Small connections matter
My Dad died last week in New Brunswick.
I write that not as an invitation to sympathy (but, thank you), but to share a few thoughts from the patient’s family perspective – not on death during a pandemic, although that intensified and complicated things, so much as death in general.
Dad had a stroke nearly four years ago and his memory wasn’t what it once was. I’ll leave parsing out what was effects of the stroke versus medication versus dementia to course case studies. When he fell two weeks ago and broke his hip, the cause of his cognitive difficulties didn’t matter so much as the fact that he was an old man who was scared who was in hospital with visitor restrictions. That is: no visitors at all, unless the patient had palliative status (and Dad didn’t until his last day). Dad didn’t really understand the pandemic, and sometimes forgot what was really going on with his care – doing such things as trying to pull out his IV and catheter, for example. He was scared and in pain and confused.
One bright part of these terrible days was the day his nurse was from Miramichi, his hometown. He was so delighted to talk with her and talk about the places of his boyhood with someone who knew where he was talking about. Who shared the same connection to the River, to the place, to home.
This reminded me of decades ago and my last visit with my maternal grandmother in a Moncton, NB hospital a week before she died. My grandmother was Acadian but lived most of her life in a predominately English community. Her children spoke English. Her grandchildren were truly assimilated with only classroom-based, mediocre French. One of my indelible memories from that last visit was that her conversations with the nurses were always in French. And she seemed so happy to be able to do that. That her first language mattered; that she mattered.
I don’t want to suggest that for meaningful connections healthcare professionals need to share hometowns and language with all of their patients. This is both unrealistic and absurd. These connections highlight just that: connections. Those two nurses, decades apart, connected with scared, dying patients by honoring their shared humanity. My father wasn’t a broken hip; my grandmother wasn’t a failed kidney.
When my mother-in-law was in palliative care in a Toronto hospital in 2010, one of the volunteers did music therapy with the patients. When I arrived for a visit one of the last afternoons, there was a Rachmaninov CD on the table with a Post-It note: “When she wakes up, play track 4 for Sylvia”. He hadn’t had one in his kit and she had spoken about it with him; she was sleeping when he came back with it. (We still have the CD, as he wanted us to keep it).
There isn’t always time in busy clinics and wards to make substantial connections with each and every patient – especially for students who are wrestling with mounds and mounds of material to learn, remember, apply. I’d argue that small connections are just as meaningful. Small moments matter – a shared favourite song, listening to reminiscing. Dignity and connections matter.
None of those things I mentioned were “medical care” for Dad, Nanny, or Sylvie, but it was medicine in the compassion, the care, and the connections. And it’s these connections which give comfort to those of us left behind.
If you want to read a bit about my Dad, check out this link: https://nble.lib.unb.ca/browse/n/michael-o-nowlan
Patients are key to our students’ learning
Students have been part of my health care journey long before I became an educational developer at Queen’s School of Medicine.
When my daughter was born in 1995 in Fredericton, NB, I had not one but two nursing students from the University of New Brunswick assigned to me. For each of them, I was their first ever patient. I was also their only assigned patient. As a first-time mom, this was both gratifying (they pretty much catered to my every need from running baths to making me snacks) and faintly terrifying (like when they, under their preceptor’s watchful eye, demonstrated to me how to give my newborn a sponge bath) and slightly uncomfortable (post-partum abdominal palpations aren’t fun at the best of times, let alone by a learner who isn’t quite sure what they’re looking for).
My mantra at the time was: “They have to learn somewhere – why not with me?”
And it’s true – there’s only so much to be learned in a classroom, a mock clinic, or simulation lab. Ultimately, our medical students consolidate all that learning during their two-year clerkship period where they engage with real patients, in real hospitals and real clinics, supervised by staff and resident physicians.
In my role as an educational developer, this is a part of their education that I don’t typically see first-hand. I’m generally classroom-based in the coaching I provide to faculty, and it’s hard to be an unobtrusive fly-on-the-wall observer of patient encounters when you aren’t a member of the healthcare team.
As a patient (and parent of a patient, and partner of a patient), however, I’ve had several opportunities to see our clinical clerks in action first hand.
I’ve watched a senior clerk valiantly (and ultimately successfully) conduct a physical exam on my pleasant-but-non-cooperative then-nine-year-old son.
I saw another clerk—working on a rotation with anesthesia—get a reluctant laugh out of my grumpy (from fasting) and nervous (because, well, surgery) husband during the pre-op airway examination and checklist.
Most recently, one of our clerks independently led off an appointment I had at my family physician’s office. I’ve hit a milestone birthday (full disclosure: 50) that can trigger a number of screening tests and things. The clerk was well-prepared, asked me good questions, and had good information. It was clear to me that they had at least scanned my file before coming into the room and had done their homework on the types of screening tests that might be relevant to me.
Along the way, I’ve also seen some of the various ways the clinical clerkship preceptors supervise and monitor our students’ learning.
For the clerk who examined my son: after a consultation outside the exam room, the clerk and physician came in together for the rest of the appointment. There was a Q&A amongst all of us which included gentle coaching and good feedback for the clerk.
Prior to my husband’s surgery, after the clerk’s exam, the anesthesiologist followed up with their own exam and pointed out a couple of things to the clerk – who then had another look down my husband’s throat which they and the physician then discussed.
For my encounter, I know my clinic has video monitoring (as there are signs posted in the examination rooms) and the clerk themselves noted they were going out to consult with the physician.
These are all different ways that clinic-based teaching and learning takes place. And that’s due in large part to patients who willingly engage in these encounters. As part of the UGME team, I feel a certain obligation and responsibility for their education and training. Most other patients don’t have this same motivation and it’s their generosity that makes this learning possible.
Through not only their classroom based studies, but especially their clinical skills training over two years, their simulation lab work, and our First Patient Project, our students are ready to engage with patients and be part of the healthcare team in their clerkship years. A sincere thank you to patients in Kingston and at our regional sites who engage with them as they learn.
Get to the point with Ask-Tell-Ask feedback
By Theresa Suart & Eleni Katsoulas
Giving and receiving feedback effectively is a key part of the UGME curriculum. It’s also key in nearly every workplace, which could explain why there are so many different frameworks and recommendations for feedback “best practices”. Some of these are more effective than others.
Have you heard of the feedback sandwich? It’s one of the more popular feedback techniques and involves “sandwiching” negative or constructive feedback with two pieces of positive or complementary feedback. It’s also sometimes known as “PIP” for “praise, improve, praise”.
The idea behind this is laudable – cushion the blow of negative feedback and reassure the individual that they are doing some things well.
In practice, however, it’s fraught with difficulties, making it not very useful for the person receiving the feedback. Think about it:
- I’ve just received two pieces of praise and one of criticism or a suggestion for improvement: what should I focus on?
- The negative feedback is about something I did today, the positive things were from last week – the positive stuff must not be as important.
- Two pieces of praise and one of criticism – guess that I’m mostly doing well!
- The last thing they said was praise – must be doing great!
Writing in Harvard Business Review, Roger Schwarz also points out the fallacies of this approach. Schwarz notes leaders who use the sandwich approach to negative feedback do so for a variety of reasons. These include:
- Thinking it’s easier for people to hear and accept negative feedback when it comes with positive feedback.
- Assuming the sandwich approach provides balanced feedback
- Believing giving positive feedback with negative feedback reduces discomfort and anxiety.
Schwarz then debunks each:
- Easier: Most people on the receiving end would prefer to skip the sandwich – get to the point.
- Balanced: Saving up positive feedback to sandwich negative feedback undermines timely delivery of the positive feedback. As Schwarz points out, research shows that feedback, either positive or negative, “is best shared as soon as possible.” He also asks: “Do you also feel the need to balance your positive feedback with negative feedback?”
- Reducing anxiety: “The longer you talk without giving the negative feedback, the more uncomfortable you’re likely to become as you anticipate giving the negative news.” Meanwhile, the person on the receiving end “will sense your discomfort and become more anxious.
The UGME Education Team advocates the use of a new feedback sandwich replacing “praise, improve, praise” with Ask – Tell – Ask. This method was brought forward by Dr. Ayca Toprak and Dr. Susan Chamberlain, adapted from French, Colbert and Pien (ASE April 24, 2015)
The ATA Feedback Model is similar to the traditional feedback model as it has three parts. After that, it’s quite a bit different. Using Ask-Tell-Ask, the Preceptor asks the learner for their input, then the preceptor tells them their impressions, then wraps up by asking the learner to help develop an improvement plan:
Ask – Tell – Ask
- Ask the learner for their perceptions about strengths and challenges
- Tell them your impressions backed by observations, and specific examples
- Ask them what can be improved and how– assist you in developing a learning plan
Examples of topics to discuss (referencing objectives of the rotation, course, or activity):
- Functioning in the team context
- Skills (communication, technical, clinical)
- Clinical Reasoning
- Record keeping
- Process or Content (knowledge or the way they use the knowledge; application of knowledge).
- Background knowledge (this is knowledge of the discipline, scientific foundations, knowledge base).
The ATA model helps preceptors focus the discussion while scaffolding self-regulation and self-assessment. It also avoids the mixed-messages of the feedback sandwich approach.
The ask-tell-ask oral feedback is best paired with written narrative feedback. Watch for a blog post on this topic in September.
We used PowerPoint slides from a presentation prepared by Sheila Pinchin and Eleni Katsoulas, with slides from Cherie Jones, to prepare this blog. We thank Sheila and Cherie for their contributions.