We're super excited that you're all here. I'm Lakshmi Santosh. I'm from the University of California, San Francisco Where I'm the APD of the fellowship and the residency and an associate professor So before we launch into kind of nitty-gritty feedback pearls I wanted to acknowledge sort of the elephant in the room which is that feedback doesn't actually look the same for each and every one of us sitting here and For anyone who saw the Barbie movie this summer Yeah, so for anyone who's seen the Barbie movie we know that Sometimes different people are kind of held to different standards Even while doing the same exact procedure and we wanted to kind of bring that elephant in the room out in the open and really Discuss how DEI issues particularly gender and race impact feedback and what you can do to avoid falling into that that trap So first off a brief tour through the data So who do we think are described as running rounds? They really see the big picture complex medical knowledge a master clinician and super laid-back Whereas perhaps another gender is filled with quotations that are disproportionately like a delight Wonderful kind and supportive super nice Lakshmi is a great faculty member, right? And so you see here in this great study done by dr Janae Heath and colleagues from Penn of thousands of faculty evaluations That men and women faculty often get quite gendered feedback And this is huge natural language processing approach that they use to look at thousands of evaluations Across the University of Pennsylvania and found this and this has been replicated again and again and again From our own institution UCSF one of my mentors. Dr. Irma Mollis-Sarkar We're some of us are deep in application review for medicine residencies or poem critical care fellowships and they looked at Dean's Letters and Interestingly, they found that that language differs both by gender and by underrepresented in medicine status for race ethnicities So just being mindful of what kind of language we use when we're giving feedback to a learner And when we're giving feedback to each other The other thing to be mindful of is that bias can be magnified when people are coming from multiple marginalized identities One of the great articles that I recommend for everyone is not not an actually academic article But a piece in stat by dr. Uche Blackstock where she talks about why are black women physicians leaving academic medicine? I recommend this article to all of you It really gives insight into how people with multiple marginalized identities Really experience the culture of medicine and particularly feedback culture in a really different way and how we can all combat that What about procedural training? That's our focus here today, right? You came here to learn about feedback and procedural training So some colleagues including Emily and I wrote this really interesting paper Looking at gender disparities in critical care procedures like a line central lines intubations Thoros, etc at a multi-site institutional process that was actually mixed methods So both quantitative and qualitative and we found Fascinating results. I won't go through the entire results So I'd encourage you to check out the paper, but if you do read the paper skim it look at the quotes The quotes are super instructive of to the culture of procedures One quote says I this is interviewing residents who are trying to get critical care procedures I do feel that when I think of a proceduralist I don't necessarily think of a woman says a female resident that just breaks my heart We need to do better so that this person doesn't feel that way another resident a male pgy3 says There's definitely a bro culture of being a procedures person and that's the general environment of what we see modeled Overwhelmingly men are going to procedural fields and I think that creates an environment where there's a disparity Here's a female intern who says I have to overcompensate with Confidence to try to make the patient believe that I deserve to be there doing that procedure Heartbreaking quotes. I feel like growing up. There's more of a perception of men as tinkers who fix things I see myself about someone who thinks about things to fix rather than someone who actually gets my hands on to fix things so these gender dynamics you can see people are bringing up stuff from childhood from Socialization as a toddler in Elementary school well before medical education takes place and we have this pretty dense figure in our article talking about how there's societal factors resident factors supervisor factors and patient factors that all might contribute to gender disparities in procedures and If there are gender disparities in procedures, then that can lead to a really pernicious vicious cycle, right? Where you start saying things like oh that person just isn't quote good at procedures and making generalizations There are readily available assessment tools For example Dean Karen Hauer at UCSF has this equity in assessment checklist with lots of great tools to give yourself Reminders of how do I avoid giving feedback with gendered language or racialized language? whether you're writing a letter of recommendation or giving feedback about a procedure and When we get into our small group super shortly, I want you to all think about that think about mentoring across differences giving feedback That's not gender That's not racialized and how do we be inclusive of everyone and show all these learners that? Critical care is the best and that we want to welcome people into the space that they belong in this space So next I'm gonna turn it over to Emily. Dr. Olson talking about how do we give that feedback effectively? Thanks for listening I want to pay the most attention to this section because it's going to be the most relevant to the end Aloha and good morning My name is Emily. I'm a fellow at Northwestern and nothing to disclose. Thank you all for that wonderful introduction I think a lot of what you'll hear is Hopefully going to resonate with you and something that you can bring back to your day-to-day practice And so to start if I could have a couple people just shout out What is your gut reaction when somebody comes up to you and says may I offer you some feedback Yeah Anxiety Terrified I want to go run in a corner because my instant reaction is what did I do wrong? and We all as teachers are feeling that and so how can you imagine how our learners feel too? And I think the goal is to recognize that throughout the procedure whether it's their first procedure or their 50th procedure that you're Supervising and providing feedback Our goal is to meet them where they're at and help address those vulnerabilities and anxieties to bring them to that next level And when we think about feedback in itself, this is like the down-and-dirty of it It's founded in observation. We want to get beyond that procedural Competence and the checklist to be able to understand. How do we? Ensure our learners are competent not just comfortable with the procedure But how are we going to bring them to a space where they can teach others themselves? And a lot of this means that we have to go based on behaviors For example if I'm giving feedback or I should say the feedback I got doing my first few central lines was oh, you're too timid trying to dilate a Change in language might be oh, I noticed you struggled with the dilation Maybe let's try this method of holding the skin tight and give them that example and that behavior rather than a comment on their personality and The thing is trainees want feedback, but we oftentimes underestimate how much we actually give and how Quality quality it is. It's not that great to say. Oh, that was great. Good job. You're you're doing great But we want to be able to identify How do we take people to where they need to be and a lot of this is adjusting to your learners? It's not just recognizing that they're vulnerable in that situation But also that we need to understand this overconfident learner may need to take a step back or this Underconfident learner may need to build that confidence and so the type of feedback that you're gonna give is based on your learner in front of you and as Aaron already said We are going to benefit from reflection and so encouraging those SMART goals as they go through the procedure and identify what they can do for that next one and For us feedback is a tool we need to keep sharp and well-oiled this is something that is deliberate practice in itself is the art of giving feedback and I know I need a lot of work on it. I'm sure I will continue working on it for the rest of my career And so the way to think about Procedure feedback is really a three-part a timeout or a pre huddle Is first step the actual intra procedure teaching oftentimes those Small adjustments and then the debrief the debrief is really where the money's at But I do think the timeout and the intra procedure teaching are essential in this process How many of you do some sort of timeout before a procedure Yeah, oftentimes. It's a quick run run by say how many procedures have you done? I'm going to encourage you all to really think about Diving deeper and it's not going to take that much time For me. I like to ask for this patient. Are you worried about anything in particular? It might help clue you in to what should you be paying attention to if you're worried about anatomy and that learner doesn't Identify that anatomy is a little wonky. That might be something that you talk about in that moment Other part would be what part of the procedure should I focus on to give you feedback? And third is setting expectations What if you have a first or second line learner and you don't tell them hey if you're Struggling or having trouble doing this part. I'm gonna jump in I want to know when my supervisor is gonna jump into an EVIS or a bronchoscopy Because that way I know that I'm not doing something wrong It's just that they're there to help and the key part of this timeout is to actually call it out and say I'm gonna give you feedback because that really puts that light bulb in their head of saying, okay Yes, I'm I'm actually gonna make a big difference on this procedure today during the procedure itself We oftentimes resort to that performance checklist That our sim based learning has helped us understand and that's a really good first step for those early learners Who are trying to understand the big picture and getting that stepwise progression? but really where the money is at is that unguided coaching just-in-time redirection and Saying okay. I see that you're trying to follow your needle, but having trouble try swiveling your head a whole bunch or Adjusting when the unexpected happens Maybe you thought too that they were headed into the vein and all of a sudden they hit artery You're gonna readjust and trying to create that environment to help understand where they're at When this happens you want to be clear and specific? Maybe do a procedural pause and say hey, let's pause redirect. How do we readjust from here? all the while being encouraging or reassuring Sometimes we have to take over and that's okay And it's about helping identify how much can I take over before handing that procedure back? depending on the situation But in its sense we also have to be cautious if we're taking over we're giving a pause that's potentially threatening to the learning environment and we want to be recognizing that potential bias that we have and Understanding that the learning environment when we're taking over is a really cautious step The other thing you might ask is what should we be doing for our more advanced learners? And this is the time to focus on those micro skills. You might think this learner is perfect they are ready for independent practice, but we all have something to learn and BA players all have coaches and Microskills during procedures are the exact place to hone in on that skill for the debrief itself there are multitudes of framework and The one that I particularly like for procedures is the SVED framework and Can really occur in less than one to two minutes depending on your learner That first step is the self-reflection. It's your micro. Yes creating buy-in Making sure your learner is there present mentally ready for feedback and ready for that next step One way to do this would be to say do you have time to chat about how that went? Or even just saying how could you improve for next time? The feedback itself is Really to help identify those Specific things you noticed so name a data point and the impact that data point had I noticed You didn't follow your needle with the ultrasound. I noticed you didn't have your kit set up. How might that Affect you in the future for me It made me very unorganized and Be as specific as possible It's gonna help people identify their goals in the future Giving encouragement is always part of feedback process and then direction. So this is that goal setting your smart goals What do you think? What will you do next time? Does this make sense to you? And so as a reminder really three parts of that check-in during a procedure that timeout saying hey I'm gonna give you feedback afterward. Is there anything specific that intra procedure Teaching sometimes it's redirection. Sometimes it's trying a micro scale and the debrief and we're gonna put this in practice because Like all deliberate practice we get to be uncomfortable and try things with out Patients in front of us. And so we are going to give a little bit of an example of A Central line and then we'll break up but so the goal for the rest of the session guys is to Get into some smaller groups and we're gonna come around with you guys and sort of help you guys practice this micro debrief The goal here is to just talk through the post Post procedure debrief with a learner one of you guys will model the debriefer one of you guys will model the learner We've got handouts that will kind of give you guys Not scripts per se but sort of learner models to choose from will come around and pass those around and then on your apps There should be a handout for the session that has sort of a rubric for observing everyone's Interactions and so if you're not taking a part in the simulation in that moment, you can take a look Identify some things that the debriefer did well or could possibly improve on and then we'll debrief that debrief The goal here is to just have two minutes at a time So we can have time for everybody to sort of rotate through and get a chance to model Emily and I are gonna demonstrate what this might look like And then we'll come down and break out those of you that haven't fled the flood the room All right All right So in this situation, I'm going to be modeling the overconfident trainee that's just finished up performing a central line Spoiler alert. It wasn't the smoothest and easiest central line in the world and Emily is my supervisor and she's gonna give me that Give me that feedback Okay So, how do you think that went oh, I think it was great, you know, I really like I really like the chances these procedures you know, I think You know really got in there got the at the lining without too much difficulty Patient was moving around a little much. But yeah, I think we're really well. Yeah What what do you think could have Gone differently or what? Do you think you want to do differently the next time? I Don't know. I mean again, I guess the patient was moving a bit. So Maybe I gotta hold him down a little harder Just get that arm bar in there as I can go in and you know get that get that line Yeah, would it be okay if I shared some thoughts on? Strategies that I might use Yeah, sure. Okay, I noticed With that patient moving around a little bit You had some misdirection with the ultrasound probe and that's that's okay that happens to all of us But I noticed that with that movement oftentimes your needle didn't quite track with ultrasound and That may if I was a patient I'd be a little nervous if I was under the all those sheets and I wonder if we helped Organize the room make him a little bit calmer help get the team involved. We could help you Follow that needle with the ultrasound a little bit better. Okay, man. I really didn't think I was losing the needle I thought I knew exactly where I was the whole time. Yeah, it's it's tough These are these are stuff that we are always working on. I'm working on that, too I thought you did a really good job overall though, too. Okay. All right, so I guess I have to just try and do what I can to keep the patient calmer and Try and find some other resources and that way pay attention to the needle a bit more. Yeah Do you want to brainstorm together on how we could? Help do that for your future lives. Yeah, sure. I mean, I guess there's always Vecchia ronium That's a really unique idea I I I don't think I've ever noticed that one before. I wonder if I I probably would use something different Okay, rocky rodeo. I you know what? I'd probably use some fentanyl instead Great idea is trying to make sure that everybody's in the room calm Okay, we could also leverage our interdisciplinary staff pull our nurse into the room help them stay calm But I like this whatever things could we try I suppose Well, you said fentanyl so I guess a little bit of versed or at a van or something like that I guess honestly, you know if the patients awake and able to cooperate just talking to them throughout the procedures They don't move so much. I I think that's a great idea Oftentimes like our patients are nervous throughout this and we can always work together as a team to help keep them calm Make sure the procedure goes smoothly sucks. I'll call you and see Okay So that's what you're about to do we're gonna ask you to centralize yourselves into four groups kind of geographically in the four sections of the Maybe three two four six Okay, so like three groups of six or seven somewhere in there and we'll come around we've got some scripts Take it from there and then we'll Come back together in about 15 20 minutes and just kind of share some final thoughts on how everything went Try to keep your little simulations to about two minutes apiece All right guys, I Hope you found those situations really helpful and in addition to learning a little bit about teaching at the bedside I think these little micro Role plays are a really useful tool for us as educators Generally speaking it kind of crowdsources knowledge in a way that's really helpful So now we're going to take that crowdsource knowledge and crowdsource it into the whole crowd. So Please take a moment to tell us what you learn some tools and tips that you can take away from this Presentation that you can incorporate into your practice Yeah, yeah, some of our learners are genuinely afraid of us and they they're not gonna they're not gonna tell us that But they will back up when you when you approach them and I think that's a really good takeaway. Thank you What other good takeaways? Can you grab? That that is awesome I love that forethought for the Help the help of the new proceduralist who's never done this before who could use this as an opportunity to learn the steps That's awesome. Yeah, I just want to I love the idea of bringing another learner into the room to narrate because it's not just a way to Normalize the narration for the patient, but maybe that learner is somebody who you know needs to be narrated through every step of the procedure But maybe they don't know that and so you can use that other learners In the room as a way to have an excuse to narrate without making the learner feel like you're overbearing every step of their procedure So I think it's a great strategy Awesome. What else can we take away? That's a really good point Keeping your feedback to what the learner needs to hear But also what they can hear at any given time is a really good pointer The more scared and the more nervous the more disrupted the learner has been by the experience the less they're going to be able to walk away with Which is why deliberate practice is so important. We have to be there for them as they grow in these small steps And it also underscores that importance of the check-in right of the SVED framework that Emily showed You really start by that check-in is is now a good time to chat is now a good time to debrief that procedure And if they're saying yes, but the body language is saying I'm about to cry right now You can you can say like you know what let's all get some food break for lunch Let's reconvene and I want to make sure that this is a good experience to debrief this or we can even do it tomorrow I know you're post call. I'm really tired. Let's chat about this later after a day off. You got this. I'm here to support you I want you to I want to help you get get more comfortable with all these procedures It's showing that you see them you see where they're at and that it doesn't have to be immediately after that procedure gone awry Awesome. Yeah crying is normal in medicine, but We try not to do it if we can avoid it. Okay. What else can you share? Awesome awesome. Well, I think this is about it I thank you all for being here this morning at 7 a.m. It's a kindness that you're doing to them, especially being that you're here in Hawaii, and you're spending this time here I hope you take some time to do some things that are a little bit more fun and as you do you reflect on The opportunities to learn that this presented for you and also the teaching technique that was used for the session with the micro Role place which I think is a really useful teaching tool. All right Thank you. Thank you so much for being here. I hope you have a great rest of the day Which I think is a really useful teaching tool, all right, thank you everyone

feedback

learners

procedural training

gendered feedback

bias

inclusive feedback