 51:02In this scenario, I'll be
• 51:04playing a PGY three in
• 51:06the outpatient clinic,
• 51:08doctor Nkandela as my attending.
• 51:12Great. So, Jada, I, actually
• 51:14read your notes and looked
• 51:15at your follow-up on the
• 51:17case with mister Jones yesterday,
• 51:19who you thought was might
• 51:21be experiencing some, agitation. So
• 51:23just wanna is this a
• 51:24good time to talk? Yes.
• 51:26It is. Alright. So,
• 51:28can you, you indicated that,
• 51:29you know, in your email
• 51:30that you weren't quite sure
• 51:32whether you did the right
• 51:33thing, whether maintaining the medication
• 51:35dosage was the right thing.
• 51:37Can you tell me a
• 51:38little bit more about your
• 51:39concern?
• 51:40Yeah. So in the patient's
• 51:42visit for the one yesterday,
• 51:43I noticed a bit more
• 51:44agitation,
• 51:45possibly paranoia.
• 51:47Wanted to make sure the
• 51:48patient wasn't decompensating.
• 51:49So in the visit yesterday,
• 51:51I didn't notice any signs
• 51:52of instability,
• 51:53and the patient didn't report
• 51:54anything unusual except for medication
• 51:56side effects that were making
• 51:58him concerned.
• 51:59I wasn't completely sure that
• 52:00there had been there had
• 52:01not been some instability in
• 52:03the last few weeks, so
• 52:04I wanted to be more
• 52:05cautious than not by maintaining
• 52:06the dose.
• 52:08But I did feel like
• 52:08the patient was a bit
• 52:10felt a bit unsupported in
• 52:11the fact that I didn't
• 52:12make the adjustment,
• 52:13that I wasn't listening to
• 52:14his concerns
• 52:15even though we had discussed
• 52:16them previously.
• 52:18Well, I mean, I think
• 52:19you handled it well. I
• 52:20you know, I know you
• 52:21two have a strong fund
• 52:22of knowledge. You have good
• 52:23instincts.
• 52:24So, you know, I think
• 52:24you did the right thing,
• 52:27in that situation.
• 52:29Yeah. Thank you.
• 52:31I tried to balance his
• 52:32concerns of mine in wanting
• 52:33to maintain stability, but I
• 52:34just wasn't sure if I
• 52:36made the right call not
• 52:37adjusting the dose.
• 52:40Well, you know, in situations
• 52:41like this, it's important to
• 52:43make some some clinical judgments,
• 52:45and you've got the experience
• 52:46to handle it. So I
• 52:47think you did fine. Don't
• 52:48overthink it.
• 52:50Yeah. I appreciate that.
• 52:52I still feel unsure
• 52:54about when I should be
• 52:55adjusting medication in light of
• 52:56side effects. I mean,
• 52:58do you have any suggestions
• 52:59about indications that the time
• 53:01is right to make adjustments
• 53:03based on severity or severity
• 53:05or continuation of side effects
• 53:06Yeah.
• 53:07How I might think critically
• 53:08about this? Yeah. I'm sorry.
• 53:10I should slow down a
• 53:11little bit. I I'm I
• 53:12kinda missed that you were,
• 53:13you know, really asking for
• 53:14that kind of guidance. And,
• 53:16I really appreciate the fact
• 53:17that you, you know, that
• 53:19you're asking for it. So
• 53:20in outpatient settings, with a
• 53:21patient like this, I agree
• 53:23that holding the, the dose
• 53:25initially
• 53:26was the right thing, was
• 53:26the right call. But, you
• 53:28know, maybe you could consider
• 53:30a more gradual tapering off,
• 53:32if side effects continue to
• 53:34truly be a concern.
• 53:35So, you know, it's about
• 53:37balancing.
• 53:39That makes sense.
• 53:40I was concerned about the
• 53:41patient and wanted to monitor
• 53:43the condition, so I have
• 53:44the patient come back tomorrow.
• 53:46Maybe we could consider tapering
• 53:48the medication if the patient
• 53:49remains unhappy with the side
• 53:50effects. It seems to stability.
• 53:52Yeah. Great that the patient's
• 53:54coming back tomorrow. Good move.
• 53:56And,
• 53:57I I think, you know,
• 53:58you should think about tapering
• 54:00the medication. If things seem
• 54:01fine,
• 54:02then, I I think you
• 54:04should begin to do that,
• 54:05maybe, you know, to just
• 54:07a small adjustment and then,
• 54:10you know, just make sure
• 54:11you follow-up,
• 54:12to make sure destabilization
• 54:14isn't Yeah. Occurring.
• 54:16That helps a lot. Thanks
• 54:17for clarifying.
• 54:18I'll keep that in mind
• 54:18for future cases.
• 54:20So you were also concerned
• 54:21that, you know, maybe the
• 54:22patient was,
• 54:24feeling a little, you know,
• 54:25not not being heard. Can
• 54:27you tell me a little
• 54:28bit about the conversation
• 54:30with the patient? Yeah.
• 54:32I did express that I
• 54:33was glad he told me
• 54:34about side effects because it's
• 54:35important medication doesn't compromise his
• 54:37quality of life.
• 54:38Reminded him of our last
• 54:40visit when we discussed his
• 54:41increased agitation, and he did
• 54:42say he remembered our conversation.
• 54:44So I let him know
• 54:45that I wanted to make
• 54:46sure we work on maintaining
• 54:47his stability, and I was
• 54:48concerned that adjusting the dose
• 54:50may create a problem.
• 54:51I re reinforced the idea
• 54:53that I also did not
• 54:54want the side effects to
• 54:55worsen, which is why I
• 54:56asked him to come back
• 54:57tomorrow so that we could
• 54:59reassess how he was feeling.
• 55:00So, you know, I think
• 55:01you did show concern.
• 55:03So, you know, I was
• 55:04there something about mister Jones'
• 55:06demeanor that,
• 55:07you know, that made you
• 55:08think that he wasn't feeling
• 55:09supported?
• 55:11His demeanor was fine by
• 55:12the end of the appointment.
• 55:14I seem to understand my
• 55:15reasoning.
• 55:16I think I felt more
• 55:17guilty for perhaps not supporting
• 55:19his concern more than conveying
• 55:21that he was unhappy.
• 55:23Yeah. Yeah. So I can
• 55:24see that you're feeling a
• 55:25bit conflicted, and that's completely
• 55:27understandable. You know, in outpatient
• 55:28settings,
• 55:29it's tricky because we don't
• 55:30have immediate follow-up. They're you
• 55:32know, the patients aren't with
• 55:33us, where we can go
• 55:35back and check on them.
• 55:36And patient expectations weigh heavily.
• 55:39But you did do well
• 55:40in listening to the patient's
• 55:42concern, and, you know, you
• 55:43did set up the follow-up
• 55:44visit, which also showed concern.
• 55:47So, you know, I think
• 55:48you did the right things.
• 55:50And all I can, you
• 55:51know, recommend is that in
• 55:53when he comes into, tomorrow
• 55:56that you, you know, assess
• 55:57the situation. If you do,
• 56:00decide to adjust,
• 56:02then maybe we can talk
• 56:03about, you know, what happened
• 56:04in that interaction, and then
• 56:06we can think about it,
• 56:08just following up so that
• 56:09destabilization
• 56:10doesn't take place. How's that
• 56:11sound? That would be great.
• 56:12Thank you so much. Alright.
• 56:14Great.
• 56:16Alright.
• 56:16Thanks so much, Jane. Yeah.
• 56:18Of course.
• 56:22So
• 56:23we have ten minutes.
• 56:26Anything.
• 56:28Response to that
• 56:30role play,
• 56:31things that you heard that
• 56:32you wanna
• 56:33talk about.
• 56:35You can critique me, and
• 56:36I can
• 56:37have the opportunity to demonstrate
• 56:39accepting critique and how that
• 56:40goes.
• 56:41Anything that you want.