SCCM Resource Library-It’s Okay to Be Wrong: How to Build Resilient Trainees During Rounds

Video Transcription

Hello, I'm Marion Vaughn-Moshefsky, an associate professor of critical care at MD Anderson Cancer Center in Houston.  I'm joining my SCCM undergraduate education colleagues as we discuss trainees. I'm going to tell you why it's okay to be wrong and how to build resilient trainees  during rounds. I think we probably all remember coming into that first day of the rotation with all of our friends eager to impress and show everything we've learned.  And then all of a sudden, getting that one question, was it something that you hadn't understood in the book, or you know you read it but you can't remember what it was, or  maybe a page you'd even skipped the night before. No matter what, all of a sudden there was that feeling. There was a target on you. Did you have the right answer or didn't you?  Well, our first response, of course, who wouldn't want to get out of there as fast as they could and make a run for it?  But only the divine intervention from a mistimed fire alarm was really going to let that happen. So then you pretty much have three options.  You can sit and wait, stare blankly, don't say a word, try to fade into the linoleum in hopes that someone else in the group will burst forth with the answer or the teacher  will move on to the next person. Maybe shrug your shoulders, say, admit you don't know it, hope they'll move on with that, or go for it.  You may think you know the answer, but you aren't sure if it's exactly right. And so do you want to take the risk? You decide it's okay to do that.  So the way that you decide to respond in this situation is really probably based on who the instructor was at that time and what they told you and how they've been teaching.  You know, I think we start, if a tree falls in a forest and no one hears it, does it make a noise? Well, here's the next question, sort of a corollary.  You know, if a trainee is asked a question and didn't say anything wrong, which means they didn't say anything at all, you know, does that mean one of two things that either  the person, well, wasn't wrong, so I guess they were correct, or at least by not doing the wrong thing that there was no harm? Is that correct? Well, probably not.  Back in the 1970s, Charles L. Bosk spent a year and a half at an academic institution observing the surgical training program to see how education was conducted and how incorrect  actions and medical errors were managed in the teaching environment. And he said, the superordinates task is a delicate one.  He must control mistakes, yet at the same time, if he wishes to train competent, independent, and eventually autonomous professionals, he must allow his subordinates enough room  to make the honest errors of the inexperienced. And this is what we're talking about, are the honest areas of the inexperienced. This isn't about a lack of accountability.  This is about making an error in the right stage of training in order to be able to improve performance on the professional level.  Let's talk about the concept of psychological safety, which has been discussed in the workplace and is now really moving into the healthcare industry.  Psychological safety at work, when it's in place, helps promote self-awareness. You don't have to think, well, I must be doing everything wrong, and anything that went wrong  must be due to someone else or a different factor. It allows one to acknowledge personal mistakes or gaps in knowledge or need for improvement.  It allows us to demonstrate concern for everyone else on the team as a person. They don't have to be perfect. We're not expecting that. We allow. We make allowances.  We work together to make sure that those mistakes don't happen. If they are, they're recognized before they cause harm.  It means that we can actively ask and ask for questions in order to improve our understanding or perhaps keep something from happening.  It's another way that we're able to show others that we value what they have to say and we appreciate what they're telling us.  It really puts a positive spin on any kind of correction or recognition of potential error or potential harm.  Before you move on, I do want to point out some specific pieces about the topic of shame and where that may be seen in our medical trainees.  Trainees have a very special place in health care. They're learning, but they still are a valuable resource for many things.  They sometimes develop those tighter bonds with family members than we can. And so how they're treated translates in their future attitudes towards work, towards working  as a team, and later as educators themselves.  There's a high degree of perfectionism in anyone who's gone into a health care field. We don't want them to feel that they may be inadequate.  There can be that sense of feeling that you're not quite as good as anyone else in the group if you're afraid to answer a question or if you see correction as a punishment.  There may be an imposter syndrome where there's a false sense of self-identity where everyone's questioning maybe I shouldn't be here. Am I good enough to really be a doctor?  What if I hurt someone? Maybe I'm not as good as everyone else and this is the wrong thing for me.  You know, accompanying those then, this shame can cause some pretty difficult emotions to deal with.  And if not dealt with in public, especially resolved, then there can be self-isolation from this and a negative belief about abilities by not having feedback about real performance  until weeks later as we used to do. And I think the biggest thing to reinforce on these, especially that perfectionism piece  is that, you know, in the future, no one's ever going to know how someone was graded during a rotation. They're going to know how they're able to manage and care for patients.  And so you want to focus on that piece. So you know, we're going to start at the very beginning because it's a very good place to start.  So in that first meeting with trainees, you want to eliminate as much uncertainty as possible. So set the expectations for both preparation and participation.  You know, allowing wrong answers doesn't mean that there's no accountability for learning or for asking those questions when there's doubt. So set the expectations.  You want them to know that they're going to be expected to voice answers and continue learning. It may be easier to move into the learning phase if pieces are templated.  You know the format for rounds. There's a template that's utilized for patient presentations. That way, there's no doubt about those pieces and you're helping them identify what the  important information is that they're going to pull out of this. You know, and you also want to know that during rounds, it's okay to ask questions if you  don't understand something or want to know why things are being done because that's the best time to learn is in the moment.  So this should enhance that participation of the learners, you know, without fear of being criticized or intimidated for speaking up.  Because what we want to do as teachers is be seen as coaches, you know, allies behind the scenes, not a ruler, not a punisher, not a judge.  And then talk about your vulnerabilities with storytelling. Tell a story of a time when you had a wrong answer and what you learned or if you didn't  get the feedback when you realized and how that stuck with you. I always share a story from one of my first days of an obstetrics rotation when there  was something I knew like the back of my hand and I completely mixed it up and did a horrible  job and didn't realize until a few hours later that everyone sat there and listened to me make the mistake and didn't bother to say a word.  And so avoiding having that happen and that's my goal with them. Now with that, you understand that you're going to have some real-time identification of errors. And so that's okay.  Expect that peace and know that that's part of the learning process. When it happens, you know, the most difficult thing for an instructor to do is respond to an incorrect answer.  To do it in the right way in order to reduce the anxiety and fear and encourage the rest of the participation from not only that person, but everyone else in the group.  You want to provide immediate feedback, you know, and sometimes utilizing active inquiry to really move into why is this important? Think about the process.  Think about the answer you gave me. Does it make sense or not? You know, providing the context of why it's important to have the right knowledge or the  right information in the medical setting. You may or may not want to provide the answers. If so, provide that reasoning behind it or maybe the later date or provide appropriate  resources to get the correct information. You want to, again, when we talked about questions, you want to encourage questions, but you do  have to learn how to manage those, you know, pick those which you're going to answer, those which you ask them to investigate, and those which you may say are something to discuss  at a different time. But working on the technique to do that in order to still maintain that participation, but not get bogged down during rounds.  You want to confirm understanding of the information when you've provided that correction. So make sure that you've had some closed loop communication about that.  And praise the fact that whether the answer was correct or not, that there was the courage in standing up and providing it. And then talk about what you do. What are your habits?  How do you continuously read to learn if there's something that you don't know? And who do you ask for help? Is it a supervisor? Is it a peer?  Is it someone in a different institution? Where are those ways to identify it and carry that through life?  Another focus to really help with this making mistakes is to talk about that teamwork aspect. You know, in the ICU, this is where we have a multidisciplinary team like nowhere else.  We talk about it all the time, and this is where we want the students to leverage that. Rounds aren't a competition. So it's not who got an answer right.  It's what's the patient outcome together. You may want to set up a buddy system. And not necessarily between two trainees of the same type.  It can be an even better experience to pair a respiratory therapist and a pharmacist or a nurse or a physician trainee or a nurse practitioner student or a PA student.  And that way leveraging those different knowledge bases, those different approaches to the patient,  and the different ways to answer a question, while really growing that sense of collaboration needed for successful health care, even outside of the ICU.  And for a really difficult question, allow someone to phone a friend. There's nothing wrong with getting an assist. We all do it.  So what happens if we look at these pieces and we utilize them? You know, everyone wins. You engage the learners by enhancing the participation on rounds.  And they're going to trust. They're going to trust that when you teach them, you're going to be kind and will still like you even if they have the wrong answers.  That's going to give people confidence and an ability to speak up and ask questions when they're wrong.  Because that really requires some confidence to admit, I'm not sure the answer, I don't think I'm doing the right thing.  You're providing immediate feedback, you don't wait till the end of the month to determine to know whether or not they did a good job.  And they can identify, they can expose those weaknesses they have, so that they can turn, they can strengthen those, as well as identify any knowledge gaps and bridging the gaps in  real time, instead of being judged and getting a summary paragraph weeks later. Now our goal as teachers is that we prepare the trainees and we can't prepare them if  we don't do that in an ongoing process with a blame-free way to learn. We've encouraged collaboration by asking students to work together and help each other with questions.  And we're giving them the way to respond to correction in a supportive environment.  Because that way they can safely make mistakes and productively make mistakes instead of not knowing and making mistakes when they don't have guidance.  This way they can be corrected and understand the right course of action when they're being supported instead of it having a larger effect.  You know the other possibility is that you're going to, they're also going to be better at questioning what others are doing by learning how to ask why and how.  And at some point they may disclose an error that they've made in order to better treat a patient because they're going to trust that the system will work with that.  You know patient safety is improved when our learners are free from blame and recrimination.  If they're requesting assistance or requesting clarifying information during patient care. And last, for those of us who are here, it's the joy of teaching.  We are able to engage, we are able to see the product of our work as we continue this and provide that feedback and see those moments where an incorrect answer is understood and  the correct answer is applied to the next patient. And I appreciate all of the time that all of you have spent in your commitment to education in joining this group.  I encourage you for some additional reading and thoughts on how you can incorporate this and create this environment in your ICU. Read The Fearless Organization by Amy Edmondson.  It's an overview of workforce psychological safety, but it also has some material particularly pertaining to health care that I think you'll all find interesting.  There's several, there are many articles about allowing students to make mistakes and learn  and how we provide that feedback and how we keep them emotionally safe during that process. Thank you so much for joining. My name is Marion Von Meshevsky.  I'm here with the SCCM Undergraduate Education Committee. Thank you for your time.

Video Summary

In this video, Marion Vaughn-Moshefsky, an associate professor of critical care, discusses the importance of creating a safe learning environment for medical trainees. She emphasizes the need for trainees to feel comfortable making mistakes and how this can contribute to their growth and development. Marion highlights the concept of psychological safety in the workplace and how it promotes self-awareness and an acknowledgment of personal mistakes. She also discusses the negative impact of shame and perfectionism on trainees and how it can hinder their learning and confidence. Marion provides practical strategies for instructors to promote a supportive learning environment, such as setting clear expectations, providing immediate feedback, encouraging questions, and fostering collaboration among trainees. She concludes by emphasizing the importance of ongoing support and guidance for trainees to thrive and improve patient care.

Asset Subtitle

Professional Development and Education, 2022

Asset Caption

This session will discuss resilience and strategies for combatting burnout in critical care clinicians. Topics will include how incorporating mindfulness can improve resilience and job satisfaction, methods to build resilient trainees during patient care rounds, and a case-based discussion of factors that contribute to emotional resilience. This session was created by the Undergraduate Education Committee and is targeted to all critical care clinicians, including preceptors and trainees (students, residents, and fellows).

Meta Tag

Content Type Presentation

Knowledge Area Professional Development and Education

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag Mentor and Mentee

Tag Workforce

Year 2022

Keywords

safe learning environment

medical trainees

psychological safety

self-awareness

instructors

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