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0:16
foreign
0:41
sorry for the short delay everyone can you can you all hear me it seems like there's a little bit of an echo okay all right thank you for troubleshooting for us so uh I am incredibly excited to have our first in-person and hybrid event since covid so it's been years since we've gotten to uh join together in person we have a few people filtering in and I guess one of the Silver Linings of covet is that we also have the zoom option now so we have quite a few people
1:17
um joining by zoom and it is my pleasure to introduce Dr Calvin Cho from UCSF he is um I think a role model for us all all clinician Educators all the uh has all the expertise that we would love to have and um often struggle with um to start from the beginnings of his career uh he trained at Yale as an undergrad and then Columbia for his PhD in medical school
1:49
um then he did his uh Internal Medicine training at UCSF works there now as in attending at the VA and is a nationally renowned expert in medical education communication skills evaluations Etc so I am so excited to hear uh and learn from all of your wisdom thank you for joining us thanks for having me yeah uh thanks all for being here both online and in person uh anytime somebody says uh he has a lot of experience that's just an excuse for me being old and I hope that
2:27
I can bring at least some of the experiences from some of that oldness as well as some of the School of Hard Knocks that we've all gone through as we've gone undergone our training uh we're talking today about how does help the struggling learner and I actually need to change the uh the title of the slide uh Learners who struggle I think is a better title than struggling learner we don't want to necessarily give our Learners an identity where they are a struggling
3:02
learner or somebody who's in remediation because that extra identity then gives them more of a problem in terms of a a moniker or a identity that they have to shed so um thinking about Learners who struggle and ways that we as faculty and colleagues can help them
3:29
did work before but I can always I can oh got it you know
3:35
you can always do sorry I have to advance the slide somehow
3:40
there we'll get we'll get this to happen
3:46
maybe if you don't mind thank you uh so I have to give a disclosure and that is my name is on a couple of books uh one on remediation uh this was that was that was published almost nine years ago and the next Edition we have just finished and we'll be out in August or September so uh a lot of the things that I'm gonna be talking about today is wisdom from the new from the new edition
4:12
and then this other book on communication called communication RX none of these books go to line my own pocketbook all the royalties go to the academy of communication and Healthcare which is my uh home organization so to speak um so never too early to buy for the holidays by early by often
4:42
I think just click like click uh there you go so some objectives for today uh it's always interesting this is one of the few times I've been giving a lecture in person and I forget every time about the computer and having a having a mouse and having um so I am in remediation right now for for this talk and so uh and and as we all struggle a little bit with what we do um it's it's just part and parcel of the territory that we have
5:16
so the objectives for today fourfold first Define remediation second talk about trajectories of where our Learners uh might be uh as they struggle name steps of remediation and features of each step and finally uh commit to best practices in education which then supports all learners how are we going to get there is on the next slide which is the road map we'll start with some definitions in framing we'll go to steps of remediation and then we'll go to
5:47
some system interventions before we start with that though I'm going to start with a
5:54
question for you why are you here so uh if you will I'm not going to have you out yourself by raising your hand I have about five options here but consider for yourself a question as you think about why you're here we have 15 folks online and a scattering of folks here um just thinking about why you're here maybe you can click maybe you're here because you do lots of remediation and you want to validate your approach maybe you're here because you're interested in
6:23
doing doing more remediation work and learning more maybe you're just kind of curious
6:30
maybe you were forced to be here maybe because all of your learners are terrible so I'm hoping that all of you fall into at least one of those categories or maybe a couple of those categories and what I'm hoping is that by the end of the session today that you'll have a sense for which of those categories you might fall into and how you might be able to metabolize some of those initial thoughts and feelings we're going to start with uh what's
7:00
called a trizz that's an acronym an Eastern European acronym for a wicked question and uh I'll show you the question in a moment and also as we start thinking about this question typically with grand Brown's type presentations the person the star from afar person up front tells you all the things that you should be doing and then you're supposed to go do them in today's talk it'll be more me asking you questions about the things that we have found
7:33
as we have put together this new edition of the remediation book and thinking about how you can Implement some of the things that we have discovered our best practices so before we so so this is just the first question of a host of questions that I'm going to be asking you throughout the presentation so I want you to consider this question first
8:00
what can we do to ensure that about that at least 20 25 of our trainees are guaranteed to be unable to practice safely without particip without supervision or have unacceptable lapses in professional Behavior what can we do to guarantee that our trainees are going to fail or are going to not get where we want them to get I'm going to open up the chat would love to have the folks in the room think about that and
8:33
tell tell me tell me a couple of things that would guarantee that our trainees would not do well
8:49
yeah and I'll repeat it for the people online what's your name radhika nice to meet you
9:03
um I'm actually thinking there's not a whole lot in terms of a hundred percent guarantee um I think that a lot of it if a I mean unless we just got rid of the program or something but beyond that I think if they're uh dedicated then they won't find a way
9:22
okay I mean in my opinion I think they're I'm hard-pressed to think of something we could do that would 100 guarantee that 25 percent would not be able to practice independently so one thing is to get rid of the program yeah yeah that that is a possibility that is not a possibility then we'd all be out of a job right we don't want that we don't want want necessarily that to happen um and one way to guarantee that that would be a hundred percent of trainees if you got rid
9:50
of the if you got rid of the program and had no recourse for them then all of them would not be able to uh perform up to standards right are there other things that you can think of that that you can think of that guarantee that our Learners would not be able to perform up to standards
10:15
foreign
10:20
go ahead yes your name
10:27
Trevor nice to meet you I I you know the the question isn't an easy one but but I guess I would say if we if we were to get a guarantee that that they would be unable to do this at the end of their training then one thing we would do is to not remediate that error when it occurred during their training you see you see an error or something not happening and you just turn a blind eye to it right don't don't pay attention
10:53
exactly other things that come to your mind let's see if there's anything in the chat
11:03
make them afraid uh Karen Karen make them afraid to ask for help or admit mistakes absolutely no question about that
11:14
other things you have any thoughts Jen I was going to say provide no feedback whatsoever sit there and let them do whatever they want no feedback exactly so just let them go so um you're all um considering the idea of lack of adequate supervision right either get rid of the program turn a blind eye don't don't give them feedback uh you know not pay attention to anybody who needs this mediation exactly and if we think about our practices now
11:55
and what we do for Learners who are maybe not up to standard I I would I would argue that a lot of the systems that we have in place right now actually make this happen we we haven't gotten rid of programs yet but I I would think I would think I know this is true for my institution that feedback provision is unfortunately relatively rare that when we see a learner who is struggling oftentimes we're like well the next person is going to take care of that I'm only on service
12:32
for the one more week right that there are things that we are that for lack of a better word guilty of not because we're bad people but because we either don't have the skills we don't have the courage we don't have the we don't we we feel we don't have the institutional support to be able to help what to give the Learners what they need so if you go to the next slide um
12:59
at some point oh we're on we're on there we go that our medical and Educational Systems conspire to make it difficult for our Learners to succeed that our trainees deserve better and that ultimately our patients and our society deserve better by turning a blind eye to folks who need remediation and allowing them to go out and practice is uh not what Society expects of us Society expects that we are going to turn on people who we know are okay next slide um so
13:40
this backbend is to remind me to um think about a time when I was a completely novice learner and for me that's yoga like I started doing yoga classes right before the pandemic started uh and and the reason that I want you to think about that that I'm bringing up novice learners
14:05
is because all of our Learners in whatever system we work in in medical school in residency and in Fellowship they are they're starting out very novice in what they do I've been practicing now for over 25 years and so I don't think I don't think about this uh as well I think the privilege of having been in practice for a while uh obvious obvious the need for us to consider what it's like actually to be a novice learner and so when I started taking yoga uh it was a very very hard
14:40
thing it's a really complex series of moves and poses uh at the very beginning I remember thinking well I had to be motivated to go at all and when I finally got went to a class I would go to a class where there weren't many people because I didn't want many people be looking at me and I'd look at one person and you know he'd be really really bendy and I'm like I can't possibly do that and look at this other person and I said well at least I'm more flexible with that
15:05
person so we go into this self-evaluated space in this comparative space when we're very very novice learners and then as I got better and better well I wouldn't I wouldn't call myself better at yoga as I got more experience doing yoga um I started to understand some of the terms and be able to hear the word downward dog and not say what is that but actually do it that oh actually I don't
15:33
know if I can actually do it but at least make a make a shape that is sort of like downward dog and then as time has gone on and when when covet happened found an online class where I didn't have to do that comparison thing as much there are not that many people in the class and so I get a lot of personal coaching in the class uh and that is I think what has really made my yoga better it's by
15:59
no means great I I'm not going to show you any of my poses right now but I will say that uh I have a better sense of what it means uh to do yoga as well as to inhabit this sense of mindfulness that yoga requires and so as we think about uh the novice learner and thinking about throwing at them all of the knowledge um uh the knowledge we that we want them to learn all the skills that we want them to learn all the professional attitudes that
16:38
we ask them to do sometimes on not explicitly that uh having empathy for that space of the novice learner will help us deepen our sense of responsibility to Learners who need remediation
16:59
so definition of Remediation in medical education facilities the process of facilitating a correction for trainees Who start out on the journey who are becoming an excellent Healthcare practitioner and then somehow have lost their way
17:16
I mentioned earlier that one of the things that happens in uh that that one of the Dynamics for when we encounter Learners who struggle is that oftentimes we will try not to pay attention to them for whatever reason you can click and that is that we kind of want to kick the can down the road particularly if you don't have that much longer on servers so there's some uh worry that we have about showing up as a as a guide to that learner and I say kicking the can down
17:51
the road but actually it's kicking the quote you can click picking the can't down the road right and when we kick the cant down the road um it's usually left up to somebody
18:05
uh who takes it upon themselves to try to do what they can to get that learner where they need to get you can click and those folks unfortunately become lone wolves they get um it's it's a labor of love there's very rarely support for that kind of position and you're kind of spending all of all of your extra time doing that work because uh oftentimes I would say that and the vast majority of Health Systems right now there is no such structure to allow remediation to happen
18:43
you can click um so one of the questions that I am going to pose of you to file away is what kind of community can you develop so that each of those people represents one of the lone wolves now now it's a group of people who are helping not only the puzzle in the middle the learner who might be the puzzle in the middle but also each other in getting each other better uh in inhabiting moving forward the remediation space uh so I I I'm not going to have you answer
19:20
that right now because uh all these questions are questions that we know must happen somewhere down the line how do you get there that is something that I don't know the USC way well enough to be able to say oh you need to do this that's um these are questions that I'm going to be posing with you
19:39
okay well moving on to the next the last framing thing which is thinking about how the learner is doing when you have uh you know you're kicking the cant down the road uh what is going to happen to that learner and um oftentimes we think about a learner who is in a uh dichotomous position they either aren't fine or they're not fine and actually it's more complicated than that there are these various zones uh which oftentimes are not as explicit as we like them to be and
20:13
each of those zones there are specific rules rules responsibilities and then thresholds from moving between zones uh which characterize each one of those zones what am I talking about we can click um the so this is the dichotomous thought okay someone either doesn't need corrective action or they need corrective action it is more complicated than that if you click there's actually four different zones actually we've come up with the fifth one let's let's go with
20:41
these four zones right now um on the on the uh x-axis is time and on the y-axis is performance and progression okay so the uppermost zone is where Zone one where someone doesn't need or any correction you can click as a learner which we hope most of our Learners are right they're they're wending their way through uh progressing through whatever program they're in and they're not needing that much correction or they're doing their own self correction
21:14
the next slide shows somebody who needs some correction and click there is an arrow where some kind of intervention happens so either that learner gets external help they get some tutoring um a program director or a course director sees that there's something they can do and they can get them relatively quickly from the corrector space into back into the non-correct space
21:42
you can imagine that there's also a trajectory where that person doesn't get help and then they go get into a remediation space and the remediation space is different from the corrective space the corrective space is a more informal like let me coach you a little bit let me give you a let me let me give you something to read and then they get better whereas the remediation space is more of a formal space where uh uh there they have not
22:09
been performing to the degree that they may be in Jeopardy of keeping their spot in the program right and so uh that remediation space requires a formal notification to the learner it requires um communication with whatever oversight committee or person is involved in determining eventually whether that learner stays or goes um if you click there's also a scenario where somebody starts their program and they don't progress at all and that's why these these lines go
22:47
up is because we expect everybody over time to get better but if someone stays at the same level they will need correction or mediation because they're just not progressing and then the final scenario here is a situation where somebody actually starts doing more and more poorly and we hope that doesn't happen but this kind of scenario happens often and folks who um have a serious professionalism lapse in fact sometimes the slope is even even quicker than
23:22
that they do something and that is so egregious that we have to kick them out of the program right those things are few and far between and they're really dramatic when they happen and so I think we all probably have stories or have heard stories of people who have done this exact thing okay and there is a there is a need in that bottom level for for an exclusion unfortunately this is a paper that was written about 10 years ago where uh there was a survey of programs
23:54
across professions across Health Professions and what they found was that 80 of programs
24:01
um said that they knew of a learner student trainee who they had passed through the program even though they knew they shouldn't have this failure to fail so even though we know that there is this bottom area where we need to exclude a learner we're not we don't have the courage to do that and there's many many different reasons for that you can click and this is from the nursing literature and I think it's a really useful way of considering
24:27
the various levels you look at the very bottom level is the student or the trainees performance um we could ask would I let this trainee look after me so that's learner level and if the answer is no then we go up to a lever a level above that is there something that I have done that that I had where I haven't helped that that I haven't helped a learner adequately right if I feel like I have done everything I can and it's at the level of learner then I also need to have
25:00
institutional support if I say to my institution this learner really cannot progress I feel worried that turning that graduating them from our program is going to be a problem to society if my institution says well you can't do that that would be a bad that would be a bad mark on our program then we can't fail that person they progress right so on all of these levels it's not just about
25:30
the learner it's not just about us it's not just about our relationship with our learner it's also the system whether our a system allows us to do what is necessary from a societal standpoint and then if we can't do that then we risk losing our license with Society for saying we guarantee that practitioners from our programs are competent so so we have a responsibility as a society
26:03
okay that's enough definitions and framing um we'll go to steps of remediation next and the next slide is five different steps that I'll go through relatively quickly we've got identification clarification collaboration on a learning plan intervention and then assessment and then you'll see that yellow arrow underneath this learning plan intervention pieces are all about throughout that uh throughout that process when you think about how are we doing as a program how
26:34
are we doing uh how is our remediation program going okay so we'll start with identification
26:44
click it's all right um before we start with that like this is identifying a learner who needs remediation right so before we even start with that you think about prevention how can we prevent Learners from ever getting into the space where they need remediation
27:01
um so a setting clear expectations I can tell you that it's only relatively recently I would say within the last 10 years of my 25-year career It's relatively recently that I've been able to clarify for myself what my expectations for my Learners are Learners used to come to me and say well what are your expectations I'm like I don't know you know be on time and now uh the more clear I can be above my expectations for when I work with a student
27:26
in clinic when I work with a team of Learners on the inpatient setting to be able to say you know I I expect that uh that we'll be having feedback conversations regularly through the throughout the course of the two weeks we we have together I expect that you come in having read about the patient that we're going to see in in our in my clinic this morning ahead of time so that you know and then come up with learning goals for that particular patient right so to be really explicit
27:54
about that so that the learner so that you're providing a reasonable scaffold for a learner the second thing is decreasing cognitive load and I'm going to get to that in a moment the third thing is fair assessments oftentimes in the uh in the pre-clerkship time period uh traditionally when I went to medical school we had these high-stakes midterms and finals uh for medical knowledge uh and the science of learning has debunked that approach completely what what has
28:30
been shown to be much more effective is ongoing quizzes uh being able to retrieve information in different settings uh on a regular basis and to be able to distribute that learning over time it's not we used to take Anatomy I think I think our first three months were anatomy and a little bit of biochemistry so we're supposed to concentrate on anatomy and and the and the science of learning suggests that if you learn across disciplines you learn better I think there's one more
29:04
early early identification feed forward I think if you click one more there we have had to have Smokey the Bear prevent you know only you can prevent forest fires only you can prevent uh a remediation thing from happening um and sometimes early early identification we all know is better feeding forward is uh an interesting concept uh in the literature there's um there's this idea that if we tell somebody who's coming up uh who like if I'm on service right now and I have a
29:36
struggling learner if I tell the next attending oh by the way this learner is struggling then we may run the risk of labeling that learner as needing extra help and at the same time if I don't do that you know if I'm the receiving attending and I don't know that a learner is struggling then then I have to kind of figure that out all from all by myself and then time is wasting so the the the way the literature is moving right now in general education a little bit in medical
30:08
education is that feed forward is useful to do as long as there is no judgment made about that learner not uh not I can't believe this learner you're going to have they're so weak but I've been working with this learner they're working on their communication skills this is as far as we've gotten I think maybe you can work with this next right the more specific competency-based approach to our uh to our struggling
30:38
I'm gonna I'm gonna take over the clicking for just a moment so um here this is a this is a time period where um will ask you to consider
30:50
uh information overload because oftentimes what happens with our Learners in the novice space is that they're overloaded with a whole bunch of information that uh we may or may not know about so what I'd like everyone to do both here and online is to take out a piece of paper and a pen
31:08
and in a moment I'm going to show you some let a series of letters and I want you to write down the letters that you see okay and then at the very end I'm going to have you uh
31:22
uh radio sales okay and this is an exercise that I stole from Nikki Woods uh in at the University of Toronto and so I thank her about this I thank her very much for this okay so you all ready both here on online okay so the first one
31:40
oops okay let me try that again I click twice that one okay there you got a little you got a little preview of the second one you ready that was number one with the two letters okay next one
31:59
ah stop oh I see I I know what I've done I I put a timer on this already
32:05
okay you got a little preview the next one was eight okay you got that the five letter one next
32:21
okay
32:23
are you ready
32:26
next
32:31
it is the same amount of time
32:35
there's one more really try hard on this one one more
32:46
okay so answer key coming up
32:53
you can see what you're able to do
32:58
I think it was I think is that 0.5 second Flash
33:04
um so I'm assuming everybody got the two right five did people get five the five okay eight pretty much okay I mean this is that psychological literature from the late 1950s where we can hang on to seven bits of information at any one given time plus or minus two so eight is kind of like pushing it anybody get all of 11 all of the eleven one how many did you how many of those did you get
33:31
four four or five what about the last one same different
33:39
so so Mikey got four in number 11 but but seven in number 12. even though it is more letters you got more than the last timer why why do you why do you think why do we think that Mike got more on the last one
34:08
foreign
34:22
are open Grant you're you're bunching letters together in the in the 12 right anybody else any thoughts about why why that last one you might Bunch together more than 11.
34:41
vowels
34:44
there were vowels in the last one and that allows us to see patterns uh in a way that we normally would see words right so there's a bum in there there's an RV at the very end if you have an RV test is not really a word but but but it may look like a word so um uh so we we anchor on vowels as organizing principles if we were in our language to be able to Bunch things together uh and the reason that num the the 11th one doesn't work so well is because I tried very hard to come
35:19
up with a string of letters that don't have any association with each other unless your initials are DNT or BSR or something like that you might you might see that um as a as a familiar grouping um but that I think that's one of the reasons why uh 12 is easier than 11 and so when we think about applying this to our learners oftentimes we're giving them the list of 11. we're giving them a
35:45
whole bunch of letters that don't have anything to do with each other and so what are the vowels what vowels can we guide our novice Learners toward particularly the ones who are in remediation that might help them integrate information more effectively I think they can do this yeah
36:05
foreign people heard of the ladder of inference
36:11
the concept from the 1970s psychological concept where uh we make very very quick judgments about people and then we act on those judgments so in terms of how we think we might think about Learners who struggle it looks like this the first thing is we take all possible observable data for example the student is reading the presentation pause between the chief complaint the history of prison element it's a flip over a piece of paper that is the data that there are there
36:42
um uh because the human brain cannot possibly integrate all of the data that are coming to us relentlessly all the time we have to select information we must select data and sometimes that that selection has to do with where we are that day that pause seems like forever and then once we select those data then we go immediately to interpretation and conclusion drawing can't the student memorize the one-liner he's always disorganized and then we go to formulation of
37:17
beliefs and taking actions he's terrible I roll my eyes and I cut off the student's presentation even though they've just said just the chief complaint has this ever happened to you it's happened to me I used to do this all the time I used to interrupt all the time uh and imagine how this learner might feel it might feel dejected press Fallen because they're trying their best and we have immediately
37:42
uh interrupted them so again how can we calm our minds down so that we can help our Learners who struggle or even not even the ones who struggle hope to help our Learners any novice learner get to the next level uh this arrow is just to say this um these inferences occur within milliseconds
38:09
so we need to get ourselves down the ladder okay so that's identification when we identify a learner sometimes we jump to conclusions this learner is terrible they they need help but I can't do anything because I'm going to take the cant down the road right
38:25
so I've done it once if you have identified a learner and said okay I think this learner is struggling in this particular area and I'm trying to figure out exactly why the next step is clarification clarification involves um really getting a sense of what's happening with this learner so here's a actual actual learner that I had in my Inpatient service many years ago she's a mid third year student during rounds her she's looking down a lot
38:55
he's not interacting very much with the team he's checking her cell phone a lot and when she does her presentations they're lackluster obviously that's a judgment like they're they're not that organized they're sort of rambly doesn't seem like he's trying very hard
39:12
ideas in this in the room about what might be going on with this learner
39:23
so lack of confidence why might that be
39:31
so there may be there may be actually an organization issue there may be a lack of a worry that that she may not know enough other things
39:44
this is the clarification stage where rather than saying okay there this person is really really terrible thinking about why um so this is another concept called the cone in the Box
39:58
um so let's say they're this cone of the box and uh let's see this this side of the room this side of the room is looking through the I was going to say the a-hole now looking through hole a and that side of the room this side of the room is looking through hole B uh Brandon you're on this item all right so people looking through hole a what do you see
40:26
Circle people looking through hole B what do you see
40:33
triangle yeah right who's right
40:39
everybody nobody both right because what's actually there's a cone so nobody's right and everybody's right from their perspective you guys see a circle that is a circle you say you guys see a triangle that's a triangle so how can you marry those two different perspectives into the cone another reframing possibility for remediation so when we are in clarification stage back to Anna what are the things that are going on with her they're actually actually lots of possible things
41:12
that are going with her is there an underlying mental health issue that is undiagnosed or diagnosed but not known about is there a learning disorder that she's struggling with that we don't know about oftentimes in the Health Professions we're not seeing uh people get get through a certain level and then finally when the um the amount of information in medical school gets so huge it uncovers an underlying learning disorder that they have been um been able to mask for a
41:43
long time finally this I this idea that there might be something happening in their personal lives that's affecting what's going on with them and then there are also systems level things I think Mike you are you're alluding this a little bit earlier maybe she doesn't have that much uh confidence because she's been there's an implicit message being told her that there's something about the way she is one of her identities that it's not right
42:11
is there something about the learning environment that doesn't allow her to succeed um maybe she's not following enough patience and she's born maybe she's applying too many patients and that's why she's overwhelmed and back to expectations if I haven't told her at the very beginning I expect you to be able to do a presentation um uh fluently uh uh ideally without notes um if I haven't given her That explicit expectation in the very beginning then that might complicate the situation
42:46
um so the answer to this particular case um was that she uh so she was a medical student at UCSF
42:58
her father lived in Sacramento it's a two-hour drive away and every and and every day almost without fail during rounds he would text her to say um I think I'm going to kill myself he had a history of depression and suicidality so duh why you know why she'd be distracted and every night rather than staying in San Francisco and studying or being on call or whatever she would drive back to she'd drive back to Sacramento and make sure her dad
43:28
was okay and then in the morning she'd drive back to do to try to pre-round on her patients
43:36
fortunately we found this out in in time and now she's a Cardiology fellow or she just finished Cardiology policy but UCSF I mean it's it's I'm glad that she succeeded and sometimes some really really serious stuff is happening to our Learners that we have no idea about
43:53
when we identify a concern there's there's a differential diagnosis and this is why we talk about clarification if it's a competency area deficiency then we can talk about how to develop ways of assessing what was happening with them through feedback and then try to help them if it is a learner specific or systems level issue it requires that we actually spend some time with the learner asking them what's going on in your life um are you having are you are
44:24
you having difficulties that you'd like to let me know about and that requires that we have trust in the relationship and Rapport building because if I am a program director I'm not and I notice this and I call Anna into my office she might not tell me we have to have back to this community idea a community of people who might feel who Anna might feel safe enough to talk about
44:51
okay third step collaboration on a learning plan so um the the collaboration on a learning plan and the next step intervention required that we have a very very good understanding of educational fundamentals that everybody should have that includes having a feedback culture that gets everybody more toward expertise involving Learners throughout the process so this is talking we're right now talking about collaboration on a learning plan
45:19
we could very easily say Anna you need to do this this and this and then we'll be able to pass you
45:26
some of those things may or may not resonate with what Anna needs or and it thinks he can do so involving our Learners is super important thinking about growth mindset self-regulation and goal setting that is going to allow our Learners to get better over time and allow them to become the eventually autonomous clinicians that we need everybody to be
45:53
um and so if we're just teaching them toward passing a specific test and not giving them broader growth mindset level tools then we're not doing them any favors
46:07
um I says oops hello us as faculty uh being able to develop ourselves so that we can construct educational paradigms that allow our Learners to succeed and for uh those in remediation be able to develop specific expertise so that we can help particularly Learners who struggle succeed and then finally to align the explicit and implicit curriculum together because there are all kinds of things that we're telling our Learners without saying them um that we align them in a way that
46:45
allows us to assess our Learners in a valid reliable way so those are the fundamentals and those are all uh wrapped up in being able to collaborate with our Learners on learning plans here are some considerations about learning plans you're wondering why the basketball this is a learning goals slide um so this March Madness right field a field goal is what I was thinking of I gave us talking in Canada a while ago and you know that would be hockey but so
47:16
field goals so so our so our learning goals how do we involve our learner how do we involve our Learners in developing a goal and plan for them that will work making certain that those goals are smart that they're specific measurable actionable relevant and timely and then documenting that plan over time giving whoever needs to have a copy and assessing progress in a reliable way so once that learning plan is in place then we do the intervention of the actual remediation
47:50
and what I have listed on this slide is one two three four five six domains there's a separate chapter for each one of these in the upcoming book
47:59
um and just some ideas of how you might be able to help Learners who are struggling in one of those categories uh I don't want you to memorize these actually that's this is another skill for the book um because I can't go into each one of these competency domains in great detail every competency is different in terms of the way that you approach them but there is a common theme between all of these and that is that almost all of them all of them require coaching feedback
48:31
reflection self-regulation okay so that's the basis of the intervention in remediation is to have coaching and feedback one um then one question I'm gonna ask the group to think about is how is your coaching and feedback process for everybody not just your struggling not just your learning who struggle how is your coaching and feedback process for everybody
48:58
and if you feel like it's lacking how can you get better expertise like that
49:05
okay finally we're up to assessment an assessment is on two levels one is assessing the learner we're back to this novice learner who's okay I know that this if you if you do yoga this is not the bridge this is the full wheel the full wheel is harder than the bridge but I I understand that and then how can we bridge to successful decision making using standardized Competency Based assessments and then thinking about this community again
49:36
a triumvirate I like to call it of educator groups number one the people who are Frontline Educators who identify Learners who might be undergoing some struggles then they refer to a program where there are expert remediation coaches who can work with that Learner in that specific competency I I I'm really good I think I'd like to think I'm really good at the communication and professionalism
50:01
competencies I'm not good at all in remediating people in the procedural competencies so having a a community of remediation coaches who are expert at individual competencies will be really helpful and then ultimately having a decider an Arbiter who can take all of these data and make a defensible ethical judgment on the basis of a portfolio of data that are imperfect and mixed Source I think of this like when we're following a patient in the hospital who has CHF
50:39
uh and somewhere in the middle of their of their hospitalization we we get these data back like their their bicarb has increased so we think oh maybe they're dry but you know but they're but the jvp is really high but they are tricots with regards and then then you look at the then you look at the Pocus and there may be some compressibility there taking all these data and being able to synthesize it is the patient wet or dry
51:04
are we going to Diaries them or not this that's that complex level of decision making is what the complex level of decision making we need to do for students from remediation as well
51:17
oh uh and resources I'm telling you all these things like the best programs have all of the resources for these people we have a standardized competency-based assessment system we have um we have faculty development for all people we have really great coaches and feed coaches and who feel really really great at feedback who do you do that how can you get all that together and what are the first first steps you're going to take in order to develop this program
51:45
and then documentation document document document
51:51
going to system level interventions thinking about how we can get our so we are we have just
51:58
um thought through how we can approach a learner who is struggling what is the system like what is that system that helps that learner along we hope what does that system look like and how can we improve that system how can we how can we improve the evaluation of the measurements that we have for success can is the time was the timeline for that learner too long too short do we need to
52:23
give them more time um and thinking also about the effects on our Learners not just the Learners who struggle meaning we're developing self-regularly learning here how am I helping you with the resilience how am I helping you with your mental health um if you have a struggling learner uh the ripple effect outside that learner sometimes can be really really Stark I was I'm just now working
52:50
with a Cardiology fellowship program where they have three follows in each year this year one of the firster fellows is struggling they've had to take her out of rotation which means that it's loading on the other two fellows and the rest of the program so the Ripple effects of somebody who's struggling can be very very severe and how can we help these peer cohorts survive
53:18
without making everybody crazy I'm asking you that question not because I have an answer because I don't um it requires a lot of a lot of work and a lot of what's the right word strategy and finally I showed this slide before in terms of some of the systemic issues that can Inspire to decrease the performance of our Learners any of these implicit bias Laden ideas learning environments that don't
53:51
support our Learners ways that we can be better as teachers ways that we can instruct our systems so that our Learners can can succeed the best they can um all kinds of things that we can think about
54:07
all right so summarizing finally uh definition remediation meaning getting somebody back on track
54:16
don't do this alone need to have a community to have this happen identifying our Learners first preventing how can you prevent uh some of these remediation issues from happening how can we um uh accurately identify Learners who need Remediation in the most supportive kind of way we think about clarifying what's going on with the learner remembering the cone in the Box the whole a and the whole B and asking with empathy and curiosity and in a safe space what might be going
54:50
on collaborating on a learning plan remembering that that depends on educational fundamentals feedback and coaching is the Crux of intervention and finally in terms of assessing not only our Learners is the learner doing okay our program is our program doing okay and are we turning out Learners who we are confident can uphold our societal Duty for a competent practitioners
55:22
final word here Nikki Giovanni the great poet um says this and I'm going to ask that we apply to remediation while language is a gift listening is a responsibility
55:41
thank you so much for your attention I would love to have any questions if you have time
55:51
and thanks for staying
55:57
can you hear me yeah there you go does anybody in the audience in person or um by Zoom have questions
56:09
um because there's more word like exactly Amy
56:15
well I have a couple of I always have lovely um how do you approach the learner who may be struggling for whatever reason who lacks insight into their struggles that is uh I think that's the most important question that underlie underpins a lot of remediation because as we know the literature of high performing Learners High performing Learners are more likely to rate their performance less less highly than they actually are and are low performing learners for whatever
56:54
reason tend to rate their performance higher than they're actually performing and some of that is because of ego protection probably as well as other factors um and uh so if I am having a conversation with a learner who appears to be struggling and they don't see it there's there's two there's three three potential um Avenues into that number one I'm asking I'm asking them first how do you think you're doing with this they say I think I'm doing great
57:29
relationship development is really really important in those in those situations because if I say well actually you're not then they're not going to believe me so I have to work really really hard on on developing a relationship with that learner so that when I say something that is counter to their own self view they they will believe me and so a relationship development B the another way to help that along is to rather than say rather than having them say
57:59
what they're doing poorly or a global assessment I say what do you think you're doing effectively and I and particularly for for Learners who need remediation because those Learners know they're in trouble they're going to be more defended they're not necessarily going to see things that they are they actually are doing it effectively and I'm less likely to see the things that the learner is doing effectively because I have because I know that they are in
58:26
remediation so I have to be really look really hard for the things that that learner is doing effectively and then have that conversation with the learner really start in the appreciative space Learners who come to me with communication skills issues medical students when I'm reviewing their when I'm reviewing videotape with them for example uh I will stop the videotape almost always this happens uh the walk into the room they say hello the patient I'll stop the videotape
58:57
uh and the learner thinks oh my God I can't even get the hello right and I'll say what did you what what did you think you did effectively there and they look at me like what do you mean I just said hello and I said my name and I said exactly right because first impressions are so important it's if we don't make a good first impression then we're spending a lot of our encounter within with another person trying to recover that so you stuck
59:22
out your hand you made eye contact and you said what your name was that is great
59:27
and so um those kinds of reinforcing comments for Learners who think they were in remediation um can really support that sense not just ego boost like I'm I'm being authentic about the fact that that was an important thing that they did and then the third thing is if the Insight continues as I'm working with a learner if the Insight continues not to progress um is a metal level conversation
59:59
so perspective taking conversation so I've been working you with you for a while and um and I'm seeing that these things are working for you and I'm seeing that these things aren't working for you and I'm not getting a sense that you're seeing that tell me why tell me why you think that is so it's a metal level conversation about not not what you're doing but what you see us doing
1:00:25
um and that can also that can sometimes break open uh break the ice a little bit sometimes the perspective taking it's also a professionalism uh competency being able to take that perspective so
1:00:42
any questions from the audience or in the chat let's see don't be shy feel free if you're joining us by Zoom to unmute and um and pose your question or put it in the chat box um I have another question for you oh yay it's a challenge oh good I'm up for it
1:01:06
kind of an important component of any of the competency Realms um and kind of fostering a partner who struggles um how let me flip it around how do I know that I'm doing it right ah yeah such a great question like uh am I am I okay am I okay that figure I showed from the nursing literature that middle level as the mentor is that my problem or the student's problem am I doing a good enough job
1:01:48
um and this is where I think having um the community around you is super important because uh if if you're a lone wolf and trying to do remediation you don't you have no idea but if you're in a community of people I can't tell you how many times that I've struggled that I'm entering a remediation process with a learner who's struggling and before I have a conversation with that learner I'm finding I'm trying to find people who know that learner from
1:02:20
another context I'm like what's your you know just data Gathering what's your what's your what's your idea about that you know what where the learner is struggling I want to make certain I'm helping this person as best as I possibly can and then once I start working with a learner I and I'm wondering am I doing is okay is going back to those same people you know this is what I've done I'm not sure if I'm not sure if this is landed from your knowledge of this learner um what
1:02:44
do you think and even if that person doesn't know the learner just having your counsel of
1:02:51
um Educators to be able to say ah you know I I'm just really struggling with this I I would love to hear your perspective of what what I'm going through right now um I I think that you're mentoring process um is really really important it would be even better if there were a formalized remediation system where you'd be able to go to anybody like a list of people like I don't know I don't know what to do I don't know quite how to do these
1:03:20
but there's a list of people who are supported to do this work ideally like let me let me call that person let me email that person to have a to have a um a happy natural conversation
1:03:35
it sounds a lot easier when I say it in actual in actual fact there's there's a lot of emotion that goes into this um and and and so having people around you who can support you and the work um is crucial I think uh the hardest thing to think or at least or I'll speak for myself as a educator and I'm sure everyone has had you know struggles in knowing how best to to help but I I think your your point is very well taken and and that we shouldn't have it just on
1:04:12
our own shoulders we ourselves need help too A lot of the time exactly get away from the low wolf and let's let's form the community and it takes more time and also ultimately more fulfilling the the more that I do remediation in a community the more I learn the better I get
1:04:32
any final questions
1:04:36
thanks so much I see Dr Lynn evaluations so she's a kind of at the core of our yeah hi I have a
1:04:49
yeah yeah that's great happy to thank you so much for staying 10 minutes over thank you everyone
1:05:04
my pleasure great all right it's a very reminiscent of
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