Hello, everyone. Thank you so much for being here. I'm so glad that you chose to spend some time with us when the beaches of Hawaii are right outside this door. So thank you so much for participating in our session. We will be presenting on Fierce Feedback, the art of giving feedback in difficult situations, something that we all encounter, hopefully not every day, but more often than we would like. So I am Michelle. I'm currently a second year fellow at the Loma Linda University Pulmonary and Critical Care Fellowship Program. I am here presenting with several of my colleagues. This is Abdullah Alismail. He is an RT with our program who will be presenting as well. We have Elizabeth Batchelor with us, and we have Aaron Kamak as well. So each of them will be kind of introducing a little bit more about themselves, but I kind of want to get into it because we'll be getting really interactive today. And so for those of you who are just coming in, there's plenty of space here at the front, and we would love for this to be as interactive as possible. If you guys didn't know or couldn't tell from the description in our description box in the app, we will be actually having you guys participate, talk, come up front. And so if you want to come up and get closer, that would be wonderful. Again, front row seats right here, best spots. I have nothing to disclose. So our session today, again, it will be a practice-based learning session. We'll be exploring and experiencing feedback in a very interactive way. And our focus, again, will be on situations involving difficult feedback and applying some different strategies to approach these situations. You can read the rest of the objectives here. So I'm sure we are all very familiar with what each of these are. I don't know if anyone wants to call out the ones that they recognize. These are just a few of the platforms and ways that we give feedback and use feedback all the time, and that companies, products, et cetera, will use feedback from customers, from people who will use their services to improve the way that they do their services, that they create their products. And so we're all very familiar with what feedback is in a practical way. But in terms of medical education, what do we mean? So if we look at the Oxford Dictionary, feedback in a general sense is information about reactions to a product, a person's performance of a task, et cetera, which is used as a basis for improvement. I mean, that's pretty intuitive. If we go specifically to medical education, what is often referred to as the seminal paper on feedback in medical education by Endy, which was published in JAMA in 1983, a long time ago for many of us who were perhaps not born, this feedback is described here as information describing students' or house officers' performance in a given activity that's intended to guide their future performance in the same or related activity. So kind of the same thing as the Oxford definition, but now specifically applying it to medical trainees. I especially like this one. So this is from an article called The Do's, Don'ts, and Don't Knows of Feedback for Clinical Education. If you want to learn a little bit more about some practical applications of feedback, how to give and receive feedback, I would recommend this article from perspective of medical education. And so you can see it here, but I wanted to highlight a few different things that are involved in this definition. So feedback is a supportive conversation. So one, it's supportive, meaning the focus and the purpose of the feedback is to bring up the learner. Two, it's a conversation, which means it implies that it should be a two-way street. It clarifies the trainee's awareness. So the goal here is to allow the trainee to become self-efficacious, and that's highlighted in the next box there. So we want the learners to eventually be able to give themselves auto-feedback and be able to direct their own performance towards success, towards improvement. So in today's discussion on feedback, we will be talking mostly about feedback in more everyday interactions, maybe, you know, every day while you're rotating with learners, perhaps your end-of-week type of evaluations. We won't be focusing as much on the summative evaluations that are more type of the end-of-the-year or semi-annual evaluations with program directors. That's kind of a different topic. So we'll be focusing more kind of this formative feedback, everyday type of conversation and feedback today. I do want to highlight the importance of the educational alliance, which I do think is really foundational to good and effective feedback. Without a good rapport between the learner and the person giving feedback, there's less likelihood of that feedback being received well. And so going into that, so factors that affect feedback effectiveness, if we were to do a root cause analysis on how effective or ineffective feedback can be, there's many different factors that influence that. So, of course, there are teacher factors, which is a little bit of what we'll be focusing on more today, so the feedback provision skills. But there's also feedback receiving skills on the part of the learner, as well as cognitive barriers, which we'll go into today in terms of the situations on difficult feedback. And then, of course, there are external factors, the setting, the timing in which the feedback is given. And then there are other things, such as relational factors. We mentioned already the educational alliance, the professional context in which the feedback is being given, among others. But that being said, I want us to get into putting it into practice. And so we'll be getting really into this. I'm glad that we've got a good group. You all look excited and ready to get into some feedback with, to, from each other. And so we'll be getting to that right now. Hi, guys. Once again, this is our Fierce Feedback Workshop. And we're not quite to the practical yet. It's my job in the next 10 minutes to give you guys all of the tools you need to give good feedback. So I'm sure you're prepared for a jam-packed session. We'll see if we can get through it. My name is Beth Batchelor. I'm currently an assistant professor at the University of Arizona College of Medicine in Phoenix. My only disclosure is that I am nowhere near perfect. And so we're all going to be learning together today, because this is obviously very complicated and very difficult to do well. So again, these are our overall objectives. But what we're going to focus on is giving you guys just strategies, tips, tools, big kind of core ideas to help you give effective feedback, because you can't run before you crawl. So we're going to learn the basics now and then really launch you into the fire in the next part of the session. So again, we have 10 minutes. Please work with me here. What is effective feedback? What is something that you guys have noticed that's helpful when you're getting feedback? Sticks to the facts. A pretense relationship or rapport with an individual. Yeah, right. So it actually is someone you trust and believe is out to help you, not get you. And again, we just work. Very specific, based on actual behavior of the personality. And I did not plant her in the audience. So we're going to get to that. And what you're going to see, and you heard this a little bit from Dr. Imperio as well, you're going to, guys, this is going to be a little redundant. I want to beat us over the head with it. But effective feedback is planned. This means that ideally when you're giving feedback, it's not the first time that your learner is hearing that they're getting feedback. It means that it's close to the event, because if three weeks later, you're like, do you remember that lady you were ultrasounding? They're not going to remember. It means the environment. Is somebody standing outside a code crying, and you walk up and go, you should have thought about pneumothorax? No. Probably not the best. So think about the situation you're in, the people that you're around. Is this feedback one-on-one, or is this something the whole group should hear? It should be explicit. If you take nothing else home today, start telling people what you're doing. I'm sure you've all seen the evidence, right? Students think they never get feedback. We think we're giving it all the time. So again, hey, this is feedback. Would you like me to give you some feedback? I have some feedback for you if you're open to it. It should be descriptive. And you said this very wonderfully, right? This should be focused on behavior, not personality. Raise of hands for be more confident, speak up more. Really, just one? Okay, one and a half. Be more confident doesn't work. Hey, I've noticed one-on-one, you give great advice to your interns. It would be really helpful if you shared that on rounds with everyone. That is something I can do, not something I have to change who I am or how to be. It should be specific, right? Your ultrasound technique sucks. You're laughing because you've heard it, I bet you. No, instead, hey, look, you're not really getting perpendicular to the plane. Your interface is not good. That's really going to help you get a better view, right? It should be concise. If you tell them every 35 things they're doing wrong all at once, what are they taking home? Nothing, right? So again, focus on a few high-impact things. We can always come back and talk more, but let's give you something today that you can digest and actually make use of. It should be honest, right? We're not going to talk about the feedback sandwich, but we don't like it because people come to expect that softening of the blow, and we don't believe that you really mean it, right? So say what you mean, and that genuine is going to help with that therapeutic relationship. Finally, it should be verified by your recipient, one, like we talked about. Do you actually know I'm giving you feedback? Yes, no. And if you do know, are we talking about the same thing? Have I told you about your technique, and you think I'm talking about your jewelry? We're having a miscommunication. Finally, and I add this, I think it should be encouraged as routine. If you're giving feedback regularly, it's no longer punitive. I'm not only singling you out when you've done something wrong. I'm praising you when you do it well, and if you're really doing it right, I'm asking for it myself as well, because if someone sees their supervisor hearing, soliciting, using, incorporating feedback, then it just becomes normal and part of the way we do things. If this wasn't clear enough, we're going to say all the same things a different way. So again, I also think you can't give good feedback if you can't take it. So we talked about this already from the side of someone giving feedback. It should be planned. It should be respectful. You can still tell people negative things constructively in a way that helps them grow. It should be descriptive. Again, your ultrasound technique sucks. It's not going to work. You are shy, not helpful. It should be based on direct observation. Like we said, we're talking about formative feedback today, not end of rotation, not end of year. This is concrete things we're doing just to help you improve and change and grow. At the end of it, you should ask for understanding. Again, did you hear what I said, and did you hear what I'm trying to help you with? On the receiving side, even though I'm telling all of you to tell people you're giving feedback every time, try and have some good assumption of intentions and say, listen, are they actually trying to help me do something here? And if you aren't sure, actively participate. Ask for clarification. Are you giving me feedback right now? Are you trying to tell me that I should change the way I hold my needle when I'm doing a central line? You know what? I don't think I understand. Could you give me some specific examples? Finally, if you know you're going to get defensive, maybe call a timeout. Look, I'm not in a place to hear this right now. Can we circle back? Can I digest what I've heard? Can I process this? And then I do want to talk about it. Finally, and I know everyone likes this part, reflect on what you should actually take with you and change versus what you shouldn't. Because not all feedback is going to be valid and not all of it is something you should incorporate. So is this for me or not for me? Together, you guys should be doing a few things. That QR code I hope for you will be life changing. It's about genuine curiosity and assuming good intentions. And the point here is I come to you with feedback. The goal for you is to assume that it's not because you don't like me. It's not because you don't want me to do well. You're genuinely trying to help even if the message isn't packaged well. On the other side of it, I shouldn't be assuming that I know why you did things. Look, I saw you yelling at the intern yesterday. I know you hate that guy, but you've got to be nicer. That's not the way to do it. Look, I saw an interaction yesterday where you seemed to be raising your voice pretty high. Can you just help me understand what was going through your mind? What were you thinking? Maybe they were scared. Maybe they're tired. Who knows? It's a stressful job, right? Trying to meet people where they are helps forge that therapeutic alliance. The next thing is creating shared goals. This is the goal of getting feedback. What do you want me to give you feedback on? What should I pay attention to today? As well as once we've talked about what you can work on, how are we going to work on it and how are we going to close that loop? You can only tell someone to change something so many times and never look out for it before they realize it's not worth the effort. Look, I want to see your technique. I'm going to observe you on rounds for the next week. Then we're going to touch base and see what worked and if we change our goal or come at it a different way because it's not falling in line. I'm sure you're surprised this sounds redundant yet. Has everyone got it down? We're going to keep going. Again, there are some basic needs for feedback. You can see them up there. It's an effective setting. It's a learner who's in the mental state and the literal geographic physical state to receive it. It's assuming good intentions on both sides, being clear about what you're communicating and how, and having a follow-up plan for the feedback that you give. An easy way to remember this is to think about stopping. It's going to be an acronym for those that like them and it's going to be a stop and think. Am I in the right place to give this? Is my learner in the right place? Am I in a good state of mind? Stop and ask yourself. Again, by am I in a good state of mind, am I too heated to be kind right now? I should be honest but I shouldn't be cruel. Have I made it clear that this will be feedback? Once again, biggest take home, tell them you're doing it. Make it campy. What message am I trying to get across? What am I going to focus on today? Finally, ask your learner for their own assessment. How do you think that went? What do you want feedback on from me? Once you've asked those questions, then you can get to your, again, who's in the front of the audience that said all those wonderful things? What's your name? Gretchen. Gretchen did lovely. Specific, timely, objective and having a follow-up plan. In case you didn't want more information, we're going to give it to you anyway. This is another QR code to a litany of feedback models. We've chosen three for you guys to run through and we'll go through them pretty quick so we can move on to the most fun part. The first is spikes. This probably requires the most level of interaction and planning but the nice thing about it is you might get learner buy-in because most of your residents and fellows should have heard about it for palliative care. Same idea here. I think you're going to start to hear more redundancy. One, consider the setting. Again, it should be close to the event so we can actually talk about specifics and have memory. The next thing is you should know the standards for your learners. I'm not sure asking a third-year med student about lung point is going to be helpful. I probably shouldn't feedback them on learning that. We should probably start with basics. The next is asking the learner for their input. What did you notice? How do you think that went? Then you're going to say, hey, can I give you some feedback? If you're open, I would love to give you feedback on how you performed that family conversation, how you did that central line. That's when you give them the specific facts. Again, objective based on behavior, not characteristic. Then you're going to circle back and say, how does this make you feel? Are you defensive? Let's look into why. Are you hearing what I'm trying to say? No, then maybe we say it a different way. Why is this hard to digest? How do I help you through it so this is the most useful session it can be for you and me? Then finally, how are we going to work together to put things into practice? Keep that in the back of your mind and then you're going to have it on your sheet. The next one, which will be very similar because these are all the same basic tenets, is go ask, tell, ask. It's kind of an intermediary between the two. The nice thing you have is if you have the time, you can review your learner's goals and then set it up. Hey, when you bronc today, I'm going to watch you do X or what would you like me to pay attention to? That way I'm focused in on the most high yielding for you. Then it comes the same way. You're going to ask your learner, how did that go for you? Once you hear what they have to say, you add in your input and then again, you check in, make sure they heard what you tried to say, you make a plan together. Again, how do you think your bronc went? I think it was awesome. I saw a lot of fellow tracks. I think you need to work on your hand control, whatever it may be. Finally, W3, I like this when you're walking in a hallway and you're pressed for time. The really nice thing about it is those questions can turn into statements if your learner doesn't have insight. Again, when you're asking your learner, what do you like, what do you not? I think the nice thing about getting that is maybe what you find out is your learner has no insight and that's what your feedback is going to be on after all. We're not even going to talk about technique, we're going to talk about how to self-evaluate. What you do is what went well, what didn't go well and what we're going to change and how we're going to change it. Again, same thing, get their perspective, review the positives and negatives and make a plan to move forward. We're going to put up a case but before we do that, do we have any questions from you guys? As you guys read this, I think you're going to take control of that. I'm going to leave it here but think about using one of those models that you've been handed out, again, that QR code I can go back to and how you would try and give feedback to a learner in this situation. Again, we're really big on feedback so please, if you would, give us some feedback and evaluate us on the app. This is going to be the next portion of our talk which is about forum theater which is the technique we're going to be using in order to learn more about feedback. This is going to be fun, I promise. It is not going to be stressful, I promise. You can kind of like shake it out, any of the anxiety that you have about talking in public with other physicians because we're going to be using a really good technique that I've used in a lot of situations in which has been really helpful. I'm Erin Kamak. I'm an Associate Professor of Medicine at the University of Kentucky and I'm a new 1.5 year Pulmonary and Critical Care Fellowship Program Director and yes, I'm doing okay. Thank you for thinking about it. So here's the technique we're going to be using. This is something that's going to apply to you here in the next few minutes and what we're going to use is forum theater. Forum theater was originally developed by a Brazilian theater director in a time of troubles in Brazil when people were dealing with day-to-day contexts involving a democratic revolution and they were trying to find solutions to the problems they were facing in the moment. This has been expanded throughout the world and has been used for the last 45 years because it's very helpful in promoting social justice. An example of the way that this has been used in my community is that it was used by a Get Out the Vote pledge recently for door knockers who were going door to door and trying to get people to make a plan to vote. They trained for that role using forum theater and it was a very successful training. We're going to be doing a traditional forum theater model. In the forum theater model there are three participants. The moderator, which is me, the collaborator, which you know is already Beth, and the SPECT actors, which is all of you. You're going to be participating in the model for forum theater. And we'll go through what each of the elements of this are. So I, as the moderator, have the requirement to keep the room engaged, to get everybody moving and talking, to be spontaneous, to be comfortable shouting things out, giving you the psychological safety to really participate. My number one goal, though, which is not listed there, is to make this fun, so bear that in mind. The collaborator, who's gonna be Dr. Batchelor, is responsible for being your counterparty in any discussion that you're having. She is to become the most obstinate, resilient learner you can imagine. Her only goal is not to change, not to break, not to warm up, not to anything, and in response to the way that you are speaking with her. So please know, you are not going to win your conversations with Dr. Batchelor. That is part of how this is fun. And then here's your role. This is the most important role in the room. We're gonna be grabbing people to participate in conversations with Dr. Batchelor. During the time that you're actively talking with her, you wanna suspend your disbelief for the opportunity to have a good time and to learn. During that conversation, you're gonna be imagining that she is a learner. We ask that you be brave, we ask that you be realistic, we ask that you be yourself. While you're watching other people participate in interactions with Dr. Batchelor, we ask that you use your empathy, but that you do that in a vocal way. Shout out things that come to your mind. Make suggestions, hold up your hand. Participate from the audience. The more that you do so, the more fun that we will have and the more we will learn. So I want you each to please grab your index card that you were given. If you don't have an index card, we have a small pile left over here at the front of the room and you can feel free to grab one. I am sorry that we're out of pens. There are some forum theater handouts circulating in the audience as well that will remind you about how things are working in case you got here late or needed a reminder. What I'd like you to do with your index card is to take a moment to search your feelings and try to remember the most challenging feedback situation you've had in your practice in recent memory. It could be any form of learner. The learner could be somebody across different medical distinctions. They could be someone who's very junior to you. They could be a peer. Write your learner type down, who is this person you had to give feedback to, and write down as much as you can in detail what the feedback was you had to give that learner. If it's possible, follow that with what was hard about that for you. So we want three things on the index card. Who is the person you had to give feedback to? What is the feedback you had to give them? And how did it make you feel what made it challenging? As you do this, we are going to be setting up an example scenario. The example scenario is something you can absolutely participate in as spec'd actors, but we're not asking anything from you just yet in this initial scenario. It's to get you a sense of how this actually works. By the time that we're done today, I hope that we've learned a lot about feedback, but I also hope that you've learned about forum theater and that you find this a useful tool that you can use in your educational practice. So we're gonna set up the example scenario now. So in this example scenario, Dr. Batchelor is our collaborator. She will be our collaborator through the entire event. Sorry. Dr. Imperio is going to be our first participant, and you are all spec'd actors. The scene that we are in is a scene post rounds after a pulmonary consult day. The pulmonary consult day contained several learners, one of which was a medicine resident who is really interested in becoming a pulmonary and critical care doctor. Raise your hand if you've met somebody like this. Okay. They want to make the most of this opportunity to impress you, and they have been trying very hard to be as interactive and as much on the floor as they possibly can be, and that's Dr. Batchelor's role. During rounds, you saw a patient with pH who was titrating intravenous prostaglandins, and during that scenario, the resident took the opportunity without being asked to spontaneously deliver a 45-minute lecture to the entire team about the value of pH treatments, what treatments are available, and what the clinical outcomes are. It was awesome. This caused the fellow rounding on your team to appear to have a mini stroke, and it caused the medical residents to lose consciousness. So Dr. Imperio, for the purposes of this setting, is trying to provide some feedback to Dr. Batchelor, and so now just remember, our collaborator can never change. All right, we can begin. So, I'm glad that we're taking this time to do some feedback. I know that at the beginning of this rotation, you said that you had some goals that included education for the residents. Yeah, I'm super excited. I can tell. Wow, that was something. Yeah? So how do you think it went? I mean, honestly, I was super nervous because pH is scary, right? We don't really get it, but I feel like by the end of it, everybody heard everything I said. No one walked off, no one answered pages. I honestly, it went way better than I thought. Okay. Do you think you could have done anything differently? Well, to be honest with you, I kind of wish that I'd brought in more pre-made pictures because sometimes it's really hard to draw when you talk. I think that would have been way more effective. You seem very enthused and excited about teaching. Yeah, just like all the fellows you want, right? Awesome. All right, so this is how things begin. And now is the part where you become spec actors. So what version of feedback delivery was Dr. Imperio trying to use there? It could have been a bunch of them, right? But you can shout out a few of them. Which one of them might it be? Yeah, you're all correct. This is the beginning of a lot of these scenarios, but she's picked one and she's using it in her head. What's something that could have gone better about her introduction? She was kind of slow rolling up to this. Exactly, come right out of the gate with being specific. That'd be great. So who was that in the back who wanted to be specific? Wonderful, can I grab you, please? Come on down. That was great. So this is forum theater and you're interacting. You're doing a great job. Welcome. Okay, wonderful. You are now the attending. So we're going to resume the scenario. And remember, this is your resident and they have given a 45 minute diatribe. Awesome. It was a very good diatribe, they feel that way. I know you're glad, sorry. All right. Go ahead, you can start again. I wanna take this opportunity to give you some feedback. Oh, thanks so much. I saw you doing some teaching just there of the, sorry, I have to use the right words because we use different words in Australia, of the residents and the other doctors. What do you think worked well in that? Honestly, again, like, you know, PH is so hard and I probably spent like five nights on this to be honest with you. And I feel like I covered everything. I'm sure that's true. You did cover everything. What do you think the more junior doctors wanted to get out of that learning? I mean, honestly, junior doctors do, they don't know anything, right? Like everything I'm telling them is high yield. So I feel like whatever we cover, it's always helpful. Hmm, okay. I wonder if there's a different way you could approach that. I mean, handouts? That's not exactly what I'm thinking. What I'm thinking about is understanding what they want. I mean, I talk to them at the end of the day. I feel like, again, they just wanna learn. Yeah, everyone wants to learn. I think that's a really valid point. But I wonder if that's meeting their learning objectives. Is there a way you could find out what they want to learn? Well, I mean, I could ask them, but again, this goes back to, do they really know anything at this point? Hmm, okay. I can see that you're really enthusiastic about teaching pulmonary hypertension. But I think that some of those doctors probably don't wanna do respiratory. Maybe they wanna be surgeons. But sometimes you have to push people. Yeah, yeah, that's true. Pushing people is important. Sorry, you're good. You're free. I'm hard to see from behind you, I apologize. Very nice job. A hand for our first participant. Okay, so those of you who haven't handed in your cards, if you've got something written down, please pass them up here to the front. We're going to be shuffling through your cards and we're gonna do these scenarios. We are hopeful that you are all as traumatized as we have been by the difficult feedback that we've been giving. And as a result, that you'll have some real fire in here for us to work through. Okay, I need a really lovely person to come for a new scenario. Can I grab you? Oh, fantastic, thank you. Can it be non-random, can I? Oh yeah. Oh no, I'm happy to have you here, welcome. Okay. Okay, so here we have a new scenario. This is a difficult and challenging scenario for one of our audience members. Okay. Okay, so this person is an attending who's working with an intern in the MICU. The feedback that needed to be given was on disengaged behavior in the ICU. We have all met this person. Raise your hand if you've met the disengaged intern in the ICU. Yes, they are challenged by this environment and their solution to it is to go inside their turtle shell, so just eyes poke out. Yes, exactly. They hide behind their mouse, they hide behind the computer. The feelings that this engendered in the attending were a lack of insight on expectations and that was very hard for them because it seemed that the learner was not receiving the expectations well and the effect that this had on patient care and the team dynamic was very negative and they felt sort of responsible for that. So now you are going to be giving this feedback to this disengaged intern. Okay, and I'm basically giving the feedback that they've been disengaged, they're not gonna receive it well. Correct. I'm gonna try to reset expectations. Excellent. Hi, so I know that we've now had several days on service together. Usually this is when I like to give my midweek feedback. Is that something that you would be open to receiving right now? Sure. Excellent. How do you feel that the week has been going so far? I mean, you know, it's like an irritation, like the work gets done, it's busy, kind of the same. Okay, and I understand that going into pulmonary critical care is really not your end aspiration. No, I wanna be a surgeon. Okay, excellent. And so one thing that I wanna try to bring you back to is kind of how we can maybe use your experience in the ICU to help enhance where you want to go, which is surgery. So I'd like to find a way for us to tie that back together. Do you see that there could be any potential link there for you? Yeah, I mean, I do all the procedures for my patients. Okay, excellent. I think that's a great start. But could there be something perhaps from a medical knowledge base that we could help enhance your actual overall care of patients? As there will still be patients on the surgical side that will need ICU care. Yeah, I mean, but isn't that the point of consulting? You bring up an interesting point. You're very challenging. So, okay. All right, so. Okay, we're gonna pause the scenario. That was really good, guys. Okay, so Dr. Batchelor, would you be willing to repeat what you just said? Isn't that the point of consulting? Yes, who's got an answer for that? That's a challenge. Shout it out. Yeah. Come on down. You are the next contestant. Fantastic. Round of applause. So I'm still uninterested? You're still uninterested. We're in the same scenario. Okay, we're gonna just play that out from the top. I'm happy to repeat for you. Oh, just like from when you said. Yeah, so like, isn't that the point of consulting? Yeah, I do think that is the point of consulting, but so one of the goals, or I guess it sounds like your goal is good patient care, right? And you want your surgical patients to have the best outcomes. Ideally, I don't wanna get sued. Yeah, good goal, fair. And it's gonna be important to consult. And I think that is true, but also having an understanding. You as the surgeon will also be the consultant, right? You will get a lot of consults and you're gonna want people to have an idea of what you can do for the patients and actually have good questions for you. Therefore, you can actually get better care for the patient. I mean, yeah, but at the same time, like no one consulting me can do surgery. Okay. That's fair. That's a great place to stop. High five. Can I just get a second little hand for Dr. Batchelor? Cause she has got this going on. Awesome, fantastic. All right, so would anyone else like to try to take a run at this disengaged intern? No? Okay, we're gonna move to another scenario. So as you're thinking through the scenarios, choose one of the models to walk it in with and then it will go from there not well. And so what we're here to learn is it's okay to laugh, it's okay to take a step back to reconsider your thoughts and then to try again. Dr. Batchelor is doing her best to rebuff you intentionally. Okay, so I've got another scenario submitted by a member of the audience. We have, sorry? Oh, a mystery? Yeah, that's me. A mystery person. Yes, please do select. You can volunteer. Oh, fantastic. Yes. I will say though that I only have one arm right now and that is hearing my feedback abilities. Duly noted. Okay, Dr. Batchelor can hold an arm behind her back. All right, we're even. We have an intern. So Dr. Batchelor is an intern with poor or unknown emotional lability. So the attending in this scenario has tried to give some feedback and the intern has burst into tears in the middle of presenting a complex patient in the ICU. The intern put herself in a situation where she was expecting to perform at a higher level than was possible for her skills. She became very overwhelmed and the attending had to deal with that outcome. The challenge for the attending was that they never anticipated such a response in the intern. And she was in a position where she had to react very quickly to an emotionally labile situation. Are we like in a group, like still in rounds? Oh yeah, we're on rounds. We've got a pharmacist. Now this is your team. Yep. And so you have an intern who has just kind of broken into tears in the middle of her performance. So I'm already crying? Yeah. Yes, you're already upset. You're upset. So think of, as Dr. Batchelor is getting ready for this, think about what you would do in this situation. Probably start crying. Can I cry? We all do sometimes. This is why I love forum theater. Could be sweat. It is sweat, I'm in white. Who's starting? I'm crying. You're crying. Okay, sorry. This only goes so far, come here. It's a lot. Yeah. It's a lot. Let's take a break for a second, okay? Am I in trouble? No, not at all. You sure I'm not in trouble? I'm really sorry. Yeah, it's okay. I think that this is a really good opportunity for us to talk as a team about how difficult medicine can be. With everybody. I think that it's important for everyone to know that medicine is really difficult and sometimes that gets overwhelming, but I don't think we need to talk with everyone about that much more. But you can like talk to them. Actually, I'd like you to stay here because we're gonna go chat in a minute and I'm gonna chat with everyone here individually a little bit later after rounds and just do some feedback with everyone because I think it's really important. But I'm not in trouble. Not at all. And I just want everyone to know that sometimes I cry too. Things get tough. So what we're gonna do is, because now's just a good time to do some feedback because I like to be really timely with it so that we can think about what's happened. We're gonna break off. That procedure that we were gonna do in room 214, can you go get consent for them and sign set up for that while we're doing some feedback? And then- But I was supposed to do that procedure. I'm sorry, I could do it, I swear. You can. We're just gonna get set up and get the consent and then we're still gonna go do the procedure with you. And then we're gonna do feedback individually after rounds with everyone else. But we're just gonna take like a five minute break, okay? All right. Okay. Now we're by ourselves. That was amazing. You were so great. I know it was hard for Beth to continue to have emotions after that because she was so reassured, by the way, that you came into the situation. So what I'd like from the audience is some suggestions on how we could deal with this situation. The crying, blubbering intern who's in the middle of rounds. She's very fearful that everyone can see her, that she's upset. That's clearly my problem. Can we approach it differently or can we approach it some way? Mm-hmm. What might you say? What are some first liners? We just heard an example of a really good one. We're taking a step forward. She's got the setting. She's got me alone. That didn't sound great. But she's put me into a safer environment. How do you start actually feedbacking what's going on? Awesome. I love that, because with all the models, we have emotions that are incorporated. But when somebody's upset, that emotions issue goes right to the top of the list. The emotions have to be dealt with before any feedback can take place. Awesome. That was fantastic. Taking a second to ask them what's going on, like maybe they're getting a divorce or their job died or something. Awesome. Great. Come on down. I love this. Thank you so much. Awesome. Isn't this fun? Okay. So we're dealing with emotions. We're doing that first. We have a blubbering intern. We've got a good setting. And go. Do you want to hydrate? I don't know. She's pulled me aside. We're alone now. Go for it. Hi. Tell me what's going on. I don't know why anybody does this for a job. It's terrible. You're not... The ICU is feeling overwhelming? I mean, don't you feel overwhelmed? This is awful. Have you seen this? This is awful. I don't know why anybody does this for a job. It's terrible. You're not... The ICU is feeling overwhelming? I mean, don't you feel overwhelmed? This is awful. This is awful. Have you seen how many people are on ventilators? Everybody's sick. I don't know what's going on. There are a lot of sick people here. Should we take them? Do you need some water? Should we... I need a lot more than water, lady. Why don't we... Let's go... Let's go outside for a walk. I mean, she's a caged animal. Yes. Very nice. And I'm in a cage with her. And now you're insulting me? The ICU is intense. It's awful. There are very sick people here. It really is. One way I like to look at it is this is going on everywhere all the time. And that's better? And we have the honor of being a part of this, to care for these people when they're vulnerable. And it's okay. We can let this experience guide what you choose to do. You don't have to be exposed to this forever. But for now, we're gonna figure out how this can be a helpful experience for you. So it's not like today or for like the rest of the month? We're gonna talk now about a plan to go forward to make this a more helpful experience for you this month. And that could be like not rounding? You're a part of the team and you're expected to do this. She's so combative. That was amazing. Thank you. That was amazing. It's hard because Dr. Batchelor is gonna continue to give you the most difficult response she can think of. But that's how we learn. I love that you walked into that situation with the context, the global context. And I think that if Dr. Batchelor was not assigned the role that she had, she'd have been very reassured. I did feel better. Okay. Well, you need a new volunteer and we have a new scenario. Oh, fantastic. Come on down. I need to tell you something. This is my fellowship program director. This is deja vu. I have faith in you, Beth. All right. We have a different scenario here. We have a person who's dealing with an APP employee who had previously been a manager in the life prior to becoming an APP. So this is a person who's quite a bit older than the person in this scenario. And they find them a little bit intimidating. This is their first time trying to give this APP feedback about the nature of how things have been going over the last week. And what the attending is concerned about is that the APP has been very defensive. When the attending says, I would recommend that you do X instead of Y, they're like, well, why? Why would I choose that? I don't need to choose that. I chose right the first time. This is emotional and challenging for the person in the situation, because they are a little intimidated by this person. So wait, I'm an APP and I intimidate him? APP? Yes. And I'm her attending? Yes. And there's a power imbalance that goes the opposite way of the actual power imbalance in this situation. Yeah. Hi, Beth. Hi, Dr. Wilson. How are you? I'm good. I'm so happy that you came to work with us. You brought in your previous jobs from really good skills. And I think that you could be a really valuable member of the team. And so I'm really happy about that. You've been here now for a few weeks, and I thought it would be a good idea for us to just have a talk about how things are going and what I can do to make you more comfortable and perhaps give you some feedback about things that I think you might be able to do to get more comfortable and to improve your job performance. I actually really appreciate that. And I'd love to hear it. And then when we're done, if I could give you some too, I think that would be really helpful. Yes. This is definitely deja vu. You know what? That's a really great idea, and I'm open to feedback, and I think we should just start with that. And I'd really appreciate it if you could tell me what I could do better. Yeah. You know, I just noticed, I feel like there's a lot of pushback for things that there shouldn't be pushback for. Like, I'm not new. I know you guys work with new residents all the time, but I've been doing this for a long time. Okay, pause, guys. Don't leave. I love what you just did, which is she said, well, maybe I can give you feedback later, and you said, well, maybe I need feedback. Let's do that first. Raise your hands if you would have put it first. There's a couple. Yeah. Yeah. Now that you've just seen how that went, would you be more likely to put yourself first in that situation? I would be. I just learned something from this, which is great. All right. So we're putting his feedback first, but we're going to move along past that portion of feedback and on to your feedback. Okay. Go ahead. Fast forward and resume. Well, nobody respects me. I feel like I'm not getting the credence for the time that I've put in, and it's really honestly frustrating. Like, I know what I'm doing. Yeah. You know, I think there's no question that you're very competent, and the way I look at it in the ICU setting is, you know, I've done this for a long time, and every time I come up here, I learn things, and, you know, it's a team approach. And, you know, so we have, you know, all kinds of people here on the team, right? We have physicians, advanced practice providers, respiratory therapists, physical therapists, pharmacists, and one of the things that I've learned is that we all need to learn kind of from each other and then recognize that there's always different ways of different people that do things, right? So you came from a different institution, and one of the values of that for us and for you is that, you know, people at different places do things differently, and so one of my messages to you is that I'd ask you to think about is, you know, just recognize that there could be different ways that people look at things, the same problem, and just to be open to that. Yeah. But, I mean, isn't that the point? Like, if you all can do things differently, so can I, so maybe we should let me do some of my things? I think that that's fair, and, you know, in the intensive care unit, I think you can take the same problem, and you can attack it in different ways, and there are more than one right way to do things, and when we're in that situation, then I think we should think about that, and people should be allowed to do things differently. Other times, there's times when, you know, we might think that there's a more right way and a less right way, and I would just ask that you kind of allow us to tell you that when we think that way. Well, and, you know, so maybe you could help me out because, you know, again, I'm hearing like we should all be open to things, and so could you just give me, like, an example of me not being open because I feel like I'm a pretty good team player. Awesome. Okay. Let's pause right there. That was awesome, guys.

giving feedback

difficult situations

medical education

supportive conversation

feedback models

forum theater

interactive setting

safe space