Uh, today's grand rounds is part of our quarterly lecture series that's focused on faculty development, um, specifically the domain of GME, and it is my great pleasure to introduce our speaker today, Doctor Marek Brzezinski. Uh, he's professor of anesthesia and perioperative Care at UCSF and has dedicated a substantial amount of his work toward faculty development and medical education. Uh, he's originally from Poland. And uh obtained his MD and PhD in Germany. After additional medical training in the UK, um, completed residency in anesthesia at the University of Chicago and then came to Boston, um, and completed a fellowship in critical care at MGH followed by another fellowship, uh, at Duke in cardiothoracic anesthesia. He subsequently joined the faculty at UCSF and also came on staff at the San Francisco VA where he is a cardiac anesthesiologist and intensivist. His clinical focus is on anesthesia care for geriatric patients, and two of his major clinical research interests are postoperative, postoperative cognitive decline and PTSD, topics on both of which he has studied and authored publications. Um, currently, he's a PI for two studies, one looking at post-op analgesia and then another study, um, looking at pre-op antithrombin 3 supplementation for patients undergoing cardiopulmonary bypass. Uh, as I mentioned, he's also devoted much of his career to medical education both by serving as an educator to medical students and residents and also through his work with several national organizations to improve medical or medical education. Um, he was elected to the Academy of Medical Educators at UCSF Medical Medical School and has also completed two teaching fellowships at UCSF. Uh, he's offered, authored multiple publications on the top, on topics of education. Um, such as resident feedback and teaching in the ICU and the OR, and he's spoke, spoken broadly on a national level, um, on how to improve medical education. And he's also been very heavily involved and with and has received recognition from, um, the Society of Education and Anesthesia, uh, for his service there. And he's here to speak to us today on um how to, um, improve our teaching skills in the OR. Please join me in welcoming Doctor Bruzezinski. Thank you much, it's a very kind introduction. I wish my mother was here to hear that, but. But, uh, in the meantime, uh, welcome to, um, to this lecture on how to make uh education in the better. And, uh, I would like to start by asking a question, question, why are we here? Why are you, you, and you actually here? Why did you go? Why did you become a doctor? How many of you raised your hands, and went into medicine because they really wanted to teach you, and that's why they decided to go into medicine. I can tell you that my motivation when I entered the medical field was actually, does it work? Works actually to become a doctor, was not to become a teacher. And only much later I developed a passion for teaching. And I'm sure I think this applies to many of us here, but the key here is that the uh skills, I'm sorry, the skills involved in clinical uh clinical care and in educations are different and they don't overlap and they're not intuitive as stated by a colleague, we are actually expected to a job in the area we never really received formal training in. And this is where this lecture actually comes in. It will describe relevant teaching theories. It will describe how we develop expertise in medicine. It will identify potential obstacles, limitations to teaching in the OR and it will provide simple, effective techniques to improve OR teaching. And since one of the most important a priori axioms in medicine states that we're all learners and teachers at the same time, this lecture is actually relevant for anyone here, everyone. So regardless where I say. Teacher, teaching, learner, learners, beginners or experts. I'm addressing each and every one of you regardless basically of your position, seniority of experience, because right now in this lecture we're all equal. I do receive the funding but there's no conflict of interest. Now lately, there's a growing perception that many faculty actually struggle with uh, with teaching in the OR. And for one, the residents spend less time in the, in the OR for teaching. Then faculty actually has less time. For teaching because the increased workload, clinical workload and uh administrative workload. At the same time, the complexity of teaching has increased and learners' expectations have increased as well, especially in regards to feedback, the quality of feedback, milestones, etc. And all this in a climate of decrease decreasing resources as a consequence, successful education in the OR has become an issue that needs to be addressed, and I think the first step in this process has to be to appreciate. The education is a very dynamic process. That involves not only the educator but also actually very importantly. The learner with their own perceptions, history, ideas, culture, expectations, past experiences, as well as the department with their own culture. So what I mean by that. Is expressed in this video, oops. So I think it's a rather common occurrence that that two people who know each other rather well, uh, at the same time, at the same place have totally opposite, totally different perception of what actually just happened of the events. So it is critical. That the educator, the learner and the department are all on the same page when it comes to the question, what is important and how should be taught? Because you could have the greatest teaching techniques, but if the resident or the department are not with you on the same page, your impact is gonna be only limited. Second, we are horrible at self-assessment. This is the classic study by Dunning and uh and Kruger. Unskilled and unaware, this is the, the, the famous, uh, um, Kruger and uh and Dunning effect. Um, they looked at logical reasoning. Perceived ability and actually actual test performance. And the first step, they actually assessed, tested the skills of logical reasoning. The x axis shows. Um, the the quartiles, the worst one, the best one. Here you can see the percentile, the worst uh performance, the best performance, and the line with the black circles. This is actual test performance. Here are the worst ones. Here are the best ones. And the second step. They actually ask about the perceived ability. How do you think you did on the test, OK? What was your perception of your performance? And the triangle, the line with the triangles actually shows the results. Basically it means that people who aced the test, who really did outperform everybody else, they beat themselves down and think, you know, they actually did much worse than they did, while people who underperformed. Though they were actually amazingly better, 6 times as good as they actually were truly. A total disconnection between reality and self-perception, self-assessment. That potentially happens in anesthesia or surgery as well. So it is important. That the educator has effective ways to identify a learner's needs that go beyond simply self-assessment. What do you think you need to learn today? The 3rd, 3rd point comes from the business world and it is actually about the relationship between productivity and the time you spend on that particular product, uh, activity. And there are many articles, and I just took one from Business Insider. And the author, author is saying, says that being valuable, a valuable employee has nothing to do with the hours you put in, but rather the quality of the work you do. So Basically, you could work 2 hours and outperform someone who worked 10 hours straight but it was unfocused. The article goes on saying people may actually wonder if you are capable of succeeding if you're working 10 hours a day and just meeting expectations. And the same could actually happen in the OR. Just because you, you, you taught for 3 hours straight does not mean that you were actually more productive. In the words of Mark Twain. No, I didn't have time to write a short letter, so I wrote one long instead. Basically means I didn't have time to prepare a focused, effective, and time efficient lecture. So I just talked and talked for hours, hoping something will stick and then later call it teaching. The point is simply that I'm trying to make is that you really don't have to spend hours and hours teaching. A few seconds of the right information, the right time could be much more effective than just simply 2 hours of uh sub-optimal, sub relevant information. And to do that, we do have to have effective and time efficient teaching methods. And today's talk we'll try to address those concerns. We'll start with theoretical introduction on how physicians develop clinical expertise to get everybody on the same page. And then we go into the second part is gonna be practical in nature. So let's start here. So in order for me to develop my learner's fellows, residents, uh, residents as um medical students or myself into expert clinicians, I need to understand what is actually the key ingredient in developing expertise. So let's take a look, what does the literature tells us about it? What do you need? Interestingly, you can acquire exceptional skills without talent. Talent is not really that important. There are no strategies that allow non-expert to rapidly become expert. That's why we often have this, you know, long educational time of residency and fellowship. Experience is important, but there's a reason why we have to get recertified because only because you practiced for 25 years doesn't mean that you're actually better. So what are we left us with that, superior knowledge and memory. Let's take a look at that a little bit closer, OK? Research on memory as a predictor of expertise goes to 1940s, 1950s and research, research by the Groth in chess. And he was actually able to identify the best measure of expertise in chess. Anybody knows what it was? What is the best predictor of expertise in chess? Actually, selection of the next best move. And what he found is that that ability is increased by memorization of thousands and thousands of game positions. That's what people do when they play chess, they just look and memorize everything. The question basically is, does the same apply to medicine? And that was actually tested. This hypothesis was tested in the recall studies where participants with different experience level novices, medical students, intermediates, and experts like you were given brief clinical cases, 200, 300 words for 23 minutes, and then they were asked to write down everything what they were able to recall. And the hypothesis was that there will be a clear relationship. Between expertise and how much they were able to write down, remember, but what they found was actually this one here, the experts did relatively poorly on that test. But obviously what makes somebody an expert perhaps is less about the amount of information. Of recall and perhaps more about what you actually do with that information, how you process that and because this is a little bit abstract, let's have an example, OK, just let's assume there's a car outside and we want to know what kind of car it is. OK, so we're just going to pick 3 people here. Going to send them out. Going to ask them to take a look and then come back and tell us what you've seen. Similarly like when you send residents to the floor to assess the patients and then they come back and present the patients during a pre-op. So, so the first resident comes back and let's call Jim, uh, 4 wheels, 2 doors, headlights. It's fantastic, he's able to remember everything. Now does anybody know what kind of car it is? It's just facts. Joe comes back and says it's a beautiful car, but more judgmental, British, from the sixties. On the, on the hood there is some animal looks like a jumping cat. Uh we, we get him the idea of what it is and then John comes in and says, it's a Jaguar. The question here is actually, who's the expert here? The person who is able to Memorize everything Just facts or somebody who's actually able to take everything together and summarize a lot of information into one sentence, the essence of the information. So expertise perhaps is less about how much you can remember and more about how you use it. As it turns out, experts and novices process the information differently and use different functionally different kind of knowledge. And because this sounds very abstract, let's have uh some fun and have uh have some uh. Um, some fun, let's say. So what I need you to do is just follow the instruction on the screen. So please choose a number between 09 and double it. Then add A to the number. Divide the number 15. And subtract the original chosen number from the new number. Then convert this number to corresponding letter. 1A, 2B, 3 C, D4D, and think of a country. That begins with a letter, and then think of an animal that begins with the second letter of the chosen country. Everybody. So if statistics are correct, then 75% to 80% of you right now are thinking about Denmark and elephant. And, and the reason why I can predict that is because of mine and yours limited horizon when it comes to countries starting with the letter D and animals starting with the letter E because the trick was to get you to number 4, correct? D. So, and um you just won, correct? So literally we one trick ponies when it comes to that. And uh this is characteristic of many of the beginners in medical specialties. The choices are rather limited, and what happens during residency that you suddenly recognize there are more choices. The different diagnosis becomes larger. And to transfer to medicine means that. That thinking process of a beginner, perhaps a resident who comes here in the 1st or 2nd year for the 1st time, is different than compared to a senior resident or a fellow attending. The big beginner is primarily focused on basic mechanisms, OK, it's more about how, how does neo, how does Neo work on a molecular level than just treat the damn blood pressure. So, and uh. Very much rule driven protocols. Why? Because it is easy. Just tell me what you want me to do. That's why this is very popular at this level. And um big picture is elusive and often there's a limited ability to filter or prioritize information and you can actually see that during pre-op discussion. You can ask yourself, do you present the information just in front of you, just read them. Everything without prioritization, or do you actually summarize the information the pre-op in a meaningful way? And I think this is a skill that develops throughout the residency because it's exactly what happens, the repeated exposure to patients actually. Leads to reorganization of knowledge, how you approach those things. Now let's have a few examples here. So the learner recognizes that there are common and repetitive patterns. If uh you induce somebody, the blood pressure will go down, then you can give Neo and the blood pressure will go up. When the surgeon cuts, the blood pressure will go up, you can deepen anesthesia, blood pressure will go down. So later, after seeing that. The resident or the uh the the the the learner doesn't have to think about it. It becomes automatic because just pattern recognitions, you know exactly what's going to happen, you know what it is. So basically you start using pattern recognition to solve clinical problems right now. No thinking involved, analytical thinking, you just do it very quickly, pattern recognition. And the research calls it intuitive problem solving using pattern recognition. So for example, which movie was that? Movie Star Wars, great, awesome. Very nice, wow. So. So, so you were able to recognize a movie based just on the one frame, correct? That's quite awesome and I think the same happens in the OR. An experienced physician comes in is able to recognize what's going on right there just by looking and within seconds. The question that you should ask yourself actually, were you able, would you be able to recognize that this is Star Wars without seeing the movie, just reading the book. Would you be able to be able to immediately recognize that, or would it have taken you a little bit longer? A minute or two to actually recognize that. So I believe basically the same applies to anesthesia that reading articles and books while essential, will never replace the clinical experience to see it for yourself, what's actually happening. Which movie is that? Good. Now, not only we can recognize it, but we often many of you potentially know what he's going to shout in a second after he killed everybody. Are you not entertained, right? And the same happens in the OR. You can actually predict what's going to happen. The patient for in the next few minutes, you come, you see the situation and you immediately want to do something because you see what's happening. Second, we developed a variety of different techniques, your personal ways to provide anesthesia or perhaps surgery, how you actually approach the patient. And the research calls illness scripts, basically how do you approach particularly particular uh disease, how do you treat diabetes, how do you treat heart disease. And everybody has different ways to do that because we're all idiosyncratic, and that's a very unique way about illness scripts. Depending where you're trained. Depending on where you come from, you're going to have different ways to approach the same disease. And typically what it means that I do it this way, basically my way is always the best one and then my colleagues, that's the control group. Treatment group, control group, and, and this is the only way to do something and you have real difficulty, why is anybody doing whatever that other way, very common. So the key ingredient to expertise, uh, to develop expertise and is the reorganization of knowledge. And if there's a road to expertise, who's actually in the driving seat? For that we need to turn to adult learning theory introduced by Mark Markel Nuns. And the thrust of adult learning theory is simply that as a person matures, as a human being and as a physician. They develop the drive and desire to learn, as well as the inner responsibility for their own training. So it is actually the, the learner in the driver's seat. So in essence it's not really important how much teaching actually took place, but, but actually how much the resident has literally learned. No teaching, just learning today. To summarize the theoretical part, progression to expert clinician happens stages. All those things are very relevant, but the key is to recognize knowledge because and develop the key skills. Prioritization, what do I need to do first. Intuitive pattern recognition so that you can be very fast in that stressful situations without too much thinking. You recognize patterns allowing you to act fast, judgment, putting everything together, what do we need to do in particular occupation and in the scripts, meaning variety of different techniques. Able to skin the cat many different ways. And the driving force behind learning is the mature adult learner. And teaching us, uh, the, the theories aside, let's move on to the practical part. And the research has shown that time efficient teaching can be accomplished with three simple, you know, steps. First, quickly assess the particular needs of the learner. Then focus just on those needs and then make sure with feedback that you actually got your message across. Simply target, teach, and ensure you're actually taught. This approach saves time because you teach only what the resident fellow medical student need and not what the learner is not ready for because it's too early for something or perhaps already knows, so it's not necessary. Step one to do is basically what we need to do is two simple and time tested tools, ask questions and observe. I love questions. Because it's a very easy way to to assess somebody. Level of experience, have you done it before? Able to set up the room. The key here is, does the learner understand 23 key steps of that particular procedure. Knowledge. This is actually, what is the level of knowledge? Simple, uncomplicated question, for example, why do we use ACT and not PGT in the cardiogram? Or what about SVR are very powerful to identifying needs that then later you can actually teach. Then when it comes to technical skills, it's not only too important to ask, have you done it, but actually to ask who actually taught you? What is your technique, why? Because we are all idiosyncratic. So it is much better to clarify the expectation and, and approach the different you know ways how you perhaps put central line in because this allows you to have a nice pleasant day because you already clarify your way versus the other person's way. Came up with conclusions so there's no conflict anymore. It's a much nicer day kind of way, less conflict. And then clinical judgment. Now putting everything together, what are we going to do in that particular patient? I think this is actually quite key because it brings very nicely everything together. Observation is very easy, everything what you have to do, just stand next to and just watch. Observe, very powerful, 12 minutes and you're done. Now most of you are doing this already and you're very good at that. What typically is not acknowledged though that the fact that this is actually a teaching educational opportunity, there's no clear link. To educational mission, the learner is unaware. There's no buy-in. So despite your good intentions, Dolora could actually perceive questioning and observation in a very negative way. For example, simple observation by the attending can have counterproductive effects by making the residents think, wow, gosh, I must be doing something wrong. Um, uh, is the attending going to take my procedure away? Similarly, well meant, well meant questions like did you give all the fentanyl? Or um did you put this or that? can be perceived negatively while hm, was I not supposed to do that? Did I do something wrong or why he or she's micromanaging me, I'm doing fine. Why all the questions? Simply the teacher and the learner are not on the same page and actually this kind of undisclosed teaching and unsolicited feedback can actually lead to communication problems between teacher and learner. What needs to happen instead is actually disclose that. That actually is a teaching opportunity. I'm not going to take anything away from you. That is actually to help your educational, education. So that everybody is on the same page and understand the meaning of what's actually happening around. And obviously the next step is to teach. And I'm going to induce 5 simple time, you know, simple time-saving and effective teaching methods. They're actually been very well established in literature and promote high value skills essential for development of expertise. There are, however, actually there is some what I call dark side of those skills, and it, again, it has something to do with the idiosyncrasies of our personalities in medicine. They can actually lead to miscommunication, disconnection in team. And obstacle can be an obstacle to teaching. For example, intuitive pattern recognition sounds great, but it is very difficult for the attending to explain subconscious intuitive decision, the heat of the battle in the OR to the learner in 5 seconds. So if somebody asks me why did you do it, I typically just look like it seems like the right thing to do. But this leaves the learner extremely frustrated and unhappy. Because you know, frequently thinking, why are we doing that? It makes no sense. My attending is so dangerous. I'm glad I'm here in the OR to protect the patient from my attending. OK, so luckily actually we have um effective technique to teach pattern recognition and today it probably will be called something like snap judgment or blink, but because it was developed in the 1940s by a radiologists, it's called on mini model. And because it is radiology, it is about pattern recognition. Some diseases, diseases are so characteristic, basically there's no other diagnosis possible. If somebody walks like on mini, talks like on Mini. Then probably it is actually on me. It's a very fun way to do. I mean, particularly for, for junior residents that sometimes struggle with medical students in the room, what should I teach them? It's a great way because everything what you have to do, just point at something and say, what is it? I don't want anything else, just tell me the diagnosis. Although for surgery it's actually great because. Just tell me what it is. Not only that, not only imaging, but also developing clinical situations, looking at the monitor screen, what is it, what's going on? Or perhaps just clinical situation. Very simple, very easy, but very educational. Now, that is one of the most important slides of the talk, so I want you to really pay attention here. So, anyway, let's move on. So, so judgment, prioritization and in the scripts have uh actually a dark side that should actually be mentioned and again it has something to do with other idiosyncrasy because every teacher, no matter where you are, attending fellow resident will ask the learner to do it their way, OK? Why? Because this is the only way possible that they know everything else makes no sense. And actually they feel very much disrespected if the learner suddenly does it a different way, their way. On the other side, the learner will always resist new ideas, techniques why? because I already have one. It works very well. Other people like it and actually I learned it from somebody who is actually much more important than you, much more senior. So why are you actually bothering me here with that? Why do you make me look bad in front of other people and just picking on me perhaps in front of, you know, my buddies? Now, But there are two very nice techniques that actually could actually teach that, that we're all on the same page, pattern recognition. The first one is actually one with the perceptor model. And here basically, let's assume you are resident and you have a medical student with you and you're learning for the opportunity to teach and suddenly the blood pressure goes down. So the first thing what you do, you basically try to obtain a clear commitment from the student. Tell me what do you think is going on with the patient, and here you're not interested in a variety of uh diff different diagnosis, could be this, this and this, no, just one thing. What is the number one pick for you? Number 2, then you go, OK, now let's probe for evidence. Why do you think that? What makes you think that? What would you perhaps do for the, for the patient to find out if you, if this is really true? And this is followed by teach a general principle I think because now you observe the learner, you understand the limitations, you see how they think. Now you can actually provide as the expert what do you, what you know, feedback to the resident or, or the student, what do you think is going on? And then finish by, by simply reinforcing what was done well and not and correct any errors. The reason why one month perceptor is so popular because of the brevity and simplicity, literally, it is as simple as it gets. What do you think is going on? Why do you think it's what's going on? Let me tell you what I think is going on and then feedback. That's all what it is, nothing more than that. As simple as it gets. It's actually very, very, very good for, for, for, for residents. Again, you don't have to prepare anything when you work with medical students. You just go along, see what's happening with the patient, and you can react very quickly, very simple, very powerful. Now, another very powerful teaching technique to promote judgment and prioritization is that think aloud approach. Actually some people believe that this is the best, most powerful method to teach clinical judgment and uh especially surgery. I think this, this is great actually to use, um. Here, the expert actually reports, shares with the learner about what was going on in their mind when they actually were making the decision. And then explained everything. I saw this, then I weighed the pros and cons, and I came up with that decision. It suddenly it becomes really clear how the decision was actually made. And not only it helps with teaching clinical reasoning, but also it improves learner satisfaction because suddenly they understand what happened, why did we make the decision, what were the pros and cons. That, uh, you know, because typically in the heat of the battle we can often not say why didn't we make the decision. I like to do that, by the way, often, you know, after the case, take somebody for coffee, sit down, and then try to explain why was I doing something um during the case. Now judgment is also required for technical skills. And here I, I recommend activated demonstration model. Here the tables are round and actually the learner observes the master clinician. You, for example, you identify that the your medical student um has some trouble with mask ventilation. So the first thing what do you do, you announce that this is actually teaching educational experience. I'm not going to take anything away. I'm just perhaps going to share a new trick with you. Number 2. You're going to actually. Tell the learner what to focus on and you have to be as specific as it gets. Perhaps look at my link, perhaps my finger, perhaps see how I'm holding my hand, be as specific as you can. Perhaps you're going to do horizontal matrices or observe me how I'm doing something. Then after you do that, show that you actually then activate the learner. That's why it's called activated demonstration model. You activate the learner, please tell me what you saw. Then you confirm that actually you got your message across and then you can say, OK, now you and feedback. Very simple. Let me actually, I'm not going to take anything away from you, you're doing very well, but you know there's a little trick that I can teach you and to do that you have to hold your hands a particular way. Did you see that? Tell me what you saw. No, you do it. And the last is actually a final teaching technique that I would like to introduce is the teach general principle method. Is a jack of all trades and uh it's a great way to correct um knowledge deficits, uh during preoperative discussion. uh and I'm sure we're all doing this. What I would like to do today is perhaps introduce a more time efficient way to maximize the learning. While mini minimizing the impact on clinical care because we're all actually getting busier and busier. So how can you actually teach well while you're doing, you know, you're moving your rooms uh fast, long. And the first step here is to identify urgent and non-urgent deficits. So you look at the deficit, is this urgent and non-urgent, and urgent means that there's a danger to patient's life. If they are not corrected. For example, let's say if a surgeon's going to inject some epinasally and uh and my resident potentially doesn't understand what could happen, I think I have to sit down and quickly talk about it. It needs to be addressed ASAP. On the other side, there are also many non-urgent. Needs. Many of the knowledge deficits are not urgent, they can be addressed at any time. So when things calm down in the afternoon, perhaps you just have one room or perhaps the case is almost done at that time everything is calm, everything is cool, then you can say, well, you mentioned earlier that you would like to learn more about how epinephrine works on the molecular level. Would this be a good time or should we do it later? Again, you combine both. You are clinically fast, efficient, moving the OR forward at the same time you provide high quality education. When you can. Now, when you do that, I think it's important that You get first buy-in. Because again, 2 to tango. Then limits learners' needs. Don't try to teach everything in 10 minutes. And focus on really the clinical person and that particular patient and what I like to do is get residents undivided attention. So often turn around from the monitor. And uh so that the resident can focus on me and I actually uh take care of the patient. And what I started doing now too is actually removing uh cellphones, which can be sometimes destruction too in the OR. Now, in all we discussed 5 brief, simple, but extremely effective teaching methods on mini model. What is that? Point the finger? What is that? One minute perceptor. What, what do you think is going on? Why do you think this is going on? Let me tell you what I think is going on and let's have a feedback. The think aloud approach. Why don't we, I saw that you didn't really understand, perhaps I didn't express myself, how I made the decision. Why don't we just go quickly for a coffee, sit down. And then you explain what was going on in your mind to the, to the learner. Activate demonstration, I think you're doing great. Actually there's a little trick I can teach you. Uh, let me show how it's done. This is, I'm not going to take anything away from you. And for that, you really have to focus on that particular aspect of, of, uh, the procedure. Then you activate the learner. What did you see exactly? OK. You, this is exactly what I meant to teach you. Now you teach your own principle model. OK, my learner has 123, perhaps deficits. What are the ones that I really need to address right now in the stress, you know, before I start the case? Perhaps only this one or perhaps nothing. And the other 3 I'm going to address later during the day when I have time. They are current, evidence-based, effective, and time efficient. Easy to remember, simple to use and implement. And modifiable to fit your individual needs, no matter if you have any specialty, you can actually use them and they can actually be. The efficiency of those can be actually increased further by adjusting to the level of the learner. Why? Because we learned that. A junior resident, for example, uh, a new, uh, resident who comes here for the first time, um. Thinks differently. This person will focus primarily on pathophyysiology. Little ability to filter, prioritize because you know it's just a new field. And often they don't have a variety of approaches, so teaching should actually focus on textbook language, offer rules and regulations, make it simple, avoid overload, cognitive overload and limit the number of techniques. So what did you do? Let's perhaps reinforce the same technique once more, just reduce the cognitive overload. No. Advanced levels, senior resident fellow, the situation is totally different. That person should be actually interested in seeing the big picture, should have the ability to filter prioritize, and should actually be motivated to develop a big portfolio of different ways to skin the cat. He obviously your focus should be on judgment, less on facts. So I'm not interested in hemoglobin, weight, this and that because of facts. We cannot discuss that. More about judgment, what does it say? What is the airway, things that we can communicate and discuss. Variety of approaches, trust in clinic develop the trust and clinical judgment and take somebody beyond the comfort zone, which sometimes can be quite unpleasant. And obviously the last last step here is to provide feedback and obviously feedback is a different thing to many different people in, in, in, in audio musicians, uh, for them feedback is just annoying noise, uh, that needs to be eliminated and, uh, I believe many of, uh, faculty sometimes feel the same way. For educators, feedback is an essential part of life. And while we may have different views and feedback, criticism like rain should be gentle enough to nourish man's growth without destroying its roots to. The trouble with most of us is that we would rather be ruined by praise than actually saved by criticisms. I think we can all agree. That it takes 2 to tango to make feedback successful, the sender and the receiver. And let's start with the sender. OK. And I think we also can agree with that, we struggle with feedback. Here's a study we published a few years ago. Um, it was a questionnaire study that surveyed 115 anesthesia residency program directors, and we want to determine the competence level of faculty to provide feedback. And the two main results were that 90% of program directors in anesthesia believe their faculty needs training with feedback, but less than 50% actually have resources to provide that. That's a problem. There is, there are no resources often to actually do that. So could we actually solve the issue feedback by better training? We actually tried to address that. We published that recently in a prospective multi-center study using a comprehensive approach to feedback. Um, faculty received 2 sessions, residents received 1 session, everything possible, we've followed the feedback records 3 months before, during, and then 3 months after the intervention. What do we find? No defense when you took all the, everybody, all the um institutions across, no defense. However The intervention was successful. And in a new engineer faculty. And when you were actually using smaller group sessions where they were able to talk to each other, it was not successful in, in, in faculty who actually were more senior. And I think, you know, it's difficult to teach all dogs new tricks and I, I, I guess our specialty is no exception and I think you should actually start doing that much earlier, perhaps just obedience training and then feedback training after that. Now, limiting feedback, discussion of feedback just on the sender sender is probably not enough because it's becoming more and more appreciated that the receiver, the learner plays an extremely important role in making the entire feedback process successful. And what I mean by that is highlighted by this study. 33 medical students who actually were taught two-handed surgical knot tying were randomized in two groups. Jour compliments. And specific constructive feedback. Jo companies where it's like, wow, awesome. I mean, nobody can tie this so nicely as you're born surgeon, wow. I'm just getting emotion by looking at that. And then the second group specific constructive feedback that could be hurtful but was done very well. And there are two outcomes, satisfaction and performance. So, What do you think? Who was more happy? People who received. Good anesthesia kind of stuff, job, well done, comments, or people who actually who try to help the student to advance their knowledge, which, who is actually happier? Global, global, what do you think? Compliments versus meaningful feedback. Which medical students were more happy? Compliments, very good. Yes. Global satisfaction was significantly higher in the compliment group than in the constructive feedback group. OK, 0.005 with 33 people, OK? It's quite impressive. Now what about performance? Which group was actually better? It is good to provide the kind of support of the kind of self-confidence or is it better to actually provide clear feedback on performance? Performance was significantly lower in the compliment group. In fact, it didn't change. It was unchanged. Nothing happened. They were still at the same level, but they were happier. I didn't learn anything, but it was a really good experience. And And so constructive feedback improves performance. But as a satisfaction, it's probably more reflective of praise than truly the quality of the feedback that was provided. So there are two things that we should actually in this consider. One thing obviously for all the learners. Because you, I think you do need to have constructive feedback to improve your, so the question actually is, do you support that system? Do you provide evaluations of your faculty that reflect that? Or do you prefer just positive journalized comments? So who do you actually provide better evaluations to? Are you trying to help and, and motivate the faculty to actually give you a tough feedback to make you better, or do you actually punish them by actually saying this is inappropriate feedback and I don't want that. And for faculty, actually what is important is, it's interesting that faculty that provide appropriate specific and constructive feedback may actually have low evaluation scores. Then faculty who just simply, you know, considers that as a popularity context. Nice, thank you very much. Good. Thank you. Now in this context, let's give, uh, let's perhaps give you a few recommendations. Number one, I would say suggest a change in diet. Don't use the old feedback sandwich because we all know that. So the moment when you start providing something beneficial, positive, everybody turns off in their mind just waiting for the negative meats that comes later, OK? So you're just losing the person and also then you have to say something negative about the performance. So again you just lose them. Try the new one, improved, it looks much better, healthier, OK? Ask, tell, us. So everything what you do, very simple, just relax and you say, OK, what do you think about today? What do you think? How, how do you think you did today? And the residents, fellows, medical students, extremely smart. They will tell you, or if you will do it with medical students when you're a resident or fellow, everybody will tell you that perhaps they didn't do something right. Perhaps they, they know exactly if they messed up. So when you actually then go to the tell part. Then you actually can say instead of something negative, you can say, I agree with you. This could have been done better. Or you know, you're right. That was difficult and sometimes you actually even say something different. No, actually you, I think you did extremely well. This was a very tough case and I've seen, you know, other people, you know, the patients could have gone much worse. You did actually very well considering what the situation was. So the first thing that comes out of your mouth is not critical, it's actually positive. You and the learner on the same page. You both share the same vision, which is much nicer. And then you can actually tell them what else you thought, and then you finish by asking, so next time if you would have a similar case, what would you do? So it is much better for digestion. What do you think? How did you do? Let me tell you what I think, yeah, I agree with you. And then uh what would you do next time differently? Much nicer and easier. Better for digestion. Number 2, and this may come as a surprise to some of you, but really nobody, nobody can reach your mind, OK? Oh How are we, how are you doing on our, on your unspoken objective? Am I what? I'm referring to the goals I have in my mind. I've never mentioned. I'm totally nailing them. So if you're doing that, just keep it on the spoken, clearly spoken objective. Everybody again is on the same page. And obviously feedback sometimes can be very difficult to take. OK, would you like some feedback on your performance? Nope. Uh, you're supposed to appreciate feedback because it makes you feel valued. How does listening to you belittle me about things you don't understand makes me feel valued? Sometimes not true. So if, so what do you do if you cannot change feedback itself? What do you do? How do you, how do you proceed? And I think the best way is to actually change your perception of feedback, how you view feedback and. If you learn, just learn from Hamlet, OK, Shakespeare's. Hamlet says, for there is nothing either good or bad, but thinking makes it so. So when you, so basically what it means is that, at least for me, is that when you receive feedback later today. It is your choice where you're going to consider it as the most rude, insulting, and useless feedback you've ever received that only had the goal to really pick on you and make you feel really bad in front of everybody else. Or, or whether you're actually going to appreciate that somebody very busy just took 5 minutes out of their busy day to provide you some advice based on the years and years of they experience and. Uh, years of experience and while the comments might have come out perhaps unpolished because they were done perhaps in a hectic and rushed, so the people, you know, who's doing this was unable to really form that in nice smooth and, you know, sugar coating, sugarcoating, and they were presented perhaps directly to you in public, you will recognize and perhaps hurt your feelings. You will recognize that and appreciate that they were really done because somebody truly cared about you. They did that because they wanted to make you better. Anyway, But if nothing works and you're really having a really one of those really, really bad days where everything is going wrong and you feel like nobody cares and nobody understands you, then. Remember the story of Caterpillar and the butterfly, OK? So So the story goes like that, a man found a cocoon of a butterfly and took it home. And then a few days later, or one day later, a hole appeared in the cocoon and the butterfly started to come out. But the butterfly was struggling very hard to get out. It looked like it couldn't break free, free. It looked like it was making no progress, just got as far as it could and no more. So what did I, what did he do? What did the man do? The man decided to help. He took a pair of scissors, snipped the cocoon to make the hole bigger, and the butterfly quickly and easily emerged. But the butterfly did not unfurl its wing and fly gracefully away. The butterfly had actually a swollen body, shrill wings. And while the men continue to observe and hoping that the wings will enlarge and expand. Actually never happened. The butterfly spent the rest of its life crawling around with a swollen body. And they formed wings. It was never able to fly. Why? Because what the man in his kindness and haste did not understand was that actually the struggle required for the butterfly to get through the small opening of the cocoon was nature's way to forcing fluid out of the body in the wings, so that the butterfly would actually be able to fly. So without the struggle, the butterfly will never ever be able to fly. In fact, it is a struggle. That causes the butterfly to develop the ability to fly, and the man's good intention hurt the butterfly. And sometimes just wait. And things are going to happen for you. You don't have to rush. So the question that we have to ask ourselves is, Do we want to fly? And for all people who actually teach, do you want your learners to fly? So to summarize The practical part, the second part of this talk, what is important is actually to get buy-in from the learner so that everybody is on the same page and uh try to understand the learner, where they're coming from, what their past experience have been, because it really helps you to understand, connect, and work together as a team. Identify the needs and be aware of the idiosyncrasies could be poison to the relationship because if people have totally different approaches to the same thing, like I'm sure if sometimes you know when a fellow here, you have bright fellows who come from other institutions and suddenly they get a shock because everything done is differently, can lead to a kind of frustration. Then maintain the buy-in. And pay attention to your, what your learner is doing and how, how they think. And really focus on the patient's hand and limit yourself perhaps to 1 to 3 things to, to you want to teach. Don't teach everything, just 1 to 3 things because otherwise you overwhelm the learner. And which is very important, wait for the right moment because sometimes we still have this urge to say something right there in the moment, but it may be not the right time. So often what is best is just wait, hold off, just wait for it to be done. And don't be defensive, be experts, set the stage and provide solid feedback, go over teaching points, review what was done, which is great, and say thank you for the for the, for the work. Overall, I think it's crucial to understand the road to a clinical experience, how we actually develop. And Buy in. If you teach, try to be productivity oriented. It's not about how much teaching you do, but really what the learner learned. And here focus on the needs that they might have, promote the high value skills that we mentioned. Less is more, it is less about quantity and more about quality and adjust to the learner. And constructive feedback is crucial, but remember that you know that. This is sometimes that taking somebody out of their comfort zone can be negative perceived negatively, so satisfaction is not really a good measure of, of, of what actually happened, the quality of the feedback. And I would like to finish this talk with a final exercise, and for that I need you to relax. We're going to meditate a little bit here. So, now what I want you to do, everybody, actually, put your hands like that, OK? Everybody. Now, what I want you to do, so you relax, so now what I want you to unfold your hands and move your right hand just one finger down and close it. How does it feel? Kind of weird, no? Funky. So basically by moving just one finger in your hand, I just took you out of your comfort zone. And it feels weird. And I hope that actually this talk created a few moments that felt a little bit awkward and maybe unpleasant because You know, The goal of the talk was actually to take you out of your comfort zone in the area of education in order to provide you with new skills. And not only that, but actually to stimulate you to think about this topic in a few days to come from both perspectives because we're all learners and teachers at the same time. How do I teach and how do I receive teaching from other people? And with that, I would like to say thank you. Can you hear me? Thank you, Doctor Brzezinski. That was a wonderful talk. Um, we're a little pressed for time. Is there maybe one question that anyone has? Any questions for Doctor Brzezinski? No. All right. We have a luncheon with him today in our department from 11 to 12:30 if anyone wants to join and, and ask any questions. I know we're probably all in a hurry to get to the OR. So thank you again for coming and wonderful review of all of these teaching methods. Thank you. I Hello
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