Difficult Conversations with Learners

All right so as we know today's speakers really don't need any introduction but i'm going to do a little tiny introduction so uh for for dean lehrman and dr tracy price as the dean of virginia tech hurricane school of medicine for the past three years dr lee lerman learman serves as the chief academic and administrative officer with the responsibility for development planning and execution of new programs related to the undergraduate medical education and is professor in the department of ob gyn dean lehrman is incredibly responsive to concerns and needs of faculty and students and fosters a close relationship between and among clinical and basic science faculty management and clinical staff now dr tracy chris has been practicing psychiatry in her hometown of roanoke virginia at curling clinic for 25 years she started very very young and has significant interest in the treatment of severe major depression and the prevention of suicide she's an associate professor of the department of psychiatry and during her time at curling clinic she even gets engaged in teaching residents medical students and pa students is an associate dean for clinical science years three and four at the virginian school of medicine she also is a strong faculty thing too because i noticed he got elected he's on the affairs center admissions committee if everybody could just make sure that you're on mute that would be wonderful thank you throughout their busy professional roles throughout the years one thing that today's speakers have learned is how to have difficult conversations with both learners and many others it is our hope that we will all be better equipped to do so at the end of today's discussion before we get started our dean and dr chris have asked that you click on the view icon in the upper right hand corner of your screen your zoom screen in the first select full screen and then go back to view and select speaker view if you're online which should allow you to see both the presenters as well as their slides we'll be sharing with case and case instructions in the chat for download and we'll also paste the text in the chat so it'd be very important for you to participate in the case to get the full benefit of the session please mute yourself until you need to or wish to contribute to the discussion as always feedback is important and you will paste a link in the to the evaluation in the chat and there's a qr code for those of you who are in the room so i think that's enough for me take it away thank you dr wicker and thank you all for joining us today both here and by zoom do we have a zoom count yet 50 60. okay awesome thank those of you for being here in person today we appreciate this opportunity for the two of us to share our approach to difficult conversations with learners including medical students residence fellows and even faculty who wish to grow in to learn so these are sort of common approaches you can use across those different groups the only disclosure we have we have no financial disclosures the only disclosure we have is that we have well over 60 years of experience to draw upon since the first time we ever had have a difficult conversation with a medical student or a resident we add up all the years of experience here in the room and over resume i'm sure it adds up to hundreds and hundreds of years and we're all here to kind of help each other and figure out how what kind of system can we follow to help help us think that we're doing the best we can in these situations so we hope this session will help you identify the situations that elicit difficult conversations describe the optimal approach for a difficult conversation the when where and how recognize and respond to the learner's immediate reaction emotionally and then assess the learner's understanding of the key messages that we're trying to transmit as we prepare for this session we came across a very recent publication from a team at stanford that describes an interprofessional course they developed for health professions health professionals 15 years ago using a series of case studies that facilitated role play dr chris is going to tell you more about it so yes as dean nirman said 25 years ago actually at the stanford university graduate school business they put together this course so that those in in the business area could learn how to talk to boards how to give financial information that might not be good uh how to talk to their colleagues so it went well and then 15 years ago as he said uh the medical school got involved in this and so they put together a course and really with the essential goal of learning to have a difficult conversation when we don't have those conversations there's something called the mum effect because we really are avoiding those types of situations because they're difficult so when we started to look at this paper and his dean lerman and i talked about this we realized that these principles could really apply to multiple types of situations whether you're a section chief you're talking to a medical student you're talking to a colleague you're talking to your child your adult child or or whomever so the principles that we'll talk about really apply to lots of different situations and so on this slide here you can see some of the vignettes that they use some of which are medical some of which are not medical and actually now at stanford there are uh this course is offered to students from any graduate school there it's not limited to just a business school and medical school so there's different scenarios like end of life care or maybe even a death or a misdiagnosis or someone not not doing well in a phd program they actually use 12 total cases in that situation of teaching and you really want to when you have these conversations offer offer hope to people you don't want to inflict more pain than what someone is is actually going through so with our next slide we're gonna we're gonna look at some of those guiding principles and then we'll come back to this later on in the talk so as you think about a conversation you really want to to assure confidentiality not report it to other people once you leave the room be non-judgmental that's a way to get off to a big argument if you walk in and you're judgmental that that's that's going to not go well during the conversation do not mislead emphasize what you know you don't want to bring things in that are rumors or but emphasize what you know show empathy and the next one is a little confusing it says do not mistake venus with compassion and that really means be direct just be direct in what you need to say don't beat around the bush be direct keep your language succinct and simple offer hope and comfort be calm and calm mean it's a difficult conversation so be calm and calming be an active listener there's that l word it's amazing how often that comes up when we're talking about communication be an active listener policies are your friend that'll give someone a chance to reflect and allow them to think before maybe they speak again so pauses are your friends and remember it's how you say things it's not always exactly what you say how you say it so as we start to get into the nuts and bolts of how to organize these conversations well and keeping those principles in mind how many of you already have a script in your mind for different types of conversations you may have a patient or a learner that's sort of a checklist of things that you follow in given circumstances how many of you have something so yeah i see hands up i see kind of kind of sort of but there this is one of those times where you have to kind of kind of engage that part of your memory into okay what's my script going to be for this kind of conversation unfortunately as dr chris uh reviewed the these kind of difficult conversations are not uncommon across multiple different types of other people learners patients etc so this is one of those scripts that if you develop it you'll be able to to put its use a lot of the time there are three stages of the conversation this is offered as a way to organize thinking a lot of people are fluid as they go through these stages but they're summarized here they're meant to serve as a general framework to consider particularly when planning and beginning and conducting the conversation and one of the themes we'll come back to is that you know careful preparation that before stage practice and then reflection on performance will help make these stages become more automatic over time so it's less of a burden to implement it once you've had some practice with it so before the conversations it's important to set aside time and prepare a lot of what we're going to do today is to think through how would we prepare for such a conversation identify clear goals and create an outline of logical talking what's one of the takeaways what are the key messages and to make sure that you use that outline to create sort of a script of what you're going to say anticipate possible questions and emotional reactions so is it hard to anticipate that there might be disbelief doubt and anger not really those are pretty ubiquitous to these situations no matter what the topic may be we are likely to either hear if we're listening carefully enough or for the other person to perceive a sense of disbelief doubt and anger so i have to be ready for those three emotions because they're so common we do need to practice what we say because it's different to kind of make an outline of talking points and then to figure out how are you actually going to put those into words um practicing what you're saying can allow you to develop your own voice and how you approach these these um difficult conversations how you can be calm and calming how can you how you can avoid unnecessary prefacing language and things and get right to the point but to do it with compassion so practicing that is different than putting that on a list of bullet points and it suggested that we're suggesting that you practice so the conversation should occur of course in a private quiet room or other setting that prevents distractions prevents people from overhearing what you're saying it's better to sit beside each other or at an angle together rather than instead of at a desk the desk creates a power hierarchy it increases anxiety so it's better to be someone who's like pulling up a tray next to you in the cafeteria but it's a private cafeteria with just the two of you chatting about what you have to talk about um as i said minimize the preamble and polite chit chat i think the setting of having a meetings already suggest that something serious needs to be talked about so get to the point that lead-in stage gives a lot of anxiety as the learner is waiting to hear what it is that you're going to be talking about follow the logical approach that you outline be disciplined and how you do that to make sure those key points are transmitted and along the way be sure to detect and address any information asymmetry oh that's not what really happened oh so now's the time to listen to what really happened from the perspective of the learner because of course you're transmitting either what you saw or what you heard and it's important to acknowledge that there may be information asymmetry it takes some time to listen to that other perspective that the learner is bringing that will help you have maybe a fuller picture of what has happened so then while conducting the conversation be sure to check in and pause frequently these pauses allow for integration of what you're saying by the learner and an opportunity for them to ask clarifying questions and to really understand what's going on at the end the conversation summarize the key points key messages you shared and also as we do with patients sometimes summarize what the learner's response was that history of illness let me let me see if i got this right this is what you said was your perspective on what happened did i get that right the same skill we might use for patients we would use in this situation to help the learner understand that they've been heard as much as we want them to understand what we're telling them in our key points you're going to outline the next steps and offer a follow-up meeting and then afterwards and here's the essential part is is to really take a few minutes to just reflect yourself on what went well and what could have been improved what's the things that you were happy with according to the pace of the conversation and what was said replay the conversation in your mind make it make some mental notes so that's sort of our kind of our overview is taking it through these three stages and now that we've been through the principles and the stages it's time to practice applying these insights to a specific case so dr chris is going to tee up the case and the breakout session next i should stop there for this i'm sorry dr chris so any questions surprises around either the principles or these three stages or the elements that we've talked about things seem to make sense so far they're saying it seemed odd or different or new another question it's it's very nice to have a a script but i think it's very easy for one or the other one of the two people or people derail sounds like a very strong negative term but all of a sudden the the reason you're there is far away from and so any uh uh other than yeah you need to bring it back is there any strategies on getting it back to the um top of the hand yeah that's a great question i think we each share our advice my i look for principles that are universal across different communication settings and in this one it would be the same things we might use with a patient and the first thing would be to make sure that we've heard them by summarizing what we've heard okay the second thing would be to say that we do have an agenda today there's a lot of important things that we could talk about at a subsequent meeting but for today we really need to focus on these elements now with the patient you set that gem together this is a little different it's not a shared agenda necessarily but it nevertheless it is important to transmit the talking points that you have in mind and not to allow the conversation to go too far astray so how you balance that listening and reflecting back and saying i hear you this was what you experienced i i just and i just want to make sure i understand that did i get that right then pivoting right back to your talking points this is the best way that i found to manage those challenges yeah i think you uh that was a great question uh which was basically how do you keep a conversation on on topic and you you want to be careful to to steer the conversation back to the issue at hand because you run the risk of sending mixed messages to someone if you get off target maybe they brought up something they do well or something you get off target you do run the risk of mixed messages and if you get into mixed messages then you're you're not going to have an effective conversation for the reason that you got there thank you for asking that question yes sir on the three stages that you listed i suspect they conduct the interview uh includes things like how to close it because the end of the conversation i think is really it's almost like a separate stage and critical to what's the carryover and what's the effect so you're mentioning that in the three stages one thing that isn't called out explicitly is closing the conversation and how important that is i completely agree i think it's important to to review the key points that were on your outline that you've been scripted uh review what you've heard from the learner identify next steps and the process which will vary according to what you're talking about and arrange some form of follow-up those would be the key components in that closure part of the conversation yeah very important to not just say oh i'm so glad i got a chance to meet today see you later it's not exactly going to work are there questions online um there's just one comment dr mizura said i think the latest advice is to avoid sandwiching methods oh the feedback sandwich are that what we're talking about yeah yeah that that's our whole whole evolving conversations around feedback and you know ongoing feedback to promote excellence is a whole different matter in terms of how we can be appreciative to allow people to understand where they can each so they can grow in their certain areas of excellence and some of the other things they need to work on and that i think although there are similarities this is probably i put this in a different part of your brain in terms of this kind of a conversation is it is different than the feedback one that we would normally have just on a regular basis to improve um performance you speak more to the reflect immediately recommendation reflect with the learner or on your own yeah reflect on your own yeah absolutely reflect on your other the if the learner is being coached or seeks advice they'll go they'll go through a reflection of their own hopefully with whoever's helping them but in your case it's to promote your own improvement and it's hard for the learner to really give you feedback on the process just now in the ideal world you get to get feedback from the learner on how to go for you but in these conversations that's usually not appropriate at that time at least one day you might reflect back on that so in this case it means reflect in your own mind this is what i intended to do did i accomplish my goal which things went well which things that i feel didn't quite get there so it's meant to be an internal reflection all right we have a case for you so we're gonna we're gonna walk through this case and then and then we'll get into some uh breakout groups so jim is an m3 medical student he's on the internal medicine courtship on his third rotation so he's you know he's not new he knows where the bathroom is at this point um also he's on on the routing team our are him another m3 a medicine intern medicine senior resident a pharmacist in the attending and so so jim started out pretty well things went pretty well for the first few weeks he gets into week three and then he started showing up late he wasn't pre-rounding not as prepared for rounds and and then he made a mistake one morning they were walking through the labs and he was presenting his patient and he gave laughs from three days ago he said the potassium was 2.7 and actually the potassium that day was 4.6 but he he was rushing and he looked back and he made an error luckily the resident had reviewed the chart and realized the report was inaccurate so then patient advocacy calls the school and and they report that there had been someone uh there and he said and i quote there was a student in here i think he was a medical student who came in to check on me he checked on me with questions about how i was doing and he told me he saw on my record that i lived out by the lake and he started telling me about some parties he'd been to out there seem a little odd to me so in a in a few minutes when we go into the breakout session we're going to look for several things think about what are your clear goals in this conversation how will you assess jim's emotional state how will you conduct the discussion what's the key message what's your tone what words are you going to use how are you going to go about this conversation how are you recognize and respond to jim's immediate reaction as dean nerman said there may be disbelief or anger denial whatever how are you going to react to that and and what are you going to say and and questions that he'll have and how will you assess his understanding of the message how are you going to summarize that that in your head to what he really said and because we're going into breakout rooms on zoom the teach team is going to be already has or we'll be sending you the case and the the assignment questions um so that you'll have them with you to go through during the case in the zoom breakout rooms and we have handouts here and we will put the things on the screen here as well for folks but um how are they going to receive that the folks in the room the zoom the zoom room sorry the they will receive it two different ways they're going to receive um a a a slide for download and you'll also receive we're going to copy this information right into the chat so we have it thank you for sending it great all right thank you for letting us know that it's there thank you so much so what we're going to do is give about a 15-minute time period for your discussions and this really is in a capsule the the planning and anticipation stage you know this this doing this carefully would allow you to then take the next step of implementing this with the learner but just going through this helps to kind of get through some of these most important issues together so we're going to go ahead and initiate the breakout rooms for the zoomers welcome back everyone um i'm just curious we had such a rich conversation here by we we created one breakout session here at eight people and if we had to come up with a team name and we didn't it would be like i would call it crazy the insight givers right that's the energy we had is really trying to help the student gain insight and that was a major agenda for us um i'm just curious um you know we have these five things and we didn't have very much time to as a way to give us some very quick feedback and i apologize if you could just put it to the chat how many of these five things did you have time to cover that'll give us some feedback for the next time we do something like this together with breakout sessions so um people are saying all five all five okay moving along moving on check the box moving on well congratulations for the all fivers they tend to be the first to respond to these requests by the council who say um so what we're going to go through now is going to go through the five and share some of the gleanings that we we received here in our discussion and then invite folks to either raise their hand or put something in the chat so we can hear what happened in the other breakout sessions so we we started out here with you know the first thing what what are your career goals and uh we heard that you you definitely want to identify the the three things and and you want to accomplish uh getting there and having them um express basically their interpretation of that and uh so so we we talked about that uh is there any um input either from folks here or in the chat about how you went about that let them know that they can either unmute themselves or put it in the chat in our group we actually talked about looking for an underlying cause knowing that the student was a decent enough student initially so we talked about the five d's um you know death divorce drugs depend you know things like that um what what's the change that made the previously good students um you know sort of suddenly decline we talked about um first of all preparing for the meeting so number one verifying that what was alleged really did happen and and sort of being prepared to um that this if it was indeed was indeed true how would you prepare to uh talk with the student and understand what was happening so that you may have had to talk to several different people around the student to understand what had been happening before having the meeting that's a that's a great point and we we talked about that as well here verify the facts because you may not actually have that student on your service you may have been handed this issue or someone's out of town but that's a great point verify uh verify what happened and then uh the other person in the chat brought up a great point this was written so that there could be consideration given to is there is there substance use or what exactly is going on because they started out well for two weeks and then things seem to take a downward turn so verify facts and try to get an understanding of how we got to to this point thank you uh on the second question of jim's emotional state uh i'm just gonna say that in our group it seemed that we were um trying to work in two different sort of universes or frameworks one was to diagnose treat and improve the underlying reason for this collection of behaviors that came to our attention and the other is to really see this interaction as one which is primarily behaviorally based so the behaviors are understood to be unacceptable and then expect that the student support services at the medical school or the student's mentor or someone outside of the context of this one-time interaction would be the ones to take a a look at patterns to take a look at underlying causes and so we found that there were a lot of people who were trying to really figure out what was going on with this student and that that in it if you have a limited time that could potentially take away from achieving your goal of them really understanding which behaviors were problematic and owning that so that they could then consult others regarding their overall well-being so that's a challenge i think in these brief interactions to decide how deeply do we go into emotional state versus uh to really be very behaviorist and making sure the student understands where we're at dr chris you have any advice for that balance finding that balance uh you know i'm curious actually if we have any input from our yes from us yes our group vote a friend okay folks out there and in the room how would you balance those two agendas dr lerman can you hear me yes hey this is don keys um i was just going to type this in but i think physicians often because we treat problems and assess problems we fall into this very easily and you gotta balance you clearly have a performance issue that may be caused another underlying problem and from an hr standpoint you got to focus on those performance issues you can't necessarily own those other ones but you have to address them and acknowledge them and then try to work with the student or the resident or the physician whatever for their resources but i've been advised over time i'm not there to diagnose their problems if they have because then you get into um [Music] disability issues at times and you gotta be careful around those so um but acknowledge that that's there and and try to get the resources so they need to be so it's a real it's a it's a balance you got to take care of both but i think docs tend to err on the side of treating the problem sometimes thanks dr keys and in fact in this case you know this as part of that closing conversation with the student on next steps one next step might be to check in with the associate dean for clinical phase two dr chris or to check in with the student affairs office let them know what happened and seek support from them to kind of debrief and reflect with them on what happened as well so that allows us to use more of a team approach to that follow-up into that other agenda of diagnosing and treating so that we can stay focused more on the behavior sure um i i know we want to move along here we have some more slides to go through but just another just to move on through how to conduct the discussion what we heard about here was you want to gain an understanding of the student and what they think is going on do they have any idea why you're there and then at some point as as uh dr mott said you you have to get to the point and you have to be direct as the guiding principle stated and get right to the point and and discuss what's what's going on so yeah i think it was helpful to talk about how abbreviated our interactions can be with students versus residents a resident said who knows you and knows that you're you're there for them all the time and will accept this feedback with the way that it's intended students may not know you as well so how do you help them understand that you're here for them you want to help them support them and that can be done either in words or in tone or in both it can be by starting out and saying i say this only to help you improve and we i know you and i and all of us want you to be the best medical student in the position you can be or with the tone compassionate calm calming supportive nurturing that can also send a supportive message that allows the student to hear what you're saying in terms of the things that went wrong and the other thing we we grappled with here in our room was um that for the first two things that we wanted to talk about the lateness and the potassium uh level those were relatively straightforward but finding the words to explain the third thing around over over sharing what happened at the lake that's where some practice and how are you going to say it what are you going to say how are you going to say it avoiding the p word professionalism that feels like a dagger in the heart for someone to hear that they're unprofessional but instead to figure out what are the behaviors there that cross the line in terms of the patient's expectations that seem more challenging yes we do have one question coming in online yeah i you know had a discussion with our group and i think one of the assumptions that we made is that this is poor performance and initially our group we also had that same assumption but this might be the best performance that's possible i mean it might have been that they got 20 admissions overnight and this is what happened so i think getting more information querying the resident you know querying and making sure we understand the picture and not just assuming that this is a poor performance issue um this might have been the best we could have expected yeah and that and you're absolutely right that goes goes back to our first point which was uh verify information receive um as i say uh sometimes in in private meetings and students don't like to hear this so i i typically won't say this to a student but there are two sides to every story so you really do want to verify the facts yeah it's so important to get that as much as you can get that 360 perspective so that the only thing that might be missing is the learner's perspective but otherwise you have a pretty strong pretty good understanding of what happens it's very important before jumping into into the stages of discussion um so would you like to think that yeah we we talked a little bit also about just responding to jim's reaction we'll just follow up about the lake issue and how do we do that because the student may say well what's wrong with that i went out to lake i was just telling him what what i did at the lake and and so what we came up with was uh you really uh it said that you don't necessarily have to say the profession's award but focus in on the patient your goal is to uh respond as a physician and talk like a physician when you're in the hospital and and that patient may not perceive the word perception came up in our group thank you dr collier brought that up patients may perceive things and we have to focus in on that and so if if the patient perceived that was unprofessional that's an important point for the student that perceptions matter thank you and then as we move to the final question how you assess jim's understanding of your message um here in the room we just sort of talked about well we would have just asked jim so what do you understand is the the kind of the key parts of our message today we were sharing with you another person mentioned it would be by by following up and seeing if their behavior had changed over time and scheduling a follow-up meeting with them to see how things were going and checking in with the clerkship directors see how things were going what are some other ideas for assessing jim's understanding that folks would like to share you may ask them to take two or three days to internalize the message um you never like to force people to put in writing but whether a response in an email that can be thought out so that there's some internalization rather than i don't remember being late i you know it um just giving those days so that he has time to digest the message especially if he was not really prepared to hear um very uncomfortable news let's assume and she said i need you to come to my office so i can give you some bad news so she was not prepared for that and so that message of 30-minute conversation may not be able to so it could take some time to reflect and integrate what the student heard in a way that really helps them to speak about their understanding in a deeper way than to parent back what they heard us say in words so giving them giving them some time to let that soak in and to formulate it on their own can be very helpful thank you for that suggestion yes sometimes i'll just ask them to give a one or two concrete steps going forward of what actions we can take and then that gives me a little bit of understanding of if they understand what the problem might be so that that it tests both their understanding of the problem as well as that's what they're planning to do about it did everyone here are the mics working in the room everybody hear that comment right all right all right so uh we're going to move on now i didn't actually hear that oh you did not actually hear that it was to actually um the student to identify a couple of things that they're thinking about doing differently in the future because that'll assess their understanding in terms of how they translate that understanding into action so that was the suggestion on how to assess gibbs understand any other suggestions in the chat um so i feel it would also be appropriate to talk to the student about going forward with this specific patient and then um said her solicit uh read back and action steps right there good great all great suggestions i'm glad that those of you on the zoom are able to see all of those because time is short we're going to just do a short wrap-up and we're going to send you all of our slides so you have them all but you know addressing poor performance workplace disagreements conflict resolution disturbing news these are such common challenges in healthcare and in educational settings and as our leadership responsibilities increase so do the frequency and intensity of these interactions so anyone who's is aspiring to to in some point their career to look for additional levels of responsibility this goes along with every single role that you will have either it's not a learner per se it'll be a similar conversation with someone else being able to jump in and have these conversations is much better than postponing them and allowing the problems to fester and get worse so we presented this three-stage framework which we feel can be helpful in sort of comparing our current approach and figuring out which other pieces might we weave into that to improve the consistency of how we come across in these interactions but with any with anything like this practices is really necessary one of the key things to practice is really finding our voice as we put words to the things we want to say in this slide we've highlighted in bold some of those principles we mentioned before that over the years the people who took this course at stanford thought were the most important for them and these resonate with us as well in our experience communication should be non-judgmental behaviorally based avoid misunderstanding information and really not just not spend too much time on vagueness out of the sense of compassion but to quickly move to specifics which is so much more helpful we should offer hope and comfort for this person who's receiving this bad news this uncomfortable news be calm and calming the active listeners plus frequently allow them to express what's on their minds and create space for the other person uh like with any other skill managing these difficult conversations will improve with ongoing practice no matter what our starting place is we can make it a little bit better uh we think that for many people this session may have put us in that awkward stage of not figuring out how do we integrate this into what we're already doing and what we would recommend here is is to is to find an opportunity after your next difficult conversation after you reflect on it a bit yourself to talk to a trusted colleague up here someone you would trust to give you feedback and when they hear your your report on how you did with that interaction where you identify something that you felt you did well and something to improve they should tell them they should tell you something they like they should ask you a question to take you to the next level of insight from something you haven't thought about they should give you suggestions it's a very simple way of giving feedback by someone who has very little time you spend a couple of minutes reflecting with them they give you a little bit of feedback if you do that over time with these difficult conversations then you can see your skills improving to the point of not only being automatic really integrated into your general approach the next time you open up that script in your head oh this falls into that difficult conversation category you're going to feel like you've done this enough to really feel comfortable that you've done your best can't always control the reaction or the outcome but that you've done your best so as we close i want to thank my partner dr tracy chris and our fantastic teach team for supporting these efforts both the technology and the rest of it uh for those of you in person and by zoom and to thank all of you for being so engaged here in the room and on zoom as well we hope this was helpful and we definitely look forward to your feedback thank you so much please uh we don't want the conversation to stop here um just please make sure to continue this conversation with colleagues how you hone your skills continue practice uh if you do have any further questions please send them to us or to dean their men dr chris and i'm sure they will be very happy to engage in a conversation with you a wonderful day.