Doves & cherubim are not strictly required for successful teach back.
[L'Annonciation de 1644 via wikimedia]

I love the "teach back" technique. Teach back is a way to verify shared understanding by asking someone to explain their understanding of the instructions and/or event.

Done well, this can keep patients from skating out the door just by smiling and nodding at the provider, even though they didn't understand anything the provider said. When I am asked to do teach back, I find it often prompts me to ask questions I didn't have when asked "do you have any questions?" I might realize I zoned out during the encounter. It forces me to pay closer attention. It also lets the provider know if I've truly understood key details, like how many times to take a medicine per day, what the next step in my diagnosis is, or what will keep the rash from returning.

However, the two most common way most learners employ teach back is  at the end of the encounter:

1. "I just want to make sure you understand everything correctly, so will you please tell me what I've just told you?" 

2. "So, sometimes I am unclear and use big words when I am talking to patients. To make sure I was clear, will you please tell me what you understand of our conversation today?"

Both of these framings are incredibly awkward. As one student told me in feedback, "It's like I have to choose between calling the patient stupid or calling myself incompetent."

So here's the best way I know how to use teach back with patients:

• Start with a summary of the history and physical exam findings. Summaries are awesome in general because they give both the learner and me a last chance to verify/update inaccurate information. But a summary also primes me for teach back because it helps me focus on the things the learner finds important, making it more likely I will recall and retain that information.

• "What questions do you have?" after the summary helps make sure that all questions are resolved before moving to teach back. No new info should be introduced during teach back. Resummarize after all questions have been answered if possible.

• Identify the patient's most relevant support network. Sometimes that information has already been obtained through the social history, but if not, questions like "Who brought you in today?" or "Who are you going to call when you get home?" or "Are you going to need to contact work?" et cetera can be helpful. The student-doctor can ask more than one question to help identify the person I am most likely to discuss my condition with. These questions should be approached with a transitionary tone rather than come across as a complete non-sequiter.

• Now do teach back! "What are you going to tell [person identified in Step 3] about [the next step/your medicines/what we talked about today]? The learner can continue to prompt me in this way about any of the key details they want to ensure I understand. 

For example:

Student-doctor: So let me sum up: You’ve had a rash for a week, and when I looked at your leg I saw circular black dots. So I'm going to prescribe some cream you'll use twice a day. How does all that sound to you? 

SP: Yeah, great. 

Student-doctor: OK. What questions do you have? 

SP: I can't think of any. 

Student-doctor: OK, then we're good. So who brought you into the clinic today? 

SP: My husband. 

Student-doctor: Great, so on the way home, what are you going to tell him about your condition?

There can be lots of nuance here depending on how the patient answers. But this basic structure makes me feel as if the learner is preparing me for a conversation I'm going to have rather than giving me a pop quiz. And because the learner seems like s/he is interested in my life and support network, it enhances our rapport.

Discussion question:

Does your school practice the teach back method? I'd love to see more examples of how to introduce teach back well, or other resources that talk about the concept. Everything I've found doesn't explain it as well as I'd like, hence the generic Wikipedia link.

Turning it around

Feedback isn't always straightforward.
[A Turn in the Road via wikimedia]

I certainly enjoy a good SP encounter. I love discovering how effective behaviours manifest and how they affect me so I can incorporate them into future feedback.

But one of my very favorite things is when a poor encounter becomes an excellent feedback session. This is only possible in places that allow the SP to have a genuine conversation with the learner, rather than using a specific format or a written form. But when it works it makes both of us leave the encounter feeling better. I see how the learners' posture & expressions change and they leave knowing how to make it right, feeling hopeful instead of defeated.

For instance (this is a living list. Last updated May 23, 2017):

• When the learner returned for feedback, he immediately admitted it had been a terrible encounter. Together we analyzed why, then I guided him through creating a specific plan to enhance those skills before the next event.

• During feedback during a poor encounter a learner admitted he had just been going through the motions during lung auscultation, but when he realized it he forced himself to do the exam again paying closer attention. It didn't affect the findings or anything else about the encounter, but I was so impressed I praised him for his self-awareness and integrity. Even if he got nothing else out of that encounter, I felt that was worth the whole thing.

• I could tell the feedback for this unsatisfying encounter wasn't landing for the learner until I stepped laterally and asked her why/how she had gotten into this particularly specialized program. Hearing her answer allowed me to target my feedback to meet her needs and her entire attitude became engaged and curious.

• "Oh, I should ask more questions!" the learner suddenly exclaimed during feedback after a particularly confusing encounter. I wanted to hug him.

• How I learned to begin each encounter with student self-reflection.

• Once a learner who had an awkward encounter came back to feedback crying. I didn't even try to give her feedback: I got her tissues, a drink of water, and asked her what was going on in her life. We talked a bit about how to compartmentalize emotions and release them between patients so she would be ready to do the next OSCE encounter in the rotation.

• We had had a lackluster encounter: even though he was using the right words, I had considered the learner scripted and demanding. So I used the Feedback Hierarchy to talk to him about posture, tone, facial expressions and word choices to convey sincerity. During feedback he became much more animated and engaged. As he left he shook my hand: "Thank you! That was was the best feedback I have ever had. That's exactly what I've been looking for."

• After a difficult encounter with a resistant client, I asked the group what questions they had. Nobody said anything for a long moment, then one woman spoke up: "Why were you so mean?" she asked, only half joking. Everyone laughed nervously, and I was tempted to laugh it off, too. But instead, I said, “Great question! Why was I so mean? Let’s ask the group! What are some reasons why people might be mean in a situation like this?” The group talked about a lot of factors that make people uncooperative: hunger, illness, power/age differentials, independence, control, comprehension. The tone immediately flipped from rejection to empathy & inquiry, which persisted throughout the debriefing. I am certain they will feel more kindly towards this kind of client in the future.

• He was clipped, curt and offered me no empathy for my symptoms. I had a feeling I wasn't the only SP who had worked with him who felt this way, so after the traditional "How did that go for you?" I asked, "What patient interaction skills are you working on? What's something another SP has mentioned that you are trying to incorporate into patient encounters?" When he told me what it was, I was able to validate I had seen him try that and we were able to discuss how to communicate that skill more effectively. That gave me a chance to talk about what I had noticed and he was able to reflect back to me that he really heard it and how he could imagine how small it made me feel. By the end, he was telling me about why he had gotten into medicine, and my eyes were shining with compassion.

• Right from the very start, the learner constantly interrupted me. She would start with an open-ended question but then immediately close it or cut me off or finish my answer before I could even open my mouth! In feedback, when I asked her how it had gone, she said fine, but she felt like she didn't connect with me very well. What was the earliest moment she remembered not being able to connect with me? I asked. "Kind of right from the start," she said. I agreed with her and we walked through how she immediately closed her opening question, and then we examined several instances of other interruptions -- even during the feedback! By the time we were finished, she was astonished. "It's true! I do interrupt people! How could I not know this? I've done a lot of these simulations and nobody has ever told me that before!" She was almost elated at discovering this aspect about herself.

Inside the Simulation Studio

An SP shows us the inside of his studio.
[Self-Portrait (In the new studio) via wikimedia]

Oh, HELLO! Has anyone heard of the free "Inside the Simulation Studio" conference for SPs?  This sounds absolutely delightful!

Unfortunately, I can't find any recent info on it. Most of the information I can find is from 2013. But happily someone has posted videos from all the speakers! They include a wide range of diverse presentations including traditional power point, creative writing, music, roleplaying, films, recorded encounters, etc. The topics also span a wide range: the future of SPs, how to approach specific encounters, case development, active listening, feedback, mannequins, the scope of SP opportunities, etc.

I love the opportunity to watch other SPs talk and do what they love. But one of the things that really makes my heart sing is the specific emphasis on SPs and their creativity. Yes, I am analytical by nature, but the magic of SPs is the combination of heart, head and hand. So I am excited to see a group not only tolerate that combination, but embrace it.

All in all it's funny, informative and heartwarming. I hope they offer it again sometime. Check out the videos for yourself!

https://vimeo.com/channels/644246/82072169

Power ballads for mannequins

Are you an SP who works with mannequins? Then this unabashedly sentimental & irreverent video is for you!