Call Me By My Name: Seven Habits To Create a Positive Learning Environment

To introduce my friend Molly dr. Terry Turner and today education paramount speaker Terry and I go way back looking on several projects together 1920 that I've learned a lot from her and I hope that you will too dr. Turner is a professor of pediatrics and Asia College of Medicine where she serves as the Martin I Warren endowed chair and medical education vice chair for education associate director of function education in founding director of the center for research innovation and scholarship and medical education for the department detective dr. Turner completed her undergraduate degree at Oklahoma State University for medical degree at the University of Oklahoma College of Medicine she did her categorical pediatric residency at Baylor College of Medicine as well as their fellowship and oh geez the doctor Turner is not pleased an advocate itself as well it continues dr. Turner also earned her and PHP difficulty effects of health design design Houston and her master's ready that concern is passionate about translating the art and science of Education into the engineering department at her for dr. Turner is a disturbance of a helping other succeed in their roles as teachers and educational strategies to the teachers within the trenches and has won numerous awards for teaching skills curriculum and program development she was the inaugural recipient from the recipients of the academic pediatric Association and make parent teaching faculty award and most recently kids she was the recipient of the 2018 American Academy of Pediatrics dr. Turner is a constant [Music] [Music] on this journey thank you for inviting me here it's a passion of mine you talk about medical education but most importantly to talk about the things that we can do to enhance the learning of our trainees because that's why we're all here so I'd like it to get us started by doing a little bit of a think pair share I want you to turn to your neighbor and think about the things that a teacher did that created a positive learning environment for you so what are some of the things that a teacher that you really admire could be anywhere along with a longer career but the thing that an enhanced ruler somehow let you get started that right back there was a lot of discussion that was in the room what were some of the things that that were really helpful that created that positive and learning environment for you all [Music] I just wanted to be in reserve I wanted that that's what that was what I was searching for that it was oh there's nobody who's really passionate I want to be passionate you so that passion energy other thoughts the punches so against you and the learning process and when we think about this is you're going to talk about seven habits to create this personal learning environment I'm gonna imagine you've hit many of these habits where this talk really originated was is we had a residences teacher session for some new medical students joining Baylor College of Medicine and they were going to be interns teaching students and we have residents that led the session and they were giving teaching tips to the students of the interns about ways that would really help the students learn and they one of the residents said you really need to know your students name and what happened at that moment for me was transformational because people started clapping catcalling and literally we have standing ovations and to me that was so pivotal in my understanding of this topic what's important to our learners so the next thing that I did was we had our intern retreat coming up in a couple of months so I engaged these reminding learners last year these are my entrances are their names and I said what would be I want you to write a postcard to the faculty about one thing they can do to enhance your learning environment over the coming year and this talk is informed by these two experiences that I had and also talking with other educational leaders to find out and looking into the literature about what makes a positive learning environment you're gonna see a lot of these quotes these come from my learners a professor knowing your name makes you feel as if you're a part of the process rather than just being swallowed by them and so with the show of hands how many of you all teach in the clinical Center any type of learner teach in the clinical session seven how many of you all teach in more of a classroom setting have a little better up boat and these techniques that we're going to talk about are beneficial to either so we're going to talk about what are those things to create a positive learning environment this is not an extensive review of the medical education literature but it's science and actionable items that you have handouts and there's several different things that's listed under each of the seven habits of things that one might do to create a positive learning environment I encourage you to either take notes to make notes beside those because at the end I'm going to ask you to identify one behavior that you would like to do in the next week or in the next month to create that positive learning environment the other thing is I like to use literature from other fields so if you're thinking this is all for medical education I'm most informed through K through 12 this is literature psychological literature and the sociology field and that's really about the integration of how we can learn from from others the very first is how important our name is and think about it sometimes you turn when you perjured your name calling it wasn't even the person wasn't trying to find you but our names are so powerful they oftentimes have familial or or cultural meaning to us and it's where we have to start our name is part of who we are and that's why we start with this particular topic when you think about the power of names the research talks about how it affects attitudes and of course it changes where a learner is more likely to seek help if you know their name and it really affects their perceptions not only about you as a teacher but also about the course one of my training said when I felt that a personal connection when I felt I had a personal connection with my faculty preceptors it makes me want to do better it's almost as if on extra accountable another is if they hear to not to remember my name in such a large class showed me that they cared about my experience in the class and education I've been told that from from individuals I'm just not good at at memorizing names and I tell people it's a skill it's something that takes practice I keep note parts I have I think 65 new learners each year and I make little flashcards that i review on an airplane usually in May with their pictures their names and also something about them that's unique or that I'm going to remember I want to talk about because when we think about what are the hierarchy it means this is not unique to medical education this is unique to us as individuals this is that hierarchy and we have to start with the physiological and then the safety before we can work up to the belonging and seen some of the higher level needs that one has and think about it if you're in a room trying to learn and the room is too hot or too cold you can't focus on the learning so you have to step up each of these levels if you do not feel safe in the learning environment you're not likely to learn so we had a conference on the learning environment to identify what were the components what were the main components and these were the six that came up and up these six we're going to talk about the latter three we're going to talk about the educational psychological and the social culture tell you that all of these influence inclusivity and asset a part of that so if you think about it there is a magical day out there where a student becomes a professional for physicians there's this magical day that one day they were a medical student and poof the next day they magically become a doctor and despite the fact that they have doctor before the they are still growing in their professional identity from that role and it's how do we help them become that professional I reflected on the fact that when I interview medical students for a position at our training program I will sometimes for many times say I hope that you choose our training program as your educational home and I reflected on why would I use the word pong because that's that's a little unusual item I just say training program and when I looked at the definition of what home is it's more than four walls and a roof foam should be a place of safety and security a place of belonging and nurturance where individuality self-esteem and confidence grow pong is the place where trainees evolve into their best selves and that's what we're really trying to create that place where they can evolve into their their best selves so how do we do that well the first thing we need to do is assess where we are using that quality improvement model taking a baseline snapshot these are some surveys you don't have to do surveys you might just ask doing the focus group among the different people that make up your learning environment there are ones around team learning and psychological safety that those came out of the business field but it's really important because our learning environment if you're practicing in the clinical environment affects patient outcomes softly shipped into this what are some things that we can actually as faculty and I literally took from Franklin Covey how many of you all have even read about I've heard about the seven Habits of Highly Effective People it's a classic out there so I've taken liberal to create seven Habits to create a positive learning environment so they may not align one for one but they really emphasize those things that I can do and I also purposefully use the word habits because habits are subconscious or unconscious behaviors that we do repeat it and this is something that we want to do in our learning environment it shouldn't be a one-time intervention this should be habits culture that we create in our learning environment now these are the seven habits what I've also done is tried to give icons so that when we talk about each of these habits I'll put that icon it just kind of gives you a visual reminder of what we're talking about but when you look at it we have develop a growth mindset putting the e back in medical education building rapport the puck the sudden learners up for success being a super model valuing the learner at the center of what we do and then promoting a sense of that so we're going to start a growth mindset I like to strike with this one and to me this is is where it all begins a mindset is a way of thinking and the one person I can influence and their way of thinking is myself so I have to start by telling a story so in the 1960s Rosenthal at all did a study and they did this with grade school children so this is not a medical education study it's one done with grade school children they administered a test to these grade school children to identify which ones would intellectually bloom over the coming year and then what they did is they gave the children that were intellectually bloom based on their their test scores to this group of teachers and they said not the students here they gave another group of students that we're going to do well but maybe they're rated Barney wasn't going to be a seamless intellectual one person I told that the teachers you've got these children and then they looked after one year at the outcomes between these two groups and that's why those that were supposed to intellectually blue blossom their rate of learning is so hot and the ones that that were going to do normal did not now you're probably thinking why my phone story that's what we expected the twist in this the set there is no test to tell whether or not someone can intellectually bloom you'll stab Akane it was a normal IQ test and these researchers randomly chose children and those children and put them into different groups those that were designated and intellectually with blue were no different than the ones in the other classroom what was that the teachers expectations so this is called the chimera Pygmalion effect if you've ever seen my fair lady this is talked about in my fair lady but it's how our beliefs as teachers influence our expectations of our learners will ultimately influence our behavior which influences the results that we get from our learners which reinforces our beliefs of still and something I do a lot of work around remediation and I do a talk on setting up to thing because I do think sometimes we set our learners up to fail when they're in our mediation because we already know that but this is one on what our attitudes what are behaviors that we as teachers can do so they examine what did those teachers do in those schools that was different than in the classes where they have the normal children and what they found is that these teachers were nicer to the children they taught more material expected more they also praised more often gave them more questions to answer let them talk more and then gave them more feedback both praise as well as feedback to get them to the right answers and these are called silent messages that I as a teacher and doing subconsciously because I believe I have the intellectual bloomers so this has informed a lot of the work around mindset how many of you all have heard of growth mindset raise your hands this is very popular in both the K through 12 higher education as well as the sociology and the psychological Luger and it comes around when we start with the mindset quiz regarding intelligence what percent out of a hundred is effort and what percent is ability so turn to your neighbor and just talk about what percent is effort and what do you perceive in disability [Music] yes okay what were some of the percentages that you guys threw out for effort just throw out a number 80 20 other thoughts well what they found is winning when Carol Dweck interviewed hundreds of thousands of individuals across all spectrums she came up with two groups of people now this is a dichotomy that's really not a dichotomy were all kind of on a spectrum but those who were called growth mindsets believed that 65% of intelligence at least was related to effort in other words these are not fixed abilities these are things that we can grow with effort it's the power of yet so I was told by Thomas I was a mid-career faculty riding some research papers and my mentor came up to me one day and he said do you have a learning disability [Music] that's what I thought and I said no I don't have a learning disability I just haven't been riding a lot yet I'm gonna get better I need you to teach me luckily this was my former program director I loved him to pieces and I said you need I need help with my grandma but that's that whole process it's not that I was a bad rider I just wasn't there yet and that's the power of yet because this is what distinguishes a growth versus space it's how we view the world when you think about it is the world in my control tip if I can work harder and work differently then that means I I can grow and get better how do I look at failures I have failed so many times I even ran for a position at a national office and I lost not one but twice and I went on the third time took a lot to get up to do it the third time when people were saying do you think you can really win we've lost two other times in a row so well what's the worst that's going to happen the other is our goals and how we look at goals am i as a student out there to show you what I can do to achieve that great or am I out there to improve my communication skills so that I can be better with patience that's a this one is a mastery goal for me to do better versus a performance students of performance focus I want to look good and not stupid and that goes along with that fixed mindset why is this important now I had a a subspecialty fellow this is someone who's been through medical school successfully residency successfully and was now in their second year of a three-year fellowship and they were getting ready to get rid of them I'm thinking it's a subspecialty we don't have very many up if I would we want to do that she's been successful for the other two years and they said we worked with her we worked with her and she's just not competent enough so what's something she does well I said she's seen her patients love her she is wonderful at communication that was my thought like why do we want to get rid of someone who's wonderful with communication she needed someone to help guide her and how to present how to interact actually I feel like I didn't do anything other than believe in her she was a great communicator we started there her patients left her and this concept they said well she doesn't read enough I asked for because I read all the time okay let's tell them let's make sure they know that you read so when you present a patient and when you get to your management plan and you say I want to use ex-drug say I'd like to use extra because in my reading last night in Pediatrics Smith talked about this having the best outcomes that and I put her in a different environment with different teachers to build her up and give her a different experience she did well she graduated then we've got another sub specialist so this is something I start with growth mindset I spend a lot of time on this it's one thing I have in my power it's what I believe about my learner's if I believe that they can succeed what are those behaviors that I can do to help set them up for success teaching about growth mindset is something very simple that we can do we've started doing that at our institution because it's been found that when you take college students particularly underrepresented minorities and those who are in a social economic disadvantage States whether it's classes etc just learning about growth mindset improves their outcomes it's also crazy for effort not prison for their innate ability but praising for the effort that they put forward and discussing your own journey and sharing those stories of failure I certainly didn't start as a wonderful pediatrician I've been fired by faculty that live patients I still have a lot of growth and when my learner's hear that that I'm not there yet that I keep working on it that helps let them know that it's okay then the next habit is is putting the e back in in medical education and I think this probably is more pertinent to the clinical learning environment when you're talking about Graduate Medical Education in nursing education where they're in a clinical learning environment and their apprentices because one of their jobs is to take care of patients and one of the things I realized is is that I don't have a clue what my learner's are going through mainly because when I trained it's been a few years ago I'd like to say it's just yesterday but it wasn't and so I don't know that patients are taken care of I may not understand the systems that they're going through so I've started going on routes and asking a lot of questions tell me about this in class me having to write notes making sure they get done in the time that the residents are allotted and I'm a skilled physician and if I can't do it then are we expecting too much but this has been very helpful to inform me and think about it flexing them back in the early nineteen hundred's did this to understand what was like to go back to medical school and this informed a lot of the work that we do I hear a lot from my learner's that I'm just a scribe because I don't be alive and attributing to the education of their their patients they don't feel like they're contributing from the outcomes I feel like all they do set orders and write them down when we think about it you need to help find meaning and one of those is why we got into health care most of us was to be at that patient's bedside and when you look we only spend about 60% of our time at the bedside we spend a large report proportion of the time in an administrative tasks and how can we help our learners get them back to being at the bedside so we decided that we would interview focus groups voluntary research with our Trinities and we used mass Lacs and lighters burnout in the work environment as our framework because we thought this was a really good one it's been a study that we these are the six things that contribute to burnout in the clinical learning environment we understood work overload that one that didn't knew what that meant but we didn't know some of these others and lack of control was one that we really wanted to get a better idea so this is what we heard economy gives you a sense of purpose that you are making decisions and growing as a clinician there's going to be so many things outside your control but if you are allowed to have control safely within your realm of what is expected and safe for the patient so that you can grow I think that's important it was that lack of control over what I was doing and over the decisions about patient care that I realized in retrospect really made it unpleasant for me not just that I wasn't able to make any decisions but that no one was even interested in hearing about the decisions that I might make me another story that came from this is a story where those uh one of our first-year trainees doctors was taking care of a patient that went into respiratory distress at our hospital we have a team and comes in when a child is Cody we have whole team that comes in they came into the room they push the learner out and I said we need you to wait outside she's sitting outside she's standing outside of the broom daddy if she hears the mother say where's my doctor the team says we're right here we're here to take care of you that's why we're here she doesn't know where is Maya that was her intern the intern walked back in the room and said I'm right here and I'll be by your side but she said I stayed the whole night that's my patient I didn't mind that I was wrecking duty hours because that's what I'm here for is to take care of patients so I want you to turn to your neighbor and just talk about what are other ways that we can help create the why and help our learners find meaning in the work that they do so turn to your neighbor and discuss for the next member [Music] what are some of the foods that you all came up to provide to help me close connection for me you want to work [Music] had a lot of buzz there was ideas coming out of there what my colleague is shy but she needs you just got put on the spot or you could gently tell us what that great idea was to the variety so that she was alright the idea you may have a way of doing something in your learner with some experience maybe something will different as long as that's not a bad thing it's kind of good we have to we learn best through personal experience you've heard how this topic thing about I don't know that I would have come up with this if I hadn't experienced those that those two events it's also revisiting the why you may want to have your learner's we visit their personal statements why do they come in to this or writing a letter to their self and five to ten years it's also challenging these old models of training so what are things that we could do better despite the fact that this is the way we've always done it I'm sorry but we are now in 20 almost 2020 and if people from the eighteen seventeen fifteen hundred's from padua the very first medical school walked into our training I don't know how much difference they would see there our patients have changed training environments has change isn't it time to make that so the next habit really goes right into that because if we start with what we believe we go to to the next about how the we can find meaning putting the evac in education to building rapport and team relationships getting to know each other we are learning and we make mistakes we are always ten times more frustrated and embarrassed for our faults than you are so when you think about it we also when you see this learner on the Left how many of you would want to work with it so we need assumptions we make assumptions about about this learner and what we should be doing is saying are you okay we all had those days in the clinical learning environment or in the classroom where something's just not going well and that has nothing to do with this but it impacts how we care for our patients and creating that safe learning environment when I care about the learner first as an individual I'm creating that psychological safety think about it our learners feel like they're under a microscope under constant scrutiny it would be like if we as as teachers throughout our day every hour of our work had someone observing us grading us evaluating us that's what that feel so how can we create that environment that is safer one of the things is looking at our hierarchies and we've talked about that implicit biases oftentimes we have an affinity bias meaning we like people who are like us I said up there was a program director that was one that gets on my nerves and I had not sought to look out for what are those commonalities between us and when he's when I was going to Vienna and he said oh I lived there for 11 years we sat and talked for an hour my whole opinion of him it's chained and nothing happened other than I found out he went to Vienna and lived there for 11 years so finding out what we have in common also having those interventions of belonging because all of our learners most of our learners feel like they're imposters and dump them on I have the strongest resident by having my training she told me the other day she goes I just don't feel like that belong I'm not good enough and I'm like oh my goodness for her for you to feel that way and how can we share these experiences so that they know this feeling is common and it's okay and it's going to get better over time it's also letting people know you on an on a more personal level so this is me in my younger years when I was teaching my segments as if he had a potty train and I said maybe that's where my love of teaching and my love of being a developmental behavioral pediatrician came about so these are all things that we can do promoting that psychological safety and building relationships first relationships are the most important thing getting to know your trainees so now we're going to talk about setting learners up for success so what I want you to do you've got enough card in front of you I want you to draw a vehicle on that color nut cart so everybody takes a minute to draw a vehicle so quickly draw that vehicle any card the you've got another about 10 seconds without regard to vehicle Braun all right now how to do is everybody stand up it's good to certainly stand up all right if you threw a car I want you to sit that bicycle or you were trying to drop by signal sit down sit down a truck sit down a balloon sit down anything other than a rocket sit down [Music] all right I want everybody to live around this is the one person that got the exercise correct somehow did you all doesn't feel very good I didn't set you up for success no he was not plentiful is that expectations at the beginning instead of waiting for us to do something wrong before saying how you want it done so think about it go in and see that patient so we don't say how how long how to write it up what we expect them to examine it cetera so these are ways that we can prime the learner it's priming the top meaning getting them ready and setting them up for success please remember I want to be doing the right thing the right way all of us as humans have three basic needs we want to be competent and whatever we do we want to be connected that's the relationship or the relatedness and lastly we want to feel like we have some control over the course of our lives so people don't do things poorly badly to get on our nerves they just don't know how or what's expected and the other thing is that's when we do observe them in the learning environment we do point out the things that they do wrong we're not bad doing that work that we're very good at pointing out when people do things poorly but we need to be better at pointing out when they do things well we should be giving praise four times to one for every time we correct them when I'm on rotations and I'm just getting to know a learner remember I'm trying to build relationships so I'm going to identify the things they're doing well again so that they trust me to know that I'm here to support them when things go wrong it's also about teaching them that it's successes not straight line and you're gonna have setbacks you're not going to know answers and that's okay you're not going to do procedures well the first time that you do it it's going to take you multiple times and that's oh okay and sometimes it's going to get harder before it gets easier and this brings up we had a learner that came to our program and unbeknownst to us she did poorly in medical school we were we were told that after she came to our program I was matched with us that she actually had several issues including professionalism issues well she's now my meeting she's my training she's in my home I want to make her the best that can be so we adjusted her training environment we gave her a mentor that would support her really tightly to make sure that she excelled and I'd liked and I'll tell you she became one of our chief residents and in the end that's the power of what we can do it's setting those learners up to success and what everyone's going to get things at the same rate it's giving a lot of positive reinforcement before we work on the corrective feedback and making sure that the learners have time to improve it they're going to tell them something they need time to get better the next habit goes into what also what we can do as teachers because all eyes are on us we are the the super role models because a lot of a lot of learning occurs through role modeling and we have in clinic one of my senior residents she was getting ready to graduate had a patient encounter and yelled at my at our social worker and I ended up taking over the patient picks the things we're not going well in that encounter and I knew I needed to give that training feedback and I could have gone in and said you don't yell at the social worker somehow I had an epiphany somewhere between in that clinic setting because I was really mad and at between the time I talked with him and I approached him and said I just want to tell you that I'm sorry for taking over the case you're a senior resident you're getting ready to graduate I shouldn't have just swooped in and taken over the case that he does know I need to tell you I'm sorry for yelling at the social then that engendered a conversation about what would you do if I wasn't here what would be your next step and he automatically went and had a conversation with the social worker but if I just told him don't yell he knew that it's not something that he didn't know but in this way I am modeled the way of saying it's okay we all make mistakes this is the safe environment that say we make mistakes the studies have shown that our treaties in the clinical environment learn more from the observations than they do from actual didactics and teaching they also learn when attended when they don't see things so I was really surprised at one point in time when we were talking about a patient patient clinic and and I was saying yeah I had to read on this last night bla bla bla the the learner turned me and sent me read it not yes I I read a lot because I don't know everything but they'd never seen that so I would role model looking things up they go we don't even know how how do you know where to go at cetera it's also that the learners pick things up and we really want to be conscious about the role modeling that we do this also includes those negative behaviors how we interact with staff that can be our cleaning crews that can be our nurses that can be our other faculty that can be our trainees if the culture is one of incivility then that's what if you're going to continue to breed and I'll tell you most of our cultures don't have verbal abuse and bad what I consider really big in misbehaviors it's smaller things it's things like ignoring the trainees it is things like interrupting someone when they're giving their presentation it is body language to where they don't feel like they're wanted so we really need to be very intentional I also role model in my patients room Oh cuz these are patients I know well and I'll say you know we just I've been your doctor for a long time what are things that I do well and the want me to continue to do every time I see what's one thing you want me to do differently the next time I see this is that a wouldn't that be a behavior we'd love to have from Oliver from all of us I still learn because each patient's different so sometimes I think I'm doing a really good job and they go that just didn't work for me back there all right we need to value learner centric miss soap on the start by telling a story so there was two boys and there was a little dog and boy one boy said to the other I put my dog had a missile and the little boy said touch doctor missile leaves down and listen [Music] doesn't hear the dog whistling so he says hey what's the deal I thought you said you taught your dog how to whistle the boy said I said I'd talk him out of this I didn't say feel honored so again this is all about privacy and power it our learners because it's all about them it's not about me it is about how they learn best and people when we look at look at this they're not going to change their behaviors unless there's a reason to do so so it is empowering them in their own learning it's also empowering them in feedback I oftentimes will say and I'll even save myself you know I gave them feedback why didn't they just get better I practice general pediatrics do you know how many patients I see with who are overweight that I just go in and say you know you're overweight you just need to lose weight and the parent of the child goes change and the next visit they came in and they were normal weight it's the same way with our learners just because we tell them if it does you know these are long-standing habits now I oftentimes here professionalism issues are the hardest to remediate they just take a little longer doesn't mean they can't be remediated that just take a little longer this is a wonderful model for feedback it's called R 2 C 2 and think about what we've talked about rapport building exploring reactions if you do have to give I mean when I ask the family and tell them that their child is above the 95th percentile for weight they have a reaction to that sometimes my mother's will say but this is the one thing I can give my child so we have to explore those reactions before we can even get to but content or coaching for change same way with our learners when they get that negative feedback so lemons express their management plans even if it's not what you would do we've talked about that as the best practice of creating a positive role plus a learning environment encouraging reflection and I'm going to hit the sighs because I do this a lot and I didn't realize how non positive it was talking it wasn't so much I talked about the good old days or what we did and when I was a trainee but my younger trainees do not like the word millennial they do not like well you're just a generation Z and this is how you learn it's that we are people too we are individuals we are not defined by a generation so I'm trying to make sure that I focus on the individual not the generations all right now I'm going to have you stand up again this is our last habit so everybody stand up [Music] that love blowing all right so for everyone standing in you have received words of affirmation or other signs of where you felt valued for the work you do in your environment your clinical environment [Music] are you receiving it this past week by the words of affirmation or something that made you feel valued in the last week sit down last month all right I'm going to have everyone sit down valuable something that we can all do better this provide affirmation for some portion to make them feel valued to be understood to be affirmed to be validated and to be appreciated his next AFER's physical survival the greatest need of human beings we all need it in some form of fashion how many of you all have heard of the five languages of love the books well this is modeled after that's the same people they wrote the five languages of appreciation in the work flow workplace and they look at gifts of appreciation self acts of service quality time this is celebration that's why you're seeing hand clapping although it's also Lissa's physical touch - celebration and then words of affirmation so when you look at the words of affirmation about half of us this is our primary language of the feeling valued is words of affirmation it needs to be authentic it can't just be something that you say it really has to have meaning and be specific can talk about their traits such as optimism as well and praise for their accomplishments one of my attendings on th gym actually did this very well where she had one day of the week where at the end of Browns she randomly made us go around the circle and tell each other something that we appreciated that another team member did that week this isn't just for physicians this is for the team as we take care of patients as a team I can't do it just by myself it can also be quality time that focused attention you see the words from one of my learners please take even two minutes out of your day to know more than just my name it's also acts of service are there things that we can do for each other specifically I think about I've been working with the same group of physicians for a long time and we are very eager when we see someone not doing well why don't you go home let me cover the rest of these patients can we do that for our trainees as well Ivan I tell my trainees I can write prescriptions I can put notes in the chart I can write orders don't feel like you have to do it all on your own now tangible gifts and physical touch are less than 6% and less than 1% respectively of a primary language but they're not what you think this is from one of my learners it's not even big things it's more tangible like food when people bring us food it's like oh I realized that you are working hard and I appreciate you whenever we get a hard diagnosis in clinical one my trainees snails it that's why I was the new nails that diagnosis we've been high fives now to celebrate and that's little things that we can do to show that value so larger team members primary appreciation language show appreciation to one co-worker a week also don't solely use words of affirmation because our blind spot is our least favorite language so mine happens to be quality time which is my least favorite language but it happens to be my favorite language of a couple of co-workers as well as my husband so I have to work harder to express that in both my work and at home all right now then in the last minute you've got your hand down and it's time for action so I want you to look at that handout and at least one of the neighbors that you're gonna within the practice in your learning environment over the next week for the next month some alleged look at those you can talk to your neighbor it's a circle one is that Matt will be Oh yeah [Music] okay the other organization and I want to highlight with statement on here extraordinary results come from taking ordinary steps every day in the right direction these are all things that we can do to create a positive learning environment so I'm curious what's something that you're going to do over the next week Vermont what what is something that you are going to take away try for this like the idea of asking the team that you're working with to express their appreciation for one another members somewhat regular other thoughts compliment or you could have asked somewhere r1x or whatever that think about it I really appreciated the words that patient fire but yet you were able to go into the [Music] those are things not too many people talk about and those are things that we've been praised now I have taken the liberty because you all had great conversations to decrease the time for question and answers I'll be glad to stay afterwards but to me this is such an important topic and we learn as a whole and as a group these were the seven habits of things you've got the handout of things that we can do as educators take a walk encourage a movement I'd love to have appreciation in the workplace so that team that's going to share that appreciation on a regular basis I bet we're going to see transformation there and also I want to encourage us to leverage the trainees voice there why we're here I wouldn't be a teacher if I had no trainees so leverage their voice and ask them how we can do it better so thank you guys for coming and spending your noon hour with us.