Faculty Development: Resource Emails

Periodically, information related to faculty development is emailed to all faculty and they are asked to save the emails in a Faculty Development folder for future reference. Here is the list of resource emails with their topics.

Resource Email 1    The Value of Civility in Medicine

Resource Email 2    Mentoring 

Resource Email 3     When Patients Disrespect Residents

Resource Email 4     Preserving the Patient's Humanity

Resource Email 5    UWSMPH Grand Rounds 1 Minute Preceptor Follow Up

Resource Email 6     Trust is Critical in Teaching

Resource Email 7    Engaging Patient Tragedies

Resource Email 8     Managing Microaggressions

Resource Email 9     Surviving 1st Month as a Doctor

Resource Email 10  Patient Engagement Tools

Resource Email 11  Impact of Being on Remediation

Resource Email 12 Tools For Residency and Career

Resource Email13 How Trainees Come To Trust Supervisors

Good day,

Periodically you will receive a short email with information and a link on a topic related to faculty development.

I recognize how busy you are so the criteria for these emails includes: succinct information; readily applicable ideas; directly relevant to faculty and to how we evaluate faculty performance. I ask that you set up an email folder titled faculty development and save these emails to that folder for your review later.

 

Today’s email is on civility. Thanks to Dr. Jennifer Michels for sharing this with me.

Christine Porath - Why being nice to your coworkers is good for business

 

This TED talk is especially well suited for our use as it is short (15 minutes), cites data and medical examples (particularly at the 6-12 minute section) linked to patient safety and gives specific, readily usable suggestions. It also strongly ties into a major article earlier this year in The Joint Commission Journal on Quality and Patient Safety, for which the conclusion was:

“Harm from disrespect is the next frontier in preventable harm. This consensus statement provides a road map for health care organizations and professionals interested in engaging in a reliable practice of respect. Further work is needed to develop the specific tactics that will lead health care organizations to prevent harm from disrespect.” (A Road Map for Advancing the Practice of Respect in Health Care: The Results of an Interdisciplinary Modified Delphi Consensus Study. The Joint Commission Journal on Quality and Patient Safety 2018).

I suspect that the term “specific tactics” in the conclusion will translate into new Joint Commission standards in the near future. So our work on this topic is good preparation for that.

Here’s the article .

 

Thank you for the time and dedication you bring to teaching the next generation of physicians, pharmacists, psychologists and other health care providers.

 

I welcome any suggestions on topics for faculty development or resources you come across on faculty development.

Thanks,

Mike

 

Michael J. Schulein, Ph.D.

Faculty Development Lead

MCHS Division of Education

Clinical Adjunct Assistant Professor –

University of Wisconsin School of Medicine and Public Health

Good day,

This is a 2 minute Faculty Development email for your review. The email is a 2 minute read and the attachment is a 5 minute read.   Please save this to your Faculty Development email folder for future use.

For faculty: This topic is on career mentoring for residents. In a recent survey, about 50% of our residents reported having a formal mentor and over 80% reported receiving informal mentoring. Our data suggest that most of us as faculty engage in some type of mentoring with residents. A frequent topic residents request faculty advice on is career options. Last week the Journal of Graduate Medical Education published a 2 page very practical guide on exactly this topic, titled,  A Simple Pyramid Model for Career Guidance. You can take this article and immediately use its examples in your formal and informal mentoring.

 

For residents: This article provides a model for what to consider in career planning and specific questions to support the consideration. I encourage you to read it, consider the questions and then discuss this with a mentor, whether your formal mentor or an informal mentor. Doing so engages a process nicely described by John Bowlby, a British psychiatrist and psychologist, that (slightly paraphrased), the more a person shares what they are thinking with someone they trust, the more they can understand it for themselves.        

For a deeper dive into the mentor topic: Here is the link to the RWBC topic page on mentors.

If you have any resources you use related to this topic, please share them with all of us.

Thanks,

Mike

 

Michael J. Schulein, Ph.D.

Faculty Development Lead

MCHS Division of Education

Clinical Adjunct Assistant Professor –

University of Wisconsin School of Medicine and Public Health

Last week’s  Piece of My Mind, Solving the Silence,    addressed the role of faculty in actively addressing patient disrespect to residents. Creating a safe learning and practice environment requires us to speak up, particularly in support to our residents and other learners. Being a resident does not mean you need to just put up with being disrespected. The authors of this Piece powerfully speak to the price of our silence when they state:

“Attending physicians must play a role in advocating for residents, and residents must feel confident that they have license to defend themselves. Each time these situations are met with silence, it sends several powerful messages: such sexual comments are acceptable, the problem is too big to solve, individual actions are inconsequential, and that overseeing physicians and the medical community at large do not value trainees enough to stop this harassment.”

Faculty: Please save this email to your Faculty Development folder on your email for future reference.

What would you do if you witness a resident being treated this way? Do you have a well-rehearsed phrase you can easily pull up and use when you witness a resident being disrespected by a patient? If not, please turn this into a learning opportunity and discuss it with your residents. One possible phrase is, “Dr. ________ is an important member of my team working hard to provide you with the best care possible. So I ask that we treat her the same way you would any other member of my team. Thank you.”

If you have a phrase you find effective, please share it with us.

 

Residents: What would you do if a patient treated you this way? What would you do if your attending witnessed this and said/did nothing about it? We need to speak up with each other about this. While we hope to be treated respectfully by others, sometimes we have to act in ways and be supported in ways that clearly state we deserve to be treated with respect.  We recommend you discuss this with your attending and ask for their active support in the patient interaction. This is an opportunity for all of us to learn.

Here are some links to MCHS policies and resources that relate to this.

-MCHS Policy

Managing Patients with Difficult of Disruptive Behavior: Policy

 

-MCHS Policy

Managing Patients with Difficult or Disruptive Behavior: Process for Policy

 

-MCHS Professional Handbook

4.18  Difficult or Dangerous Patients

Difficult patients include those who are obnoxious, rude, profane, unreasonable, demanding and sometimes threatening, those who are noncompliant, especially with appointments, but also with recommendations and treatment, and those who are mentally ill including especially substance abusers who are drug-seeking, patients with various forms of somatoform disorder, personality disorders and organic brain syndromes with behavioral manifestations. In rare circumstances, these patients make serious threats or may become physically violent. It is the Clinic’s belief that medical science provides both a system as well as knowledge that should allow us to understand the problems these patients present to us as we attempt to provide them with the care they need and, in some cases, formulate a management strategy that can facilitate our interactions with them. It is the Clinic’s intention to actively seek out these patients, to develop useful problem formulations and management strategies that will allow us to provide these patients, like all other patients in our community, the medical care they need and deserve.

While the Clinic provides a spectrum of resources to assist individual clinicians in dealing with difficult patients, it is understood not all patients’ problems and clinicians are a good match for one another. If a workable physician/patient relationship cannot be developed or maintained, it is expected that clinicians will identify problems specifically that undermine the relationship, discuss them with the patient whenever practical and, if it is determined that the relationship is not longer functional, make arrangements for further care within the Clinic system. Generally, this can be accomplished within the department with the assistance of the Regional/Service Line Medical Director and Department Manager. Unilaterally severing a physician/patient relationship is unacceptable and, in some circumstances, may constitute legal abandonment. Therefore, if an orderly transfer of care cannot be accomplished within the department, the matter should be referred to the Risk Control program for consultation and assistance.

Individual practitioners and the Clinic are not obliged to continue relationships with patients who threaten violence, who are unmanageably abusive or disruptive, who are dishonest in their dealings with the Clinic, or are otherwise unwilling to reasonably contribute to a workable physician/patient relationship. In such cases, the Clinic may deny access for non-emergent care. Emergency care will never be denied. A request to deny access should be referred to the Risk Control program where a decision will be made considering the individual circumstance, the patient’s condition and the Clinic’s legal or contractual obligations, if any, to the patient.

-Also, the “patient behavior” incident form in RL Solutions has a selection for this type of situation. Log into the RL Solutions and look for the Patient Behavior Icon

 

Mike

Michael J. Schulein, Ph.D.

Resident Well-Being Committee chairperson

MCHS Division of Education

Good day,

This week’s Piece of My Mind, is not from JAMA. It is from Dr. Erik Stratman. Recently he shared the attached article with his Derm residents. I’m sharing it with you as it is a powerful Piece.                                      The Name of the Dog,   describes a powerful and simple way of engaging your patients that results in improved patient engagement and improved patient adherence to treatment.

In our highly work compressed world, we are continuously pulled away from engaging our patients as humans. The article Dr. Stratman shared with his residents is important in at least 2 ways. First, it is important for its message that is clear and concise. It provides an easy way to keep in mind that each patient in front of us is a human being. Second, it is important as it is a residency program director telling his residents that this is important to him, he uses it and he advises his residents to use it. That’s being human.

I had the good fortune to experience a program director in my training who did what Dr. Stratman did. He told me what he does to preserve the humanity in each patient he treated.  To this day, it guides me. Once, as I was staffing a patient, he paused and said, “Mike, it’s important for me to find at least one likeable thing in each person I treat.”  Sometimes that has been hard for me to do. And each time it was critical to how I worked with the patient. Sometimes that likeable thing has been the patient sharing a photo of their dog!

 

FOR FACULTY: What helps you preserve the humanity in each patient you treat? Please share that with your residents.

FOR RESIDENTS: Learn from your faculty, your peers, your own experience and develop  a word or phrase that will help you preserve the humanity in each patient you treat.

Please share that with each other. It’s a critical part in our learning to provide the best care for others and for our own well-being.

 

Mike

Michael J. Schulein, Ph.D.

Resident Well-Being Committee chairperson

MCHS Division of Education

Good morning,

Please save this email to your Faculty Development folder for future use. It’s a 5 minute read.

Thank you for joining us for the MCHS/UWSMPH Faculty Development Grand Rounds last Wednesday.

A goal with the presentation was to demonstrate tools UWSMPH has developed which are Simple, Efficient and Effective (SEE). The topic for the presentation was one you picked last February in an email survey, teaching on a busy clinical service.  The SEE tool demonstrated was the One  Minute Preceptor

We made a 3-minute video (thanks to Drs. Wright and Hanneman) to demonstrate the 5 elements of:  Get A Commitment; Probe for supporting evidence; Teach general rules; Reinforce what was right; and, Correction. The difference between the Fail version and the Success version of the scenario was only 105 seconds, yet the impact was significant in terms of resident education, learning environment, patient safety and resident evaluation of the attending. Here’s the video

 

One of our presentation objectives was for faculty to pick 1-2 elements of the tool and email to their residents’ program director the ones you will try out or use more often.  Please pick 1-2 of the 5 elements of quick teaching and email the program directors which elements you’re working with.

For a deeper dive into last week’s presentation:

-here is the link to the UWSMPH Office of Faculty Affairs and Development (OFAD) Developing Educators website with it’s tools 

-here is the link to the UWSMPH Interprofessional Continuing Education Partnership (ICEP)  website

-and in particular for the ICEP website,  here is the Virtual Journal Club

 

Please offer us suggestions for topics and resources you find for faculty development

Thank you for all you do for our residents, students and all learners on campus.

 

For Residents and Students: This information is very relevant to you as you are the future teachers and supervisors in health care. Please consider this tool and these resources. It’s likely you will have opportunity to try them out with junior learners now and with new residents very soon. Also when you see your seniors or attendings using 1 or more of the 5 parts of the tool, THANK THEM!

Please offer us suggestions for topics to address and resources to share.

Thank you for all you do for our residents and all learners on campus.

 

Mike

Michael J. Schulein, Ph.D.

Faculty Development Lead

MCHS Division of Education

Clinical Adjunct Assistant Professor –

University of Wisconsin School of Medicine and Public Health

PLEASE SAVE THIS EMAIL TO YOUR FACULTY DEVELOPMENT EMAIL FOLDER

“Performance only improves when the feedback is absorbed and acted on,

and feedback requires the learner to trust the expertise and integrity of the person delivering that feedback. In medicine, this process relies heavily on personal relationships because the sophistication of the skills being taught and evaluated is not always reliably assessable.”

I’m straying a bit for today’s Piece of My Mind. This is from today’s JAMA Viewpoint and is titled Trust Between Teachers and Learners. The authors address the fact that medical education requires relationship. And an effective teaching relationship requires trust. Trust by the learner in the teacher. Trust by the teacher in the learner. Distrust causes fear and not feeling safe, which undermine learning and patient care.

This might seem a bit different from how you were trained. Perhaps in your medical education, learning from attendings and seniors was based more in fear rather than trust. Fear of being humiliated, disregarded, disrespected, or dismissed whether in the classroom or at the patient bedside. As you consider this you might be tempted to think that trust has nothing to do with teaching or that it is just a ‘millennial thing.” If so, please step back for a moment and look at the authors of this article. One of them is a physician at ACGME. Trust is critical to effective medical education and effective patient care. ACGME gets that and emphasizes/requires it in the clinical learning environment. You can count on Joint Commission to get it and, if not already, emphasize/require it in the clinical practice environment.

 

For Faculty: check your evaluation summaries by residents for the past year. How do residents view you on the core questions that relate to trust? Do you have opportunities for improvement?

Here are the relevant items:

L3. My attending made it safe for me to bring up concerns without fear of reprisal.

L4. My attending was approachable and accessible to address patient care questions.

L5. My attending showed respect to patients, other residents, colleagues and staff.

P1. My attending modeled behavior worthy of emulation.

P2. I would recommend to other residents that they work with this attending.

 

For Residents: How do those learners following you in training, such as interns and medical students, view you on this?  Do they trust you? How would they evaluate you on the five items above?

Trust is a critical element of learning and practice. When we experience trust, it supports our growth as lifelong learners and practitioners. And that supports our wellbeing. 

To Do:  In less than 3 weeks, our new residents join us. And, with their anxiety in being new and doing more patient care than ever before, they will be watching carefully to see if we are safe and trustworthy to learn with. Here is a 5-minute video example of how seniors and attendings can create safety for interns to do bedside presentations.

 

Mike

Michael J. Schulein, Ph.D.

Faculty Development Lead

Division of Education-Marshfield Clinic Health System

Adjunct Clinical Assistant Professor, UW School of Medicine & Public Health

“We need to be able to say, “Stay here. We’ll be with you.””

Even when being “with you” is in a toilet stall.  

This Week’s Piece, A Pitiful Sanctuary, is not an easy read. Here’s the link to the Piece

The author describes meeting patients where they are, literally. And for these patients, with severe drug addictions, it is in the stalls of the clinic. As you read this Piece, notice your own reactions. They may be visceral. Don’t turn away from it. Rather, embrace it AND then consider what you do to tend to yourself when faced with tragedy with our patients.  Failure to do this sets us on a path that can lead to depersonalizing our patients, disconnecting emotionally and losing our passion for the fields we worked so hard to enter. 

After reading this Piece, consider this. Several terms are used for what this author experienced in these patient encounters. One is Second Victim by The Joint Commission.  Another is Vicarious Trauma.  Don’t let the reference to mental health clinicians and adverse events fool you, this applies to all of us who tend to patients where they are. And, because it applies to all of us, then all of us need to be mindful of the impact and on how to care for ourselves and each other.

For our Residents in Second year and beyond: A new group of residents joined us this week. And they will encounter patient tragedies and elements of second victim/vicarious trauma. Please remember what that was like for you. And as this author noted, please tell our new residents as they face this  “Stay here. We’ll be with you.”

For our faculty: Please save this to your Faculty Development email folder.  A critical component of wellbeing in a career in medicine is learning how to engage the tragedy AND work it through. Please be transparent with your new residents as they encounter this. It may be one of the most powerful lessons they learn from you.

For our new residents: Welcome to the weekly Piece of My Mind from JAMA. Each week we send this to all our residents, faculty, medical students and DOE staff. These offer a brief opportunity to step back, reflect, reset and resume. Please take that moment to read this and even better, to talk about it with others.

And, when you encounter patient tragedies, reach out to any of us, we’ve been there and want to be there for you.

Mike

Michael J. Schulein, Ph.D.

Resident Wellbeing Committee, chairperson

Division of Education

For Faculty: Please save this email to your Faculty Development email folder

“When women introduced female speakers, professional titles were used 97.8% (45 of 46) of the time; when women introduced male speakers, professional titles were used 95% (57 of 60) of the time. By comparison, men introducing male speakers used a professional title 72.4% (110 of 152) of the time, But when men introduced female speakers, professional titles were used only 49.2% (31 of 63) of the time.”

What’s your immediate reaction to this data? It’s likely influenced by your gender.

For our male faculty, residents, students and other staff, we do not get to decide whether or not we verbalized an implicit bias. That decision is owned by the receiver of the communication, not the sender.

 

This week’s Piece, What’s In A Name, addresses implicit bias and the microaggressions that result. Perhaps the term microaggression is bothersome as we don’t view ourselves as aggressive. After all, we are in the helping professions. However, any language that disregards or discounts (including in the use of titles)  puts us on the slippery slope into disrespect and then discrimination.

 

Here is the link to the Piece. Please read it and consider it. Consider if you have unintentionally fallen into this at times. Perhaps in emails, or report, or staffings or introductions at conferences

Here is the link to the article that the Piece author cited the data from:

 

MCHS addresses this is a number of ways, starting with the MCHS Core Values of Trust (“We earn trust through honesty, integrity, respect and compassion”) and Teamwork (“We work together, respecting each other and our professional roles). The August 16th Grand Rounds will be on Understanding and Mitigating Implicit Bias. Keep this Piece of My Mind in mind as you attend or later watch this Grand Rounds.

 

For Faculty:

Make it clear to your residents and students what is the appropriate use of titles in emails and interactions. Don’t assume the learner knows what it is. You model the proper culture of our clinical learning environment. When you witness language or behavior that is disregarding or discounting of another person, speak up. Supportively state what you noticed and state the correction that needs to be made. Whether intentional or not,  it is critical that you address it in your role as a model of our Core Values.

 

For Residents and Students:

As you join the medical culture of MCHS, ask about the correct, respectful use of titles in emails, report, staffings, introductions. Do not assume. Ask.

 

Your attention to this promotes our Core Values and it makes a difference for everyone’s wellbeing.

Mike

Michael J. Schulein, Ph.D.

Resident Wellbeing Committee, chairperson

Division of Education

Good morning,

A week from tomorrow, Tuesday July 30th, all the new residents meet with RWBC  from 7-7:45 in MMC Classroom 4 for our one month follow-up. The purpose of the meeting is to review your first month adjustment to residency. We may have the summary of all the health survey data to review as well.

Today I’ve pasted below suggestions for new residents which was published a few days ago in the NEJM Resident 360. Take a look, they appear to be very practical and applicable to you. Also consider subscribing to NEJM Resident 360.

 

For Faculty and Chiefs: Take a quick look at these suggestions and encourage our new residents to use them.

 

And here ‘s the article:

Surviving the First Month as a Doctor: Advice from the Community

Published Jul 18, 2019 - Written by Colonel (CA) Ronit Katz, MD

 

Welcome new doctors! Yesterday you were medical students and today you are physicians! What a scary feeling. Remember that everyone shares similar concerns and fears as they start their residency and wants to succeed. Getting into residency is the beginning of an incredible journey. Savor it, relax, enjoy the ride, and be open to learn, grow, improve, and become the best doctor you can be.

 

Each year, NEJM Resident 360 hosts a very popular discussion on Surviving the First Month as a Doctor that includes medical students, residents, fellows, attendings, and program directors from around the world. In this post, I draw from these discussions to provide advice and answers to questions that likely are on the minds of new physicians beginning residency this year.

 

First-Month Pearls

The following are some approaches that I wish I had utilized more during my first month of residency:

 

Ask questions: I would have benefited from asking more questions and understanding that there are no stupid questions. Other residents likely have the same question but are reluctant or afraid to ask. Remember, as doctors, we are the patient's best advocate and must use our voices to improve their lives.

Ask for help: I kept reminding myself that asking for help is not a sign of weakness. Patients have trusted us with their health, so it’s better to ask than to make a mistake. Ask for help when you know you need it and when you are not sure if you need it. Taking care of a critically ill patient can be quite challenging, especially early in training. Keep in mind that no one expects you to have all the answers. Don't be afraid to admit that you need help and call for back up when necessary, even when asking for help means waking up senior residents or attendings.

 

Establish open communication: It is better for patient care to have open communication with the team from the start. The more you communicate on a routine basis, the easier it will be to bring up questions and concerns as they arise. Include patients and families in your lines of communication. Keeping everyone on the team up to date on the plan of care will empower patients, move care forward, and help you anticipate issues before they arise.

 

Get to know other members of the care team: I found it helpful to include input from nurses, social workers, pharmacists, and others support team members regarding my patients. These team members are great first-line resources for patient care and have often been caring for patients and working at the hospital longer than you. The more you communicate, the more you will learn about your patients and the practical implementation of medicine.

 

Under-promise and over-deliver: I wish I had been more mindful of the time and energy it took to participate in activities or projects. If you are eager to join resident committees, start research projects, or participate in extracurriculars, you will feel better and learn more if you can fully participate in one or two activities rather than feel the pressure of overcommitting and needing to push back deadlines or bedtime.

 

Attend institutional educational conferences (e.g., morning report, grand rounds, noon lecture): Best medical practice dictates that you attend, but you will be surprised by what you can learn by just being present and by the opportunities they provide for networking and meeting colleagues.

 

Don’t reinvent the efficiency wheel: It was helpful to ask senior residents about task management tools and templates in the electronic medical record to become more efficient on the wards and in clinic.

 

Make home life easier: It was important to estimate how busy I’d be in order to prioritize my efforts. You will be busier than you have ever been. Pay attention to what matters to you outside of the hospital so you can prioritize those efforts. Automate as much of your personal administrative life as possible within your budget (e.g., auto-pay or calendar reminders for birthdays or administrative tasks). Although paying for house cleaning or grocery delivery every week may not be within your budget, using these services every few weeks or months can provide some welcomed relief. Recharging while spending time with family and friends on your one weekend day off may be more restorative than deep cleaning your bathroom or grocery shopping.

 

Take care of yourself: I wish I had known how necessary self-care is for self-preservation and to avoid burnout. You cannot take care of others if you do not take care of yourself physically, mentally, emotionally, financially, and spiritually. Stay in touch with yourself, with the activities that make you happy, and with friends and family for support. If you can, put the phone away and don’t check email so you be present as much as possible and enjoy your moments outside of the hospital without thinking about work.

 

Cultivate your professional interests: It was helpful to start early by simply observing and keeping an open mind. If you aren’t sure of a subspecialty, that’s okay. Some physicians start residency with a clear goal, many do not. Talk to senior residents and rotate on a consult service to get a sense of what you enjoy clinically.

 

Residency Survival Skills

Stay Current  Choose at least one patient condition daily to review on PEPID, Epocrates, or UpToDate.

-Review orientation materials at least the night before starting a new rotation. Use NEJM Resident 360 Rotation Guides prior to starting a rotation for an overview of the field and to learn the relevant language and understand the major clinical problems.

-Register for table of contents (TOC) email alerts for NEJM, JAMA, and specialty journals for the most common conditions in your field of interest. Scan the headlines. Only review in depth the articles that you find interesting or are important for your patient population.

-Subscribe to literature surveillance news alerts (e.g., NEJM Journal Watch).

-View online medical grand rounds and conferences from large medical institutions.

-Use mobile apps (e.g., QxMD), social media, and Twitter: Find trending medical news by searching hashtags (e.g., #MedEd, #MedTwitter and #FOAMed)

-Participate in journal clubs (in person or online) to gain more in-depth knowledge of practice-changing research.

-Use NEJM Resident 360 to keep up to date, participate in discussions and journal clubs, and seek advice from experts.

-Keep a record on your smart phone (or a notebook) of important clinical pearls.

-Pay attention to the differential diagnosis of the disease.

-Listen to podcasts and audio board review courses for efficiency. You can listen in your car, during exercise, or while washing dishes. Some reputable podcasts include:

-The Curbsiders is a great internal medicine podcast featuring board certified internists who interview experts and provide clinical pearls and practice-changing knowledge.

-NEJM Resident 360 Curbside Consults is a podcast that critically discusses practice-changing research with experts. The Curbside Consults Statistical Review series provides short primers on study design and common statistical concepts.

 

Develop Time-Management Skills

You may have developed a time-management system in medical school, but now that the number of patients and demands have increased, you may need to rethink your strategy. Medical training is a marathon, not a sprint. Here are some tips to help you stay efficient:

-Try different methods early on to stay organized, find what works for you, and stick with it.

-Develop a system to prioritize tasks. Don’t be afraid to ask your senior resident how to prioritize your tasks.

-Give yourself extra time. Know how much time you need to run through the morning routine and give yourself some extra time. You will become more efficient later in the year.

-Focus on moving patient care forward as you prioritize your tasks on the wards. Complete daily progress notes after you finished your to-do list.

-Find a task organizing template (e.g., medicine scutsheet)

 

Learn Coping Skills for Challenging Rotations, Patient Death, and Poor Outcomes

Rotations can be challenging for a variety of reasons. Long hours and little sleep can be mentally exhausting. Although you may have completed a couple of overnight shifts in medical school, adapting to nighttime coverage, which can often mean several consecutive days or weeks of night shifts, can be tough. Other rotations can be challenging because you are so busy that you feel like you are constantly running from one patient to the next and putting out fires. Emotionally difficult rotations can be the most challenging. Communicating each patient’s condition with the family throughout the hospital stay is important. When the outcome is bad, make sure to let the family know how much you care and that you and your team did the best you could.

 

The following are some strategies to help you cope with challenging rotations or the death of a patient despite having provided excellent care:

-Prioritize sleep

-Keep a supply of healthy snacks and drinks on the ready

-Use the stairs instead of elevators for fitness

-Remind yourself that physicians before you have survived, and you can too

-Debrief with members of the care team

The PEARLS Debriefing Framework and Script (Promoting Excellence And Reflective Learning in Simulation) is one example of a blended approach designed to promote effective debriefing by integrating educational strategies to promote learning.

Share your feelings about the outcome and brainstorm, analyze, and discuss if the team could have done anything better

Pause and take a moment for yourself to reflect on the situation; do not internalize your feelings; not dealing with your loss and your sadness is not healthy

Seek professional counseling (e.g., Employee Assistant Program).

-Turn Mistakes into Learning Opportunities

This is one of the most important things to learn as you go through medical training. The obvious goal is to never make a mistake that hurts or harms a patient. But we are human, and we all make mistakes despite our best intentions.

-Don’t criticize yourself

Remember that residency, and particularly internship, is designed for multiple layers of oversight to catch potentially damaging mistakes. Residents, fellows, and attendings are supervising you, and nursing, clinical care partners, and pharmacy help check orders and assessments.

-When in doubt, always ask. If you are worried about a patient, unsure of a diagnosis or medication, it is best to verify.

Understand how a mistake was made. Were there missed warning signs? Did the EMR order the wrong medication? Did a lab test not get drawn? By understanding the origin of the problem, we can prevent it from happening again.

Debrief to help bring everyone to a common ground and lift the burden of a death, poor outcome, or mistake.

 

 

Colonel (CA) Ronit Katz, MD is the CSG State Surgeon-General. She is a Clinical Associate Professor, Medicine - Primary Care and Population Health at Stanford University Medical Center and Director of Post Deployment Health Services & Clinics for the War Related Injury and Illness Study Center (CA-WRIISC) in Palo Alto, where she treats patients and teaches the Stanford new doctors and medical students. She is Board Certified in Preventive, Occupational and Environmental Medicine, and a Fellow of the American College of Preventive Medicine.

 

Colonel Katz is an AMA-IMG Governing Council Member & Delegate to AMA-HOD and was selected from Stanford University Medical Center to be the Stanford-OMSS Representative to the AMA.

 

In 2007, Dr. Katz received The American Medical Association’s “Excellence in Medicine and Leadership Award”. In 2013, Dr Katz received the prestigious " NASA Group Achievement Award" for her role in the NASA- AMES Human Performance Centrifuge Project Team. Dr. Katz serves on many boards and committees for local and national professional organizations, including Medical Director (Act.) at Stanford University Medical Center, Judge for the AMA Research Symposium, AMA-IMG Scientific Committee, AMA-IMG Nominating Committee, Chair of the AMA-IMG Leadership Development Committee, and Chair of the AMA-IMG Governing Council.

 

 

Mike

Michael J. Schulein, Ph.D.

Resident Wellbeing Committee, chairperson

Division of Education

Good afternoon,

This is a Piece of My Mind from JAMA and a Faculty Development email.

Faculty, please save this to your Faculty Development Email folder.

 

This Piece, titled Primarily Care, is written by a primary care physician retiring after 40 years at Cambridge Hospital/Harvard Medical School. Here is the link.

 

The author reflects on the highlights of a career well-practiced. In that reflection, the author provides us with an evidence base, his career experience,  for the ACGME General Competencies of Patient Care and Interpersonal and Communication Skills. Here is a highlight:

 

“There are 3 things that I am most proud of in my career. They are not the articles I have written on the patient-physician relationship,

though I am proud of those. It is also not the unusual diagnoses I have made, though there is a certain thrill in recognizing

something obscure. I am most proud of 3 things that patients or their family members said to or about me.

 

The first was by a patient who said that unlike other physicians he saw, I never made him feel like I was rushing to catch a train.

 

The second was relayed to me by a colleague who shared a mutual patient. The patient told my colleague that when we were together,

I made the patient feel like the patient was the only other person in the world.

 

The third was from the son of an older immigrant patient who told me that he was proud to bring his father to see me because,

unlike many physicians in his home country, I treated his father with respect.”

 

 

The second article, Practices to Foster Physician Presence and Connection with Patients in the Clinical Encounter, is a systematic literature review (1997-2017) of practices used by physicians to engage with their patients. Here is the link

5 major practices were distilled from the analysis:

(1) prepare with intention

(2) listen intently and completely

(3) agree on what matters most

(4) connect with the patient’s story

(5) explore emotional cues

 

The article is an excellent guide. It is short and direct, meeting the MCHS  faculty development goal of providing Simple, Efficient and Effective tools. For example, here is the article’s explanation for the 1^st practice to prepare with intention:

“This practice includes 2 components that comprise physical and psychological preparation for a clinical encounter:

(1) personalized preparation for the patient and (2) taking a moment to pause and focus.

 

Notice how the evidence base of a literature analysis from a 20 year span, fits with the experience base of a physician with 40 years of practice.

Both forms of data inform us on best practices for engaging with our patients. Those practices are critical to training, to quality care and to how we evaluate ourselves. That’s why 2 of the 14 Common Questions in the Resident Evaluations of Faculty address this (#6 and #7: My attending showed respect to patients, other residents, colleagues and staff; My attending encouraged me to put the needs of patients first by being caring and sensitive to their specific needs.)

 

For Faculty: Please share and discuss these guidelines with your learners. Demonstrate use of the guidelines in your patient care and debrief with your learners afterward to make sure they noticed and valued it.

 

For Residents, Students:  Practicing these now in training sets up a skill set that will benefit you and your patients throughout your career. As a result, many years from now as you reflect on your career, you could also write a Piece like this author did. And that benefits your well-being during and after your career.

 

Mike

Michael J. Schulein, Ph.D.

Resident Wellbeing Committee, chairperson

Division of Education

The August JGME article linked here, is very relevant to our work with residents on formal and informal remediation. It’s an 8 page article packed with perspective and guidance on how we might fine tune what we do. In my years with RWBC I’ve been involved with a number residents on PIPs and informal remediation plans and from those experiences, I see in this article some ideas we might use.

Some starting points

1. Have our faculty read the article to provide a baseline of info regarding the experience for a resident on remediation

2. Ask any faculty actively involved in a resident’s PIP or informal remediation plan to review the article and consider how it’s points may apply.

3. Include in new resident orientation, a presentation that teaches how we view and address remediation, as this could help mitigate the stigma.

Unheard Voices: A Qualitative Study of Resident Perspectives on Remediation

Sara M. Krzyzaniak, MD; Bonnie Kaplan, MD, MS; Daniella Lucas, MD; Elizabeth Bradley, PhD;
Stephen J. Wolf, MD

Good morning,

The RWBC asked me to share this with you and I’m happy to do so.

Thank you for the opportunity to talk with you at your 2021 Residents’ Retreat on September 23^rd.

Our topic was Tools To Help You in Your Career.

It has been my privilege  to support residents through the RWBC for the last 16 years. My intention with this presentation was to pull as much of that experience  together, along with what I have learned from so many others in my 42 years in clinical psychology,  into a top 6 things that may be of use for you. Thank you for choosing a career in caring for others and for choosing Marshfield. I wish you well as you continue your journey.

Mike

Here is the video of the presentation. Nothing fancy, but hopefully real and useful.

BEGIN WITH THE END IN MIND.  This means stop and consider “How do I  want to be doing at the end of the day? At the end of the week? At the end of my career? In the stressful busy-ness of residency we are so focused in on the moment it is easy to lose perspective, to lose track on why we decided to go into healthcare, to think that the stressful moments will never end, that residency will never end. And with that, we may drift away from WHO we are, our values, our passion about medicine, our caring. Begin with the End in Mind is a gentle reminder we give ourselves about this. Doing this helps us reconnect to the bigger picture and reset our intention about how to BE in the midst of all we do.

We all have tools. Here are my top 6 tools I’ve learned through my career.

1. VIVID.

Each of us is VIVID. The letters stand for:

Valuable: You are valuable. You belong here. We want you here. We’re glad you’re here.

Imperfect: We all make mistakes. We all have things to learn. And we remain Valuable. What do you tell yourself when you are imperfect? Does it support growth or judgment?

Vulnerable: All of us can be hurt, especially in stressful times. It’s OK to admit our vulnerabilities, our injuries, our limits. That admission allows us to move to the next step of taking care of ourselves.

Immature: It’s important to play, be silly, not expect to be serious 24/7. What have you done to play, to be silly lately?

Dependent: We don’t do this on our own- residency, patient care, our lives. What do you do that shows you accept the need for teams and for support in training, in life?

2. REPAIRS

When we are imperfect, we make mistakes (like missing a lab, forgetting to call in the consult, being irritable with a team member, etc) and  we can make a repair.

Repairs involve 3 parts:

-Own It: Admit the mistake, the imperfection  (“I did that. I forgot to do that.”)

-Apologize It (“I’m sorry I did that. I’m sorry I missed that.”)

-Amend It (“Here’s what I’ll do to fix this. What do you suggest/want me to do to fix this or make it less likely it happens again.”)

Humans want to accept repairs from each other.

3. The 3 Cs for your Professional Manner

1. Be CARING.  How do you show caring with your patients? Your peers? Your team? What are your ways of CARING?

2. Seek CONTEXT.  Start with eye contact and listening.

3. Invite COLLABORATION.  Ask before you teach/prescribe. “What do you think this may be?”

In our work with patients, the 3 Cs help us move from the 20th century perspective of being the sage on the stage, to the 21^st century perspective of being the guide from the side.

4. The 3 Cs for your Practice

1. Demonstrate COMPETENCE. Do what you know. Just do it.

2. Be COMMITTED.  Engage where you work and with  those you work with. Make the best of every place you practice. Bloom where you’re planted. Commit to your patients, your colleagues, your staff, your system whether you are there for 1 year or your entire career.

3. Be COMPATABLE.  Be the colleague whom others would like to practice with.

5. 3 GOOD THINGS

This is a daily gratitude activity that is simple, efficient and effective. Each evening pause, reflect and tell yourself 3 good things from the day. This shifts neurological activity and neurochemical balances that benefit mood, motivation and professional manner (The 3 Cs).

6. HAVE I HANDLED THIS BEFORE? The farther in life, training, career we go, the more we learn what works and what does not work. When we encounter new demands or situations we may forget that we have practice with this and have learned ways to manage it. Pause in those situations and ask yourself, Have I handled something like this before? Your answers help guide you. This is especially useful when facing big transitions and higher than usual levels of uncertainty.

Residency is  the time to practice these tools because what you practice in residency likely becomes permanent in career. Pick a couple of the tools and practice with them. Tell others which tools you are trying out.

Let’s return to the idea of Begin with the end in Mind. Imagine as you approach the end of residency, what tools have you used?

Thank you for the opportunity to share these tools.

You are VIVID.

Mike

Good Day,

A recent issue of Academic Medicine has an article, How Trainees Come To Trust Supervisors in Workplace-Based Assessment  that relates to patient safety, Just Culture, Entrustable Professional Activities, assessment of residents and faculty development. With that many connections, I have to share this.

From a  faculty development perspective  it starts with the concern faculty and PDs  have voiced to me over the years regarding new residents and residents with performance concerns. It often sounds like this, “How can I trust what they are doing?”  The article addresses trustworthiness as a conceptual piece blended with a semi-structured interview study.

The quick answer is,  If you want to be able to trust your residents, first, facilitate your residents trusting you.

This article can be e a nice faculty development mini-module you could drop into a faculty meeting, or impromptu discussions on how we demonstrate our trustworthiness to our residents and students. . Doing that fosters patient safety, EPAs, accuracy of your assessment of residents, accuracy of what your residents report to you (especially errors or suboptimal care/encounters). Also it could be a nice addition to your documentation on those topics for various outside accreditation/credentialing groups you report to.

Here are 2 key conclusions from the article:

“However, this study suggests that supervisor behavior is a key influence upon trainees’ willingness to learn from their assessment. Almost all of our participants could give an example in which they felt safe to practice authentically rather than in a performative manner in workplace-based assessment with a supervisor with whom they had a trusting relationship. When the conditions were favorable, trainees were willing to trust and engage in assessment for learning. The implication is that the trainee behavior observed in workplace-based assessment reflects the behavior supervisors invite. Enhancing supervisor behaviors that promote trainee trust seems an essential requirement for improving trainee engagement in assessment for learning.”

“In our study of workplace-based assessment, trainee trust in supervisors started with an initial trust based on the expectation supervisors would fulfill their assigned role but then progressed based on trainee experience with the supervisor. Supervisor trustworthiness invited more authentic trainee behavior in their observed practice. We found that trainee trust judgments represented a feel for the game that allowed rapid, intuitive adaptation to supervisors in the moment. Ultimately, perceived supervisor investment in the trainees and their learning allowed deeper trust to develop between trainees and their supervisors and facilitated a learning focus in workplace-based assessments. Because short trainee rotations decrease opportunities for supervisor-trainee relationships to develop, investigating ways to facilitate a culture of trust within a department may help realize the benefits of workplace-based assessments for learning.”

Mike

Michael J. Schulein, Ph.D.

Faculty Development Lead

Division of Education-Marshfield Clinic Health System

Good Friday afternoon,

I attended the UW Teaching Academy Winter Retreat this morning. The retreat is held for educators in the UW system and I was able to attend given my adjunct appointment. The retreat was well done and while the attendees primarily work in undergraduate and some in undergraduate medical/health fields education, there were many points of relevance for GME and the time flew by.

Here’s an example.

A rose metaphor helps teachers remember to include key elements in the feedback they provide. As providing effective feedback is typically one of our opportunities for improvement, I’ll share this as a snippet.

Rose: the blossom is what the person is doing well.

Bud: the bud is emerging skill/competence. You see it starting and it needs support to blossom

Thorn: the thorn is a deficiency, obstacle, vulnerability that needs careful attention

Effective feedback involves addressing the entire rose.

The presenters noted that educators use the metaphor to guide their feedback and easily instruct use of the metaphor for learners in self-assessment and goal setting.

What’s your reaction to this metaphor to help us remember and include the key elements of effective feedback?

Do you have a metaphor that already works for you or your faculty?

And that’s your faculty development snippet.

Have a nice weekend.

Mike

Good afternoon and happy new year!

A faculty development activity involves the use of teaching snippets. These have a number of names and one of the latest terms is snippets. You may already know the idea as pearls, quick reads, just in time learning, brief faculty development, etc. It’s the idea of fitting teaching into existing activities, meetings, etc. Here are two examples. Dr. Rehman developed a  8 minute video that does a great job demonstrating Recognize, Respond, Refer for attendings working with residents. Here's the link. Consider how you could use this as a snippet in your work with residents and faculty. It could easily fit into a seminar, meeting, or other interactions. Dr. Stratman developed a video snippet on how to develop snippets, or what he calls brief faculty development. He has developed a BFD series at the national level for Dermatology. Here's the link. Consider how you could use the steps described in that video snippet for constructing a teaching snippet for your learners.

Another example is an interactive pdf from the Faculty Factory Community  which demonstrates use of a snippet format. Here is the link. Each section is a quick read along with 3 questions to support quick learning and the longer podcast as a deeper dive into the topic.

UWSMPH uses this format with its resources in the Office of Faculty Affairs and Development (OFAD) Here’s the link to an example from their website. 

We have the beginnings of that set up for the 14 common questions on the resident evaluations of faculty. It includes quick reads and deeper dives, here’s the guide for question #2  My attending encouraged me to learn and ask questions.

The creative collaboration for us is to consider where and how we blend snippets into existing things and doing so without it becoming onerous. One of my goals with faculty development is to support that blending it in for your program. 

Thanks and again, happy new year!

Mike