Psychological Safety in the Learning Environment from Both UME and GME perspectives

I have not seen a room like this uh filled with real humans in a super long time but this is a a testament to I think how you feel about today's presenters standing um today we're talking about psychological safety and our presenters are outstanding conveyors of the psychologically safe environment um today we have doctors uh Chad Mott um Dr Demotte is a associate professor of internal medicine he is also clerkship director for internal medicine and Associate program director for The Residency program um so he has lots of experience making environments cycle logically see we also have Dr Aubry Knight who is full professor at the um School of Medicine in both internal medicine and Family Medicine he is also the senior as you might imagine yeah join me actually put hands together and welcoming me thanks Sherry and uh Chad and I are so I'm excited to be talking about this topic but more importantly doing it in a room where there are people that are sitting here that can engage with us that's thick and fake heads and give us give us weird looks and help us to know whether we're on target or not and uh and we do want to make this a dialogue um uh with the audience and while we obviously have some slides and and want to project them and want to introduce a couple of topics Concepts to you um we do want this to be a dialogue and and we'll commit to saving some time if not in the midst of certainly by the end so that we can talk through some of these things you know I think you're we we all recognize and are experiencing that the learning environment is is changing the the the ways in which we interact with students can sometimes cause us um to pause and wonder you know is is the way that I've taught um I mean I've I've been I've been teaching for a lot of years and is the way that I've been teaching through the years no longer applicable to students today um and and I would suggest to you that it that it is but but I think that we do have to be wise and and and recognize um uh the uh the importance of the learning environment both for us as Educators but also for our Learners um and so what we like to do today is to is to frame that conversation around the concept of psychological safety so we titled this psychological safety in the learning environment from both you and me and gme perspective maybe not what you think um and and our objectives are to number one Define what we mean by psychological safety um helping understand a little bit about what the learning environment advocacy committee is there's a lot of discussion I'm sure you all if you've not heard it heard about that committee you from someone else you've uh you've wondered what is it and why am I so afraid of it um right um and then um to kind of wrap it up by talking about how how can we make the learning environment more psychologically safe and how can we do it in a way that that provides for learning for for our Learners um so psychological safety was coined in the in the um the end of the the last century by Harvard Business School Professor Amy Edmondson um and and and she defined it as a belief that we can share our thoughts feelings ideas questions concerns or mistakes even without fear of punishment or humiliation it was a business concept obviously it was around the the the teams that exist in the business World um and that team climate was characterized by interpersonal trust and mutual respect and and and uh and it was that climate of mutual respect and interpersonal trust that allows um for both the in in the case of the business world the employer and the employee but in the case of the of the learning environment and specifically the clinical learning environment the teacher and the learner to um to feel safe and move forward um um so it it and if it's done well it enables the team members teachers and Learners to take risks to be creative and to learn from each other so what we're going to do is let Dr Edmondson Define for you a little bit about what he means by psychological safety one of the most important factors in delivering safe and effective care is psychological safety to Define that as a belief that the workplace is safe for speaking of with ideas questions concerns and even mistakes and it's a sense of that your voice is valued you can think of this as a sense of permission for Candor that the workplace is somewhere where we count on your voice being heard because you never know when you will have had the observation that someone else missed that will be Mission critical to delivering safe high quality Care that psychological safety is not about being nice it's not about holding back on something you think might be unpleasant in fact quite the opposite it's about Candor it's also of course not freedom from conflict when you're in a psychologically safe workplace there will be conflict people will have different points of view and we'll get into it and we'll seek to understand each other's views better and come out with a better solution psychological safety and a psychologically safe workplace doesn't mean that all of your ideas will be applauded and it's certainly not permission to slack off it's not a license to whine it's not over sharing we still want people to be thoughtful and considerate in Sharing work relevant content and you important to mention psychological safety isn't the goal psychological safety is a means to the goal and that goal is Excellence that goal is commitment to high quality Care so it's important to recognize that for really high quality care you need you need not just psychological safety you also need urgency and commitment to Excellence if you don't have either psychological safety or a commitment to Excellence then you are working what I call the apathy Zone where your heart isn't in it you don't much like your colleagues and you're just not giving the work what you could give it and certainly if all you had was psychological safety and no commitment to Excellence then you'd be in what we call the comfort zone where it's a quite a relaxed State of Affairs I know that that's not characterizing care delivery today however this is worries when your commitment to Excellence and your sense of urgency are high but psychological safety is low I call that the interpersonal anxiety Zone where your commitment to Excellence is thwarted by not feeling that your voice is welcome so finally if you have both psychological safety and a commitment to Excellence that's the Learning Zone that's the high performance Zone that's where problems get solved day in and day out especially in healthcare delivery all right so thank you for coming um you guys got the handout this was copied with permission um from somebody that if you like infographics it's a lot of information but it's from it's based on Amy edmondson's book so if you want to get a summary of her book that she wrote specifically about psychological safety some um someone did this for her and and I contacted them got permission to print it out so it's got like all of these aspects on that so we want to I want to get this all the way across this it's not just being a nice person everybody's kind everybody's sweet but we never disagree that's not psychological safety and psychological safety is everybody's kind everybody's nice but we don't care about Excellence we don't care about making good decisions that's not what we're talking about as well we're talking about framing it in a way that everybody has a voice and that we can and everybody can get their voice out and I don't care where the voice comes from if it's a good idea it's a good idea I was reminded of this I'm going a little bit off topic but you'll get used to this song so I was reminded of this I saw a trailer for a movie and it was the back I don't know it looked like in the 70s I didn't pay attention too much but they were said in like the 70s or 80s and um the custodial guy of Frito-Lay had a good idea for a chip uh flavor and he ended up like calling one of the high level Executives and uh he's giving this and he goes well who are you and he's like well I'm the janitor or something like that and I was I remember telling my wife I said that's exactly what this is about I don't care where it comes from if it's a good idea it's a good idea it's a bad idea if a bad idea comes from the pending I don't care how good they are or renowned they are it's a bad idea it's a good idea and it comes from whoever we should be willing to embrace that and that's all about psychological safety so um some things to start off with betting the stage so these are the three factors that this include and you heard that in her speech setting the stage purpose and expectations you stigmatize failure and risk you want to set right up front I want you to get it out there I don't want you to be afraid of offering suggestions I I don't want you to be afraid of saying things some of the best things I've ever heard on a war team were by students that I've been so far away from the physiology and pathophysiology that they said something and I'm like huh and then you look it up and say well that's actually that's pretty brilliant you know but if you just discount them because of their junior nature you're going to miss that or if you create an environment where they can't feel free to speak up they're not going to speak up and you're going to miss good care and Excellence for the patient so setting the stage inviting participation all voices are credible and the team is open to change I'll talk about this on my personal stories later on kind of what I do to invite this but inviting participation getting letting everybody know on the team that we want to hear from you when we don't hear from you we're all at a loss and you're saying that out loud so they can hear it and then responding productively Express appreciation and layout next steps so this is not always yet you have to agree like this is a good idea they might be wrong it might be wrong but you can tell them it's wrong and here's the next steps or here's what we want to do or here's what we want to go this is not a meeting my pet peeve with meetings people that know me know I'm not a big Mickey guy because they tend to Dr sweet's laughing because they tend to like go on and on and on there's never next steps and what what are we doing here so that's you say well that's psychologically safe that's not psychologically safe not for the person like me that I don't want to be there if we don't know what the next step is like tell me what the next step is tell me what the actionable item is and then I can get behind that so this is all so if you get like it's not what you think it's not just about being kind it's not just disagreeing it's disagreeing but being free to disagree and how we disagree and how we express those things so this is one of Dr Knight's slides so trust and psychological safety trust and psychological safety they're similar but they're a little bit different so will you give others the benefit of the doubt when you uh when you take a risk will you give them the benefit of the doubt you can I would say you can have a psychologically say you don't have to necessarily trust somebody to make sure to hear their opinion like I might not be at a point where I'm trusting them but boy I want to hear their opinion because even if I don't trust them even if I don't like them I want to hear their opinion I want to hear all opinions and psychological safety has to do more with Will others give me the benefit of the doubt when you take a risk so when I take a risk when I step out and say something well I get swatted and then guess what I'm never going to say anything again and you probably can all think of a time when you were in a meeting or a department meeting or an occupation or a private hopefully a previous employer previous employment where it's like you had a boss that was just what the boss wanted to do and you know what happens you just stop talking because you're just sick of getting swatted down and that was not that's not psychologically safe and setting the stages would allows that that to happen when you do feel that others can trust you when you when you step out there and this is another of those those Graphics that I found as I was um looking at learning about this a little bit more you know there's you know if you think about it at one level it's like I want to be comfortable and I want to be safe right right I want to own everything I want to be up in this quad here but in reality you want to be down in this quadrant maybe not down here you want to be you want to be in this quadrant but a little bit just with a little bit of discomfort there and we want our students and to be to be over there those are the meetings that they don't go anywhere right like you want to press people but you want to do it in a safe kind way so right yeah exactly okay so really simple I call this the transcendentals of education so if you study philosophy you know about truth goodness and beauty and I like and if this sounds familiar like if we go back expectations questions and feedback now you go back to what we said about expectations questions feedback and it ties in psychological safety is all about um how we do that right so I can ask questions until I can keep asking a student or resident questions until they're like they're in the corner like rolled up rocking back and forth because I'm just I'm or I can do in a way that hey that's the wrong answer but here's where we went wrong here's where we're going to get you right right you can do it in a kind way expectations for the team and then feedback not just you're doing fine doing fine is like the worst thing you can tell somebody because it doesn't tell them anything it doesn't get them to the next step so psychologically safe environment would be like I'm going to tell you how you can get to the next step it might be some things that you just don't want to hear but that's okay within the trust in a psychologically safe environment you can get to those next steps so remember expectations questions and feedback the same for psychological safety but there's more of a how component to it and and the witch had to describe that of of when he tells the student or the learner that you know I'm gonna I'm gonna tell you something you may not want to hear that before they tell them something that they didn't want to hear is is again setting the stage and that's a key component to this okay so not so psychological safety what it's not and you heard this in the video it's not an end of itself because then you get in the nowhere land so this is everyone is happy but the companies are going into the ground that's not good right we want to you know you gotta press people a little bit they got a job to do they got expectations and and it's in its expectation if you don't do your job then the the company or the organism or whatever that is that you're looking at it is hurting and that's the bad thing so we want everybody to be part of the process and when they're not a part of the process that's bad so it's not just hey it's an end of itself it's an end of the reason why Google and big companies do this type of behavior is because they want to produce a product that's really good right they want to have an end product or they want to make money and doing and selling their product and it's the same with Healthcare we want to provide excellent health care and excellent education and psychological safety is one of those ways that we can kind of Ensure that's going to happen it's not simply about Wellness or niceness you know that's why I said it's not simply it's not what you maybe think what it is this is not just like everybody's Well everybody's kind we're giving out cookies because this might be in some meetings and really if you've seen this if you've seen a a meeting where everybody trusts each other but yet there's discourse and argument um this happens this happens with me and the program director uh quite often like we'll have a internal medicine so we'll disagree quite a bit but we do it in a way that it's like total respect for each other and we go with an understanding of what the other person is trying to understand and when you see it done well it's a thing of beauty okay so you can disagree on things and still be respectful and validate their opinions and look at it and try to hear it from their side so it's not as simply about wellness it's not avoiding conflict it's quite the opposite when you move you got to have there's conflict and there's things there's friction there's people are gonna have different opinions on how things should be done and that's okay and that's what you want because you don't want everybody if everybody if on my team if everybody is saying the same thing I get a little bit nervous that I'm making the mistake that I'm not seeing all of the possibilities and it's not a word diarrhea or over sharing so this happens in meetings too you got when when you come to the table have something to say but just don't talk just talk because that goes nowhere that's not a that's not a commitment to Excellence as well so it's inviting all opinions but it's understanding that if somebody's dominating a conversation then other people are not getting their opinion out there as well so so when you talk about the clinical learning environment as as we talk about psychological safety within what we are doing in in teaching students and teaching residents and and involving people in the clinical learning environment I would suggest you there are three primary stakeholders and that there are stages or or ways in which we um we should be or can be safe and the three stakeholders um not just the teacher and the learner but also the patient we are we are with the patient as we are in the midst of this clinical learning environment um and um we need we need to um feel included and include others um we we all should be collaborating in this teacher and Learners alike and we all should be we as teachers should be empowered to challenge and students should be empowered to challenge as as they're learning so um uh so in a psychologically safe environment the learner should feel safe to discover to learn right should feel safe in asking questions should feel safe and saying I don't know um and and getting to the end of that that that barrage of questions that Dr Demotte is asking until you get to the point where I don't know and feels safe in in getting to that point um and not cower in the corner to feel safe and experimenting um experimenting with the ways in which they present their their patient presentations experimenting in the ways in which they are interacting with the patient they should feel safe in that and and then safe in learning from their mistakes and not being not being um made to feel less than um because of a mistake that they've made similarly as teachers we need to feel safe to ask questions we we should not feel uncomfortable because we're afraid the student is going to report us to the learning environment advocacy committee if we ask them a question um um we should feel safe in sharing our experiences um in in sharing our successes and our failures around the kinds of things that we're seeing we should feel safe to challenge the Learners I and as as uh Chad so um rightly explained we should be setting not just feel safe we should be setting expectations and providing constructive feedback but the the Third on the player or stakeholder in that clinical learning environment is the patient um and we as teachers and as Learners we need to recognize in the midst of this complex thing that we do in in bedside teaching um that the patient that we're teaching is vulnerable they may have a health literacy that's different from ours um so as we teach recognize and and if we're teaching a learner but wanting to convey something to the patient to recognize that they're they're there may be some health literacy issues that need to come up um recognize the background and potential misconceptions preconceptions or misconceptions of the patient um and the our need to clarify and ask for questions for understanding um for those patients and to allow the patients to clarify and and also ask questions I think it's important too I'll just comment that the um it's okay to say I'm frustrated and then explain why you're frustrated so when a patient's frustrated it's okay just invite their frustration like tell me why you're frustrated or as the teacher if something's not going you know going right or there's haphazards or there's like system problems it's okay to say the learner I'm frustrated because I feel like this could be better it's not that you're making a barrage against the institution or failing against the way things are but you're saying I'm frustrated because I think this can be better now how are we going to make it better so I think opening that up and allowing when the patients are safe they can be frustrated and you don't take it personally they're frustrated they're sick they're in a vulnerable position yeah and also as pertains to the patient we we as as as uh the teachers or the Educators sometimes are going to need to I'll ask other people and when we sense that frustration or sense that we need to have a conversation with this patient without um the rest of the audience there um to to have permission to say um would the rest of the team go outside I I need to I need to have a conversation with this patient and not feel like we are you know not allowing them to be a part of something that's happening yes they we are not allowing them to be a part of something that's happening but it's something that that we are first and foremost um uh positions caring for patients yeah as we enter this complex world of the clinical learning environment we need to convey we we need to feel um that that we're valued but we need to convey that every member of the team is valued um and and not and and we do that by valuing them and treating them fairly by allowing open contributions um and by allowing them to sense that their opinions matter um and sometimes their opinions are wrong but their opinions matter um and and and and there are ways to do that um uh and and I I added this little line here that it's a moral imperative that we do that um in the midst of this clinical learning environment um convey to our Learners that we are collaborators here we're we're trying to take care of these sick patients um and and your input is important to me engage and interact with them have mutual respect and access to them maintain this open dialogue and Foster constructive divide debate which um leads to openness and Trust I saw this done really well can I you're okay with my comment and I told him I was going to interrupt them a lot so the collaborator safety I saw Dr Gonzalo I saw him run a meeting the other day with the clerkship directors in one of the clerkship directors this particular picture director harps on one one idea quite a bit and I happen to agree with her um but she brought it up against USA you know what I'm going to say right and then uh Dr Gonzalo said he goes it's okay you're safe just say what you're gonna say and it was really a beautiful thing to behold and then everybody that's an example of a meeting where everybody's like challenging each other and throwing things out and disagreeing a little bit but he said it's okay you're safe and that was a beautiful thing to see here and then as as we've mentioned in a couple of different ways um giving permission to challenge um to express ideas to challenge the status quo to identify problems um and the result of that is creativity and innovation okay so what is the learning environment that does the committee what is this feared committee called liak um uh and I I we we wanted to add this in here because this is this is kind of what we're hearing is that there's there's there's uh a discussion around okay I you know what is this committee and and and why am I so why should why am I told to be so afraid of them um so first of all the the uh the lcme requires medical schools have a means through which uh students can report concerns in an anonymous fashion so the students have to have the ability in an lcme accredited medical school to anonymously um Express concerns concerns about the learning environment or anything else about the about the medical school um uh and and then students are then asked um in in the double AMC surveys whether or not they have this ability do they know how to take advantage of this ability and um what kinds of mistreatment have they have they recognized so so and the reason the reason this became an lcma emphasis 10 years or so ago was because of the disconnect between what the what the graduate questionnaire said where where graduates of medical schools we're reporting all kinds of misbehavior and medical schools were saying we do everything perfectly there there is no misbehavior there's no um uh or no learning environment even before there was the concept of learning environment um uh uh problems going on at our school so this this this disconnect resulted in the lcme saying okay students need to have a safe way in which to report these things so so and and these are the two I'm not going to read these these are the two lcme standards which deal with um the requirement that the medical school has to um provide for these uh these ways in which students can uh can report and um uh uh and mechanism through which the school responds to these reports so that's what the leak is the leak is the committee that the medical school has appointed as the committee that responds to student complaints about the learning environment it is a it is a multi-disciplinary committee it meets monthly all reports to the to the actor de-identified so um the committee does not know who reported it and most of the time no one knows who reported it because the students must have the ability to to report anonymously some do sign their names to it but most of the reports are Anonymous and the um the the uh those who are being reported about are Anonymous the committee does not know either the reporter or the uh the alleged um violator of of the learning environment the committee hears the report and determines whether or not this is in fact a learning environment issue a professionalism issue or just a student right that that neither neither is results it neither leads to a report of an unprofessionalism or a learning environment um concept and and the committee I will as a and there are several people who either are on or have served on this committee here today I hopefully they will agree with me when I say the committee really does take these things seriously um spends a fair amount of time on on each complaint um uh sometimes more time than I mean I'm not a meeting person either and and some of these meetings um uh go go quite lengthy um uh as we as we deal with these but I think it's it's appropriate because we really want to provide the students the ability but we also want to make sure we're doing the right thing by by The Faculty um they want to make sure they're doing the right thing by the by the faculty and then and then determining how best to proceed based on the um uh the degree of um egregiousness I guess of the of the complaint questions on that so how do faculty and students learn about the learning environment and how are they educated on what this is and how do students um I guess this this slide says how do students know how to report and what to report so they again an lcme requirement is that every year we must have a face-to-face session with each class so every year each class each class gets the sport times is a a learning environment session um where they are explaining what the learning environment is and provided some examples that are um some of them have occurred here um some of them are reports that were reported here that were determined not to be learning environment learning environment uh missteps and uh and and some of them are not from here but are are just a list illustrative of a very um uh good examples of of the kind of thing that we would maybe want them to make us aware of um uh these are discussed as a group um we we kind of do this developmentally we don't talk about clerkship learning environment to the first year students it's it's more about the learning environment in the context of the of the pre-clinical curriculum and then and then the third year orientation which actually is happening in in the next week or two um uh for the upcoming third years is uh it really does focus on the bedside hospital clinical learning environment to a greater degree um at this point we have not introduced the concept or or they have not introduced the concept of psychological safety into those um but we probably will do that and and probably spin these um in in a similar way to what Dr Demotte and I are doing uh today faculty learn about the learning environment at new faculty orientation um and then within your department you have routine um reminders of them um and and I do know that on occasion there there have been twice in the history of the school um where the GQ really did um um make us a little concerned about the the learning environment where there there again was a mismatch between what graduating students reported and what we had heard um while they were here so we really wanted to kind of get to the bottom of that so we we actually asked the Departments to just to discuss those in the context of of their department meetings so I I put a couple of slides in here that I think are just important kind of maybe conversation starters or reminders um and this one I titled words matter um uh and and and and these next two are really some some thoughts that I have or or suggestions that I would make to you to try and and make the learning environment a true learning environment and not this not this come by on moment of everybody loves everybody else where we're up in that up in that corner where where no nothing gets done and no learning is occurring um but but words matter so know the names of those on your team and and ask how to pronounce them and and don't be embarrassed about um names that that when you look at it you're not 100 sure how to pronounce it if you're not 100 sure how to pronounce it um ask how how you would pronounce that um and then refer to them by that name um once you have that once you once you feel comfortable that you're you're ready for that for let me interject here too For Better or For Worse like I try to I try to do this and sometimes uh the residents or students they'll have it's not their name but they'll have like a nickname and they're okay with calling a nickname what I try to do is but yeah but yeah but what's your name and then I actually try to lose learn their name and sometimes it's difficult like I'll work with them for a week or 10 days and I darn if I don't try for 10 days and sometimes it takes me 10 days and by the end of the 10 days I'll have their name and you can see them smile a little bit because you just hung out there and you cared enough to try to learn their name if you can't get that that's why sometimes they'll have a surrogate name that they'll use and that's okay they've given you permission to use that but make an effort because it'll be rewarding and it nothing's better than just calling somebody by their given name I think we've all been in situations where you can you've said something and you look at the people that you've said it around and and and either their response is not what you would have expected based on what you said or um there is this this you know wide-eyed look um and if you if you have a situation like that let me just encourage you to to call it out and say what did I just say um that made you have that look um uh don't don't you know or if you realize you just said something that deserved a look whether whether whether it got a look or not um maybe back down a little bit and and say you know what I might have been misunderstood when I what with what I just said and um and and try to clarify that um and if there truly was a miscommunication be willing at that point in time to acknowledge and apologize for that miscommunication what about humor um uh this is a this is a Hot Topic and and one that that I think we we all kind of dance around and maybe walk on eggshells around um humor can be a coping mechanism it is for me I know um uh uh um and humor can be made can be used to make connections with our patients um uh and with our Learners and um uh I I there have been circumstances where I have used humor in a patient that I know so I've got I've got some Learners that are with me that don't that haven't been with me very long don't know me very well my patient knows me better than they do um and I use humor with my patient um uh and and I've been I've been called out by a student on this one time um at least I can remember one time um and and when we left the room the student said I can't believe you said that to the patient and and my answer was I've known that patient for 20 years um I know that patient's kids um uh and and you know that that I I don't think the patient was offended by it should have asked maybe but um uh you know that that that thing that I said was uh was intended was intentional it was I was not making fun I was not I was not using humor inappropriately that was intentional in a way to to in in this case to try and and and and uh uh soft and soften a uh a conversation that we were having and and therefore it can be perceived as insensitive and and this student perceived it as insensitive on my part that that I was being and absolutely inappropriate and insensitive I had some bad news to give but but did it in a way that I brought up you know something that was a little more humorous um uh if you use humor let your team know and be willing to accept the feedback that they might get give you that they perceived it a little bit differently um uh and and when you use humor um don't use it aiming at specific people I just told you a story I was aiming humor at a patient but but be very careful about aiming that humor at a specific person but rather at the human annoyances that occur we talked a lot about Chad and I when we were talking about this talked a lot about humor and the the ways that we can that it can be beneficial in the ways they can be um harmful and hurtful we actually had a teach session a couple years ago on vero's humor and and the uh the uh care with which we we ought to be using that so as we as we kind of wrap this up and kind of talk about about psychological safety in the different settings the the there in the pre-clinical setting um I think we're going right back to the to the second or third slide on here that that we can create that environment of safety in the pre-clinical setting whether it's a pbl facilitator a health HSS facilitator um or a lecturer or a uh an Oscar by setting Expectations by inviting participation like being willing and and giving um permission to challenge and then by providing and accepting ourselves any feedback that that might be sent our way okay so now I'm getting a little bit vulnerable I interested you only gave one example from your life and it was a good thing so one of these that he told me to give and I'm putting myself out there so don't get don't get mad at me for for this but I'll tell you what I did so um a couple things I do this is a good thing and the other thing was a vulnerable thing where I um said something I shouldn't have said and then kind of how I dealt with it okay and then you'd be thinking about how you want to rail against this or give on other scenarios because then we'll have time for lots of discussion which we hope that there is we can talk about Lee act all questions about the liac you can send to him so flattening the hierarchy this is what I do first thing uh with any team when I sat with the with the team I say I have a cardinal rule and my cardinal rule is that everybody is allowed to ask questions everybody is allowed to Give opinions don't think just because I say it that it's right I want you to challenge me and in fact I tell them I open up I said effective if you challenge me and when you challenge me and I'm wrong and you can prove it I have a high level of respect for you and that will definitely go on an evaluation you need to be respectful about it I will be respectful to you when you say something incorrect I will say I think he meant this let's investigate that but we're all we're just flattening that out so they're not thinking oh he's just a seasoned attending he's always right because then that's how I make mistakes and my biggest pet peeve is I tell the teams is that if I've gone three days and I said something that was nonsensical on the chart and and then I realized it was nonsensical and then I look at the resident or whoever is around and I say did you guys not read this he goes oh yeah we thought you meant this but we we didn't know and we didn't say anything I get really upset because I tell them up front that doesn't need to it's like a patient's care you got to be willing to say something so right off the bat first thing first rule cardinal rule we're flattening the hierarchy you're allowed to say things you're allowed to come up with opinions and you might be you might be wrong nine times out of ten that's okay the one time might save somebody's life so I I like I have it come and then the the embarrassing uh thing when done well uh not done well but repaired um so shutting down helpful voices this goes we talk about like students and residents and fellows but the nursing staff as well I had a moment a couple months ago it wasn't my finest moment where we just went off Geographic routing so we're rounding all throughout the hospital and we're in units where the nurses and staff don't know each other don't know us as well and I had a patient scenario where the patient probably was heading toward hospice and palliative and we we were already all over that we were talking the patient documenting communication I'm talking to the family and the next day the nurse you know well-meaning nurse um she came up and she said and I'm and I'm rounding and we're talking about this and she starts um talking to me she goes well I I think they're confused I I think he should consult palliative care here and what palliative care does and she explains what palliative care is to me well she doesn't know me you know and so what I said I'm not proud of but I'll say I'll say I I understand the definition of palliative care and that's what I said now that's harsh right and the nurse you should shut down a conversation and then I recognized when I said it so I took care of the patient and I went immediately back to the nurse and said hey I hope you forgive me that was wrong with what I did we were frustrated because we were dealing with this back and forth and this is what I did and then I went to the charge nurse and I said the same thing I shouldn't have said this this came out wrong this is my internal frustration came out of my speech and I hope you can forgive me and they were so gracious no it was like we get along fundedly there's no problem try being a doctor that uh says that you are wrong to a nurse that nurse will be your best friend for as long as you're here and they will back you up and they will help you you know why because it's kind of rare and it shouldn't be rare okay so that's psychological safety goes with nursing staff and everybody else as well and then just just so you know if we didn't hit this hard enough some of these things what this does address is the hitting curriculum there's a curriculum where it's like well this is you know what's the hidden curriculum in medicine this is an attending this is an expert I don't want to challenge the expert no challenge the expert that's okay that's how we move things along well in science and medicine team functioning team Wellness just culture so just culture has to do with looking at systems and saying what's the process problem not that we're going to smash the person that did the thing well what's the process problem this is where when this is not done well like in the aeronautical industry when they fly a plane into a mountain because the co-pilot this has actually been done co-pilot there was not the culture where the co-pilot could talk back to the pilot and so that is just no good for a lot of reasons so just culture means that if I'm reporting that this went wrong will I be the one that's like slapped or will we look at the system in the process and this happens quite frequently in medicine and then diversity Equity inclusion if you're if you're in a if you're in a minority situation you're under a lot of thread so you have a lot of threat to do I express my opinion and just inviting that to come forth psychological safety deals with all of this as well so you see a lot of these things that hits thank you all so much what a wonderful learning environment would be if we were all really super skilled um if you want and your local assistant or you want to talk more about it because you have a super wonderful service that we offer through teach it's our observation and consultation service Chad is actually on the subcommittee and so you want to talk about it you want to talk to some of these Concepts through call us up fill out a form online do we will have conversations about how to um apply it to your situation or we'll come and observe you practicing um enough psychological safe feedback uh uh for doing so so enjoy the rest of your day come on ready together.