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Dr. Jessica Trier

Medical Grand Rounds featuring Dr. Jessica Trier

Sophia Linton, PhD Candidate (TMED) and Graduate Student TA 

Signaling the start of the Fall term, it is a tradition for the Queen's Department of Medicine Medical Grand Rounds to begin with Education Rounds. This year we have welcomed Dr. Jessica Trier, a physician in the Department of Physical Medicine and Rehabilitation, to speak to us about effective coaching relationships and the clinical practice learning environment. After the Rounds, the graduate students in Translational Medicine (TMED) joined Dr. Trier to discuss her research and experience in Competency-Based Medical Education (CBME) and her career.

 

The clinical learning environment (CLE) can be defined as the overlapping space between the work environment and the educational context. This overlap is complex, so much so that Nordquist and colleagues approach the CLE from six avenues: architectural, digital, diversity and inclusion, education, psychological, and sociocultural (1). When the CLE is suboptimal, it has been associated with adverse patient care and learning outcomes, contributing to higher levels of stress, burnout, depersonalization, and emotional exhaustion in medical trainees and their teachers (2,3). Clinical coaching has emerged as an educational strategy to improve resident learning. The coaching model is different from the traditional concept of pedagogy because it aims to strengthen task execution through coaching feedback and does away with the presumption that, after a certain point, the student no longer needs instruction (4). Dr. Trier referenced the Coaching by Design (CBD) model developed by the Royal College (5). In this model, coaching feedback focuses on specific, actionable suggestions for improvement and occurs in the moment and over time.

 

Dr. Trier continued to introduce several coaching frameworks but focused on one called the R2C2. The R2C2 model describes four phases for assessment discussions with medical learners: (1) develop Rapport and relationship, (2) explore the trainee's Reactions to the feedback, (3) assist in understanding Content of feedback, and (4) Coach to identify performance or knowledge gaps, then set goals and plans (6–8). Dr. Trier's research focuses on applying the R2C2 for in-the-moment feedback where coaching conversations occur immediately after a specific clinical experience (9). In-the-moment feedback is especially beneficial for CBME settings where learners are expected to meet milestones or complete entrustable professional activities (EPA). Dr. Trier performed a framework-type analysis with colleagues to successfully create and test a new tri-fold for effective R2C2 in-the-moment feedback. This resource is available online for all clinical educators (9).

 

A safe bidirectional relationship between coach and coachee is key for the R2C2 framework to be productive. In Rounds, Dr. Trier asked the audience to think about a time in their residency where they felt safe enough to take a risk and why. The answer has to do with psychological safety or the belief that you won't be punished or shamed for speaking up with ideas, questions, concerns, or mistakes. Dr. Trier explained that psychological safety is associated with improved p atient care outcomes because team members have improved communication and are more likely to report errors. She segued to the complex ideological concept of allowing failure for educational purposes in the CLE, saying optimal knowledge occurs when both psychological safety and performance accountability are high. Many audience members resonated with this question, contributing personal stories and anecdotes of their experience with interpersonal risk-taking. We continued this conversation post-Rounds, asking how EPAs and CBME could impact psychological safety in the CLE and learned the jury is still out; interpersonal risk-taking behaviors and their effect on residents are unclear (10).

 

A common thread of our time with Dr. Trier was the importance of practicing a growth mindset where people believe their basic abilities, like intelligence or skills, can be developed through perseverance and hard work. This mindset contrasts with a fixed mindset, where people believe their basic qualities are fixed traits. Dr. Trier stressed that coaches and coachees must have a growth mindset for coaching relationships to be effective and safe. When asked about the benefits of being a clinical coach with a growth mindset, Dr. Trier referenced her practice as a physiatrist. She explained how her desire to grow enables her to learn from the residents and her multidisciplinary team, ultimately improving patient care.

 

As TMED students, this presentation allowed us to appreciate the complexity of medical education and encouraged us to reflect on our mindsets as biomedical researchers. On behalf of the TMED students, I want to thank Dr. Trier for her time and reminding us of our roles as translators of medical discovery driven by patients and their diseases.

 

References:

1.          Nordquist J, Hall J, Caverzagie K, Snell L, Chan M-K, Thoma B, et al. The clinical learning environment. https://doi.org/101080/0142159X20191566601 [Internet]. 2019 Apr 1 [cited 2021 Sep 13];41(4):366–72. Available from: https://www.tandfonline.com/doi/abs/10.1080/0142159X.2019.1566601

2.          Irby DM. Proceedings of a conference chaired by Improving Environments for Learning in the Health Professions [Internet]. 2018. Available from: www.macyfoundation.org

3.          C K, A W, C B, P F, N F, M H, et al. A national stakeholder consensus study of challenges and priorities for clinical learning environments in postgraduate medical education. BMC Med Educ [Internet]. 2017 Nov 22 [cited 2021 Sep 13];17(1). Available from: https://pubmed.ncbi.nlm.nih.gov/29166902/

4.          Gawande A. The Coach in the Operating Room | The New Yorker [Internet]. Annals of Medicine, The New Yorker. 2011 [cited 2021 Sep 13]. Available from: https://www.newyorker.com/magazine/2011/10/03/personal-best

5.          Coaching and CBD :: The Royal College of Physicians and Surgeons of Canada [Internet]. [cited 2021 Sep 13]. Available from: https://www.royalcollege.ca/rcsite/cbd/implementation/wbas/coaching-and…

6.          Sargeant J, Mann K, Manos S, Epstein I, Warren A, Shearer C, et al. R2C2 in Action: Testing an Evidence-Based Model to Facilitate Feedback and Coaching in Residency. J Grad Med Educ [Internet]. 2017 Apr 1 [cited 2021 Sep 13];9(2):165. Available from: /pmc/articles/PMC5398131/

7.          J S, JM L, K M, H A, A W, M Z, et al. The R2C2 Model in Residency Education: How Does It Foster Coaching and Promote Feedback Use? Acad Med [Internet]. 2018 Jul 1 [cited 2021 Sep 13];93(7):1055–63. Available from: https://pubmed.ncbi.nlm.nih.gov/29342008/

8.          Bannister SL, Wu TF, Keegan DA. The Clinical COACH: How to Enable Your Learners to Own Their Learning. Pediatrics [Internet]. 2018 Nov 1 [cited 2021 Sep 13];142(5). Available from: https://pediatrics.aappublications.org/content/142/5/e20182601

9.          Lockyer J, Armson H, Könings KD, Lee-Krueger RCW, Ordons AR des, Ramani S, et al. In-the-Moment Feedback and Coaching: Improving R2C2 for a New Context. J Grad Med Educ [Internet]. 2020 Feb 1 [cited 2021 Sep 13];12(1):27. Available from: /pmc/articles/PMC7012514/

10.        JM K, LA L. Allowing failure for educational purposes in postgraduate clinical training: A narrative review. Med Teach [Internet]. 2019 Nov 2 [cited 2021 Sep 13];41(11):1263–9. Available from: https://pubmed.ncbi.nlm.nih.gov/31280625/

 

Comments

Name
Kiera Liblik

Tue, 09/14/2021 - 10:54

Dear Sophia,

Thank you for an excellent and thoughtful summary of last week's MGR. Indeed, a 'growth mindset' is something that can be taken beyond medicine and implemented into our roles within graduate studies as well as our pursuits of personal development. As a Graduate Student TA for TMED, I imagine this session was also an excellent start to your time as one of our 'coaches' in the learning environment. Looking forward to future sessions, I wonder what you recommend (now that you've been through this course) for us as students to prioritize as 'coachees' in the way that we approach our time in our first year of TMED? Especially in the 'student' role where we do spend the majority of our time in a lecture environment and then on our own independent projects.

Cheers and thank you for your time,
Kiera

Name
Kiera Liblik

Hi Kiera,

Thanks for your comment and thoughtful question.

A notable takeaway from my first year of TMED is taking a growth mindset and being kind to myself.

Balancing your lectures and your new research role is not easy and will take time to figure out. It's tempting to compare yourself and successes to classmates, but you must recognize that everyone's situation is different (classwork, lab expectations, study design, etc.), and you are on your path. Like the R2C2 says, creating an individualized action plan with yourself and your coaches is helpful and can make you feel better.

A growth mindset is so important in your first year because you will be challenged and fail, and that's ok. Be kind to yourself in these moments and learn from them.

I would love to hear from other students and their advice.

Name
Sophia

Name
Alyssa Burrows

Tue, 09/14/2021 - 11:50

Hi Sophia,

Thank you for your thoughtful summary of Dr. Trier’s MGR lecture and for facilitating the discussion afterwards.

Dr. Trier highlighted the importance of setting clear expectations within the coach and coachee relationship. It is also helpful if the coachee outlines their goals, as this will help the coach provide them with constructive feedback on their performance. Throughout the talk giving feedback to trainees was discussed. It is recommended that feedback is provided frequently in low-stakes settings focusing on what can be improved (again, that growth mindset!). R2C2 and RX-OCR, as mentioned, are valuable tools that have been designed for coaching in the clinical setting. Although our interactions are short during our observerships, I am sure some aspects of these tools can be used.

Residents and clinical teachers varied in their perspectives around coaching and experience; residents reported that they found it was more helpful if the clinical teacher had recently been in their shoes, whereas the clinical teachers felt they were better coaches the more experience they had. I think this observation has to do with establishing a rapport with the coach and coachee and leads me to ask how this could be assisted? To this point, one physician from the audience asked if it would be helpful for more experienced clinical teachers to be forthcoming about challenging experiences they had throughout residency to better connect with the resident trainee.

I also appreciated when Dr. Trier shared with us about the interdisciplinary team that she works with, including nurses, occupational therapists, physiotherapists, speech-language pathologists, social workers, PharmD, behavioural therapists, neuropsychologists, and a hospitalist. From my understanding, collaborative and interdisciplinary teams are immensely impactful to patient care. During my observerships, I look forward to learning from interdisciplinary and/or multidisciplinary health care teams

I look forward to hearing what others gained from Dr. Trier’s exceptional talk.

-Alyssa

Name
Alyssa Burrows

Hello Alyssa,

Thank you for your comment on last week's MGR - I found it very insightful! I noticed that you mentioned approaching challenging experiences as an opportunity for teaching and creating safe spaces. I imagine the process of normalizing discussions around failure will come with growing pains (as with any culture shift). Do you think that it would help to formalize this part of 'coaching' to make staff feel more comfortable? For example, having a lecture series annually from different attending physicians around the topic of challenging experiences?

Warm regards,
Kiera

Name
Kiera Liblik

Name
Katie Lindale

Tue, 09/14/2021 - 13:11

Thank you for sharing your insights and key takeaways, Sophia! The intriguing discussion during MGR reflected the importance of finding a balance between safety and discomfort in order to create an optimal learning environment. We learned that both safety and discomfort are critical ingredients for growth, however, the ideal proportion of each is debated depending on the situation and stakeholders. As Dr. Trier mentioned, an environment that emphasizes safety, as well as accountability, promotes growth. How do you find this concept of safety versus discomfort in an educational setting compares to your position as a learner in clinical research? Do you have indicators or strategies to optimize your growth through safety and discomfort in your research? Thank you!

Name
Katie Lindale

Name
Sophia Linton

Tue, 09/14/2021 - 22:48

In reply to by Katie (not verified)

Hi Katie, 

Thanks for your excellent comment. 

I think this is a great question for all of us to think about, and I encourage everyone to reply to this thread with their experience and advice about balancing safety and discomfort. 

To answer your question Katie, I think the lessons learned in Dr. Trier's lecture apply to us. In the same manner, taking risks in research is very situation-dependent.

The most important tip I can give anyone is to keep your goals in mind and outline the steps to get there. When coming across a risky situation, I always connect with trusted lab members and my supervisor before moving forward. Your supervisory committee, TMED, and the Queen's community are all there to support you, and don't be afraid to go to them. 

I apply the same process for personal endeavors; however, you need to know yourself and your limits. Introspection is difficult but necessary. This awareness takes time and, as I mentioned above, failure. Don't be afraid to fail and think about why you did! 

Name
Sophia Linton

Name
Kyla Tozer

Wed, 09/15/2021 - 13:07

In reply to by Katie (not verified)

Hi Katie and Sophia,

Katie, I think we were on the same page regarding the importance of a balance between safety and discomfort in a coaching session.

One thing that comes to mind when thinking about this is ‘going over goals and action plans’, within the moment. I have been blessed to spend many hours in the operating room observing various neurosurgical procedures. One of the protocols that has been implemented is going over the goals and plans of the surgery, before they begin. In the moment this allows for a clean mind and refresher on what the plan is and how they are going to get there. During the surgery if something goes wrong, you have the goal in mind, so it’s a little easier to think quickly. I think this is important because as we do things repeatedly, they become second nature and our ability to step further outside that zone grows. Do you think pushing our comfort zones often is a good idea to lessen the degree of discomfort? I wonder this because the more we do things, the easier it becomes. So even if we are becoming good at being uncomfortable, we are still learning.

I think this also touches on what Sophia said in her answer where getting foundational steps and a clear outline allows for someone to be more comfortable with the journey. This is absolutely like graduate school where we have committee meetings to focus and move forward.

The one question that kept coming to mind is “when do you let go of the reins and let someone attempt to be uncomfortable?” And I think with Sophia’s tips this removes that barrier because it’s a step-by-step process versus an all or nothing.

Is there a time in your education, or even life, where goal setting, and outlines don’t work? And, maybe discomfort is the best option.

Thanks Katie and Sophia,
I am excited to hear your thoughts.

Name
Kyla Tozer

Name
Lubnaa Hossenbaccus

Tue, 09/14/2021 - 17:55

Hi Sophia,

Fantastic summary of Dr. Trier’s talk at last week’s Medical Grand Rounds! I especially liked how you connected the R2C2 model with the newly implemented CBME framework.

In our discussion with Dr. Trier, I found the involvement of patients and their feedback in CBME to be quite interesting. It’s understandably an important aspect in medical education, given the focus of patient-centered care. A recent study (https://doi.org/10.1080/0142159X.2018.1460658) in a pediatric emergency room setting found that both positive and constructive feedback provided by parents were well-received by residents. Residents found the feedback to be complementary to that provided by their educators, shedding light on their communication skills, professionalism, as well as specific aspects of care interaction not observed by their educators. The benefit of patient feedback appears to support the personal and professional growth of the resident, in combination with their clinical coach.

In some ways I find that this further promotes shared decision-making efforts between physicians and their patients by allowing patients to have an active voice in contributing to their care.

I’d love to hear your thoughts,

Lubnaa

Name
Lubnaa Hossenbaccus

Lubnaa,

Thanks for your comment and link to the article.

Did you notice how the interview questions follow similar language to the R2C2?

I would have liked to see them discuss an action plan for future interactions with patients, but I digress.

Did anyone else find interesting articles? Share them below!

Name
Sophia Linton

Hi Sophia,

You make a great point about the interview questions; the way they are grouped (Participant’s Background, Reaction, Use, Closing) certainly matches the R2C2 framework. It’s an interesting and practical application of the R2C2.

Thanks for your insights!

Lubnaa

Name
Lubnaa Hossenbaccus

Hi Lubnaa,

Not Sophia, but I'd like to chime in! I think a genuine dialogue between care providers and patients is mutually beneficial in that a genuine critique can:
-Provide physicians with reinforcement on what they're doing well and help them further refine such features of their practice
-Give physicians potential food-for-thought on aspects of care that they're potentially not as strong with

and/or

-Help a patient understand why certain decisions were made so as to give them some perspective on why their care providers chose the route they did.

Cumulatively, an empathetic and supportive approach from both sides of the patient-provider relationship would ideally give both parties satisfaction and some perspective into how to better play their part in the future. The challenge here lies in time and emotional constraints placed on both physicians and patients, though whenever possible, communication should be encouraged to aid in the education of each.

Ultimately, I think reasonable and supportive feedback, regardless of the speaker, should be supported in helping residents develop their clinical prowess. This is definitely a very important Rounds topic!

Best,

Nolan

Name
Nolan Breault

Sophia,

I see the potential of integrating patient feedback during the phase where the resident and patient are developing an action plan. This may be an opportunity for patients to provide in-the-moment feedback. Additionally, an anonymous resource accessible to patients, perhaps a feedback survey (whether available in paper copy or in digital form), may allow patients to submit feedback over time.

However, I imagine the practicality of these ideas may vary by discipline.

Lubnaa

Name
Lubnaa Hossenbaccus

Hi Lubnaa,

I really enjoyed following this discussion thread thus far and your suggestions here. I think it is a wonderful idea to implement patient feedback when developing an action plan. Your post made me wonder whether the integration of patient feedback into training would differ between various fields of medicine. For example, I could imagine the long-term interaction and development of plans for treatment within oncology could create a much better avenue for ongoing feedback for trainees; whereas residents training in critical care or emergency medicine for example would have vastly different opportunities to receive feedback from their patients, or at least I'd suspect this might be the case. I'm curious about your thoughts on this.

Best,

James

Name
James King

Nolan,

I agree with you that effective dialogue would be mutually beneficial. In addition to your point on allowing patients to better understand their physician’s perspective, I think it’s a balance between understanding their physician’s recommendations while being able to choose what they feel is best for themselves.

Your point on the time and emotional constraints of both patients and physicians is valid and especially relevant during a pandemic, when everyone is feeling strained and burnt out.

Thanks for sharing your thoughts!

Lubnaa

Name
Lubnaa Hossenbaccus

Name
Nolan Breault

Tue, 09/14/2021 - 21:55

Hi Sophia!

Firstly, thank you for the wonderful examples you've set in TMED 800 and 801 for the student-led 3-minute summaries and discussions. I think you've set a tone that helps students to feel more relaxed about these exercises and able to approach them with their own personal style.

With that said, I think this Rounds' topic is exceptionally interesting in the way that it merges what is traditionally seen as a sports-based approach to teaching with a field that involves an exceptional amount of learning via textbooks and procedural practice. There's a little-known adage that goes, "the master has failed more times than the student has tried", and I think that's really captured in Dr. Trier's mentioning of Olympic-level athletes still benefiting from coaching. Similarly, medical residents, who've each shown on many occasions through their clerkships and exams in medical school that they are highly competent and skilled at what they do, stand to gain from the show of humility that comes with accepting coaching. It acknowledges a respect for the complexity of one's craft despite past accomplishments, and I think if done in the manner proposed by the R2C2 model, stands to greatly benefit all parties involved.

My greatest concern with the adoption of such an approach to medical education is the additional strain it might put on coaches. As a long-time distance runner, the greatest experiences I've had with coaches have been with those who could commit to meeting on a frequent basis and would put a great deal of honesty and practical advice into their practice. Cultivating such high-quality relationships as an additional expectation of busy physicians, I imagine, would not be sustainable over the long-term, where the greatest fruits of coaching lay. Indeed, I think there is wonderful potential in introducing coaching to medical education, but the rest of a coach's duties need to be modified to accommodate this responsibility as opposed to having it tacked on.

Lastly, some questions for other readers: do you think a good coach should themselves be coachable? What aspects of coaching do you think need to be most receptive to critique?

Thanks again for leading the way as we begin our programs, Sophia!

Best,

Nolan

Name
Nolan Breault

Nolan, 

I am so happy to hear you feel relaxed and can be yourself in class. I can't think of a better way to head into graduate school. 

I would really encourage you to read Personal Best by Atul Gawande (https://www.newyorker.com/magazine/2011/10/03/personal-best). Based on your comments here, I think this article would really resonate with you.

Let me know what you think below!

Sophia  

Name
Sophia Linton

Hi Nolan,

It was very interesting to hear your concern about the strain coaching may have on the coach. With so many responsibilities as a physician themselves, I imagine that it would be hard to provide the same model of coaching that high performance athletes receive.

I definitely believe that a good coach is someone who is coachable themselves. In fact, my hope for medical coaching is that the coach would be able to learn from the coachee, whether it be new communication skills, different ways of thinking or even how to be a better coach! I think that a two-way street like this would greatly benefit both parties.

Cassie

Name
Cassie Brand

Hi Nolan,

Thank you for sharing such excellent ideas! One of the concerns on my mind during the Rounds discussion was one that you voiced here - that it may simply not be feasible for physicians with other responsibilities to dedicate the time and energy needed to coaching. However, an idea that I found interesting during the talk was that oftentimes coaches themselves are not “experts” in the field in the way we imagine - for example, sports coaches may not necessarily excel in the sport themselves. This makes me wonder if it is possible to have an effective coaching relationship for residents with the coach being a non-physician? Do you think it could be possible to have a patient/community member, nurse, or other healthcare professional assist in forming a multidisciplinary coaching team, to help decrease the time required by busy physicians?

To touch on some of your other questions, I definitely believe coaches need to be receptive to critique and coaching themselves. A common thread in our discussion was “psychological safety”, and I think this would need to be an ongoing discussion between the coach and coachee. Interpersonal risk and discomfort are different for everyone, so coaches may need to be explicitly debriefed regarding situations in which they have pushed coachees too far. Furthermore, the field of medicine is always evolving, and I believe having a coach with a strong growth mindset is essential. Thank you Sophia for your excellent description of growth mindset in the initial post, and for the reminder of its importance!

Best,

Trinity

Name
Trinity Vey

Name
Emmanuel Fagbola

Tue, 09/14/2021 - 23:36

Hello Sophia,

Thank you for your summary of Dr. Trier's talk at this past week's Medical Grand Rounds. It was both a delightful and insightful read.

One of the things that you touched upon was the concept of a growth mindset versus a fixed mindset. You stated that a growth mindset comprises individuals believing that their basic abilities can be honed through hard work. This concept seems to relate to the positive correlation between psychological safety and performance accountability to optimize knowledge.

According to these concepts, even coachees with a strong growth mindset may be disadvantaged in a clinical learning setting if they feel psychologically unsafe when expressing ideas, concerns, and questions. Additionally, this ties in to the discussion of interpersonal risk-taking behaviours and their effects on clinical learners.

In this situation, a coachee with a growth mindset in an environment with sub-optimal psychological safety may be met with adverse effects on interpersonal relationships when expressing ideas. A cycle where the most eager learners develop a constant and growing anxiety around taking this kind of initiative may result from this learning environment. Moreover, they may be more likely to refrain from doing so, which leads to the effects you mentioned when the clinical learning environment (CLE) is suboptimal.

Overall, I found that these concepts and research findings instil an appreciation of the complexity of medical education.

Looking at this from the lens of a Translational Medicine Graduate Student, I was wondering what your supervisor does to optimize psychological safety in the lab environment? For others as well, what have your supervisors or past coaches done that helped to optimize psychological safety in that respective learning environment?

Emmanuel

Name
Emmanuel Fagbola

Hi Emmanuel,

Thanks for your thoughtful question. Katie asked a similar question above and I encourage you to take a look.

To answer your question, I had a discussion with my Lab Manager, Jen Thiele.

Dr. Ellis promotes a lab culture rooted in collaboration. From the moment trainees interview for a position in our lab, current or past lab members get involved. When Dr. Ellis and Jen conduct interviews with students, they probe for many behaviors we discussed in lecture with Dr. Trier (AKA. having a growth mindset) and importantly they compare student vs lab expectations. Academic standing is not the only thing they look for.

As a student in her lab, being surrounded by like-minded individuals with similar goals helps me feel safe!

This is just one of the ways Dr. Ellis and Jen optimize our learning.

Name
Sophia Linton

Hi Emmanuel,

Thank you for sharing your insight on this topic (and thank you Sophia for your very thought-provoking blog post)! Emmanuel, one of my big takeaways from Dr. Trier's talk was something you touched upon in your post, the idea of psychological safety. In my own undergraduate research experience, being in an environment where I felt safe to completely fail at experiments and ask any and all questions was paramount to my ability to thrive (and eventually develop the confidence to pursue a research MSc)! Feeling supported by the entire lab team, including the graduate students, contributed to my ability to take interpersonal risks in that environment. Following that thread, while doing additional research into this topic, I found a research article noting that resident well-being was correlated with both perception of psychological safety and overall program support (https://proxy.queensu.ca/login?url=http://dx.doi.org/10.1097/01.AOG.000…). I personally feel very fortunate to be entering a supportive program, but I wonder if anyone else has thoughts on the necessity of program support (and a perception of community) to achieve an optimal clinical learning environment, apart from the coach-coachee relationship itself? How might perceptions of program support be improved?

Best,

Trinity

Name
Trinity Vey

Name
Bethany Wilken

Wed, 09/15/2021 - 20:09

In reply to by Trinity Vey (not verified)

Hi Trinity,

I appreciate your enriching comments on psychological safety and the supportive environment you have experienced throughout your studies at Queen’s. I agree that one must feel comfortable in their environment in order to take risks and learn from mistakes. I have also experienced psychological safety in my research and academic endeavours at Queen’s. We are very lucky to belong to an institution with such caring faculty and students that allow us to develop into confident students who are not discouraged by adversity. To answer your question, I believe program support is completely necessary in order to excel in clinical settings. To perform well, members of the program must not fear judgement or ridicule when they encounter failure. Perception of program support could be improved by continuing to diminish the hierarchy system that is prominent in healthcare. As mentioned in previous discussion, perhaps if "coaches" and senior staff are more open about their failures and show an active effort in learning from their less experienced counterparts, a truly compassionate, supportive interprofessional environment will be created.

Kind Regards,
Bethany

Name
Bethany Wilken

Name
Cassie Brand

Wed, 09/15/2021 - 11:34

Hi Sophia,

Thank you for your summary of last weeks GMR. As a former high performance athlete, I found it very interesting to be introduced to the concept of coaching in areas outside of sport.
One of the coaching frameworks that was discussed in your summary and Dr. Trier's presentation, was the R2C2 framework. Comparing this to coaching in sport, I found that the 4 phases were similar to what I believe to be a good coaching relationship. Interestingly, a physician at GMR commented on differences in sport and medicine that would make the same type of coaching hard to achieve. I see a lot merit in making medical coaching more widely used, and am wondering if perhaps teaching and practices in the health care system are due for some restructuring to better accommodate medical coaching. Does anyone have any thoughts on what changes might allow for more effective medical coaching?

Looking forward to hearing your thoughts!

Cassie

Name
Cassie Brand

Cassie,

Thanks for your comment.

Something that immediately comes to mind is Dr. Triers work on in-the-moment feedback, where coaching occurs immediately following a session or scenario and lasts only 5-8 minutes. Maybe this type of feedback could be integrated in the CBME framework?

Name
Sophia Linton

Name
Pierce Colpman

Wed, 09/15/2021 - 15:03

Hi Sophia!
I wanted to firstly say thank you for setting such a good precedent for our 3-minute summaries, The way that you went through the key points of the lecture emphasizing how it connected to our speakers was very well thought out! Following your presentation I feel much more confident in how to formulate such a presentation and am looking forward to being able to have my turn on the podium!

The portion of the presentation which I found to be the most interesting was your description of how the clinical learning environment is an overlap of both the work environment and the educational context. From this, Nordquist and colleagues created six avenues or pillars on which the clinical learning environment can be based: Architectural, digital, diversity and inclusion, education, physiological, and sociocultural. It was stated as well that when any of these important considerations have been thrown off, that it has been associated with adverse patient care and learning outcomes. My question here is whether there have been studies which have evaluated which of these pillars or avenues is most important to promoting a healthy CLE? For example, is it possible that a CLE which is extremely diverse, inclusive, and has good physiological practice but lacks in the architectural and digital categories to be better than a CLE which only has adequate performance in all categories? Secondly which avenue do you think would most negatively impact the CLE if it were to be omitted from consideration?

My second question has to do with a study which I came across showing the impact of the R2C2 model in residency (1). This study looked at the relationship between residents and supervisors in terms of feedback and collaboration to explore the utility of the R2C2 model. This study found that both supervisors and residents alike reported that using the R2C2 model enabled more meaningful, collaborative, and goal-oriented feedback discussions (1). My question to this, is how practical this model is in a real world setting (not a study) where time is not always unlimited. When tensions are high as they often are in a hospital setting how well do you think supervisors will be able to adapt to be able to give good feedback and have adequate collaboration while stressed and busy? The 4 steps outlined in the R2C2 model are well thought out and do indeed facilitate discussion and collaboration, but how realistic is a multi-step, time consuming approach, in a setting such as a hospital where time is often of the essence? The thought that I have now is that these steps will become seamless and second nature the more they are practiced, however my concerns still exist that the extra time this will take could have a negative impact on the functioning of the hospital. I would be very interested to know what people think about this, is this approach feasible in a fast pace, high stress environment? Or is there a time and place for R2C2.

1. Sargeant, J., Mann, K., Manos, S., Epstein, I., Warren, A., Shearer, C., & Boudreau, M. (2017). R2C2 in action: Testing an evidence-based model to facilitate feedback and coaching in residency. Journal of Graduate Medical Education, 9(2), 165–170. https://doi.org/10.4300/jgme-d-16-00398.1

Name
Pierce Colpman

Pierce,

Thanks for you comments and questions.

Funny enough, Nordquist et al. actually discuss (in the paper Dr. Trier referenced) how they are publishing standalone papers for each avenue so you can look out for this.

As per your second question, I think its important to recognize that medical education must occur in the CLE. There is no suitable alternative and so we need to adapt medical education to suit this fast pace, high stress environment. The R2C2 was developed for this reason - to make coaching in the CLE easier. Likewise, the paper I referenced by Dr. Trier and her colleagues presents an in-the-moment feedback tri-fold where coaching occurs in 5-8 minute sessions!

Name
Sophia Linton

Name
Bethany Wilken

Wed, 09/15/2021 - 15:55

Hi Sophia,

Thank you for your insightful summary of the exceptional Grand Rounds presentation made by Dr. Trier. I thoroughly enjoyed learning about aspects of the clinical learning environment coach-coachee relationship that differ from my prior sports-based conception of the coaching role. I appreciate the emphasizes on a safe bi-directional relationship that diminishes the hierarchy role of the coach and introduces how the trainee can contribute to optimize the learning environment. I believe a growth-mindset is essential in the trainee to foster this bidirectional relationship and ultimately to demonstrate skills and behaviours that meet evolving patient needs.

Focusing on patient needs, the ultimate goal of continued medical education and clinical coaching is to improve patient experience. I am interested to hear your thoughts on how you believe patient experience directly benefits from a clinical coaching model. I propose through this outcome-based approach, rather than time based, we are producing physicians that are not only better trained but also more confident in their abilities. Confidence facilitates the ability to self-reflect and critically analyze patient treatment. On another note, I wonder if the coaches themselves can also contribute to improved patient-centred care. Do you think the coaching qualities they acquire from training residents and other personnel can be transferable to patients? I question if physicians in a clinical coaching model show improved ability to coach their own patients through treatment and thus, improve patient accountability.

On a more critical note, the clinical coaching environment and competency-based medical education (CBMD) promotes a safe environment for failure. It also focuses on individual learning, where trainees move at a pace that is congruent with their own strengths and weaknesses. I can see how this is different from traditional models which typically cause heightened pressure in meeting expectations at a timeline comparative to their colleagues. In my eyes, sometimes this pressure and competitiveness can enhance performance. Do you think by creating this safe environment which places less emphasize on competitiveness, that we are preventing some people from reaching their full potential? For example, it is a common practice in sports now to give all children participation ribbons. Some sports have even removed the conventional “first”, “second” and “third” place. This may cause children to not practice or try as hard because no matter what, they will be rewarded. Although not as extreme, I can see this problem arising in medical trainees. I do think healthy competition is necessary in encouraging people to do and be the best. I would love to hear what others think about this.

Again, thank you Sophia for leading this discussion and to Dr. Trier for teaching us the importance of clinical coaching in the learning environment.

Best,
Bethany Wilken

Name
Bethany Wilken

Hi Bethany,

Thanks for your thoughtful questions.

I do think qualities learned in coaching can improve patient outcomes. The first thing that comes to mind, and I look forward to hearing others ideas, is communication. I am specifically referring to formulating action plans. While I am no expert, I imagine setting action plans for a patients care increases transparency and patient autonomy.

As for your second question, you are touching on the discussion we had in class. As I recall, some students argued the opposite of your viewpoint whereby the CBME actually promotes shame as residents are always being evaluated.

I think, as with everything, the context is important. I can think of many personal situations where competition was helpful and hindering me. The main takeaway, however, is that when psychological safety is high and accountability is high, you get optimal learning.

 

 

Name
Sophia Linton

Name
Georgia Kersche

Wed, 09/15/2021 - 16:50

Thank you for the excellent summary of the presentation and our discussion at Grand Rounds, Sophia. I like that you touched on the concept of psychological safety, as this part of Dr. Trier’s presentation stuck with me.

As you mentioned, a balance between safety and accountability is key in CBME to promote risk-taking and growth. Based on the definitions Dr. Trier gave, psychological safety seems like it would be a subjective experience, differing significantly between individuals and situations. It made me wonder how each coachee’s sociocultural experiences would influence their experience of clinical safety, and in turn their growth as a care provider. I recall Dr. Trier discussing how looming reviews from superiors can make people hesitant to push themselves and make mistakes. If someone feels that unfair judgement may be placed on them, they may be less likely to advocate for themselves and be more wary of failing. Do you think that women and members of minority groups may be prone to feeling less psychological safety in the CLE, especially if their coaches are not aware of internal biases that they may hold? If so, do you have any ideas on combatting this?

Since medicine is rapidly becoming a more equitable and diverse environment in Canada this will hopefully become less relevant over time, which is great for learners and patients, alike. However, I feel that it’s important to continue fostering a tolerant environment among physicians to ensure that all learners gain as much as possible from their coaching relationships.

I commend your ability to synthesize the main takeaways from this valuable discussion, and I am looking forward to applying our knowledge of the “growth mindset” to future discussions. Personally, a goal of mine this semester is to improve my ability to speak up in class discussions. Though I have had difficulty with this in the past, you are doing a great job at fostering psychological safety in our own learning environment, thank you.

Georgia

Name
Georgia Kersche

Georgia,

Thank you for posing such an important question.

I hope that all coaches practice growth mindsets and are encouraged by leadership to learn about these issues.

There are incredible workshops listed on the DOM website: https://healthsci.queensu.ca/academics/edi/training-sessions

I would really like to hear from others about their thoughts.

 

Name
Sophia Linton

Name
James King

Wed, 09/15/2021 - 21:53

Hi Sophia. Thank you for taking the time to summarize some highlights from last Thursday’s wonderful talk and discussion. I wanted to contribute my favourite part of the experience.

I really enjoyed the sub-discussion that occurred between Dr. Archer and Dr. Trier. You’ll recall that Dr. Archer emphasized a sport-centric approach to coaching wherein the coach establishes certain rules that increase clarity and can reduce angst in learning. Dr. Trier believed that you cannot simply translate sport coaching into a medical context as the relationships are different and thus the coaching style must differ as well.

For what it’s worth, my opinion as a student-athlete falls somewhere in between Dr. Archer’s and Dr. Trier’s views. I think that the new style of coaching that is emerging in athletics does in fact emphasize the bi-directional interactions that were encouraged between coach and “coachee” within the continuing medical education framework, however, this is something that I’ve seen evolve as the years pass.

I thought the most insightful aspect of the discussion lied in the subtle dynamics of the conversation we were witnessing. That being Dr. Archer, the Head of the Department of Medicine, being directly (and respectfully) disagreed with by Dr. Trier. Dr. Archer’s response to being disagreed with was cordial and I think that everyone in the room was better off having heard two contrasting views. It was great to see that within the discussion of creating psychologically safe spaces for physicians in their continued medical education, that we received confirmation in this act of healthy disagreement that the discussion was itself a safe space.

Seeing this firsthand encouraged me to participate in the discussion afterwards. Oftentimes, my inclination would be to keep questions to myself and attempt to answer them on my own (and with the help of the internet after learning sessions, of course). It’s great to know going forward that we have a space available to inquire further and take the risks that are required in order to learn.

Best,

James

Name
James King

Thank you James for sharing your thoughts. It is interesting that you bring up the conversation between Dr. Archer and Dr. Trier and that you noticed the subtle dynamics of this conversation. I think this conversation is a great example of what Dr. Trier was lecturing on with regards to psychological safety.

I think one of the most impactful steps you can take to promote psychological safety within a team is to promote healthy conflicts/disagreement. Although the concept of conflict or disagreement in a team setting may seem counterintuitive, it is extremely vital to promote a safe environment so that it can occur. Often in medicine, residents or junior staff may feel uncomfortable in disagreeing with seniors. The problem with conflict is not actually the conflict itself but rather the consequences that people attribute to it in the moments afterwards. Undoubtedly, there is a fear that their senior or colleague would be angry about the comment or question, in that, lies the lack of psychological safety.

It is vital for team members particularly in health care to normalize respectful conflict and foster an environment in which all team members feel valued. Ultimately, senior staff should reassure the group that patient safety and quality improvements are the utmost important goal and ensure that there is no toleration of behaviors that embarrass or disrespect other team members.

Great point indeed James, and I just wanted to add my thoughts to it.

Best,
Dilakshan

Name
Dilakshan

Name
Samantha Ables

Thu, 09/16/2021 - 15:35

Hi Sophia,

Thank you for your detailed summary of the MGR last week.

While doing background reading on coaching in medicine, I came across an article about the experience of faculty learning to coach medical students. I think the title of this article really hit the point – that for many physicians, this new idea of coaching instead of mentoring is something they will have to learn. In fact, Dr. Trier began her talk with an explanation of what coaching is, compared to more traditional forms of teaching in medicine, because it’s such a new idea. The article I read found that some faculty had uncertainty about how to structure the coaching sessions and what to discuss, as they met one-on-one every few weeks for a set amount of time. This approach to coaching is very different from the models Dr. Trier discussed, in which teachers discuss with and coach their learners in the moment. These faculty may have benefited from the R2C2 model, in which there is immediate feedback. In addition, this model provides a structure for coaching more generally, with coaches first aiming to build rapport, then providing feedback and discussing the learner’s reactions and understanding of the feedback, and finally for the coach to work with the learner to set goals.

Later in the talk, Dr. Trier mentioned a conflict in medical education, that sometimes learners avoid exposing their mistakes or taking risks because their teachers are responsible for teaching them, but also complete their performance evaluations. Coaching aims to make a safe environment where learners feel comfortable taking risks and sharing their mistakes. However, some learners may still feel this conflict. In the article mentioned previously, the coaches were assigned their learners and by design, they had no part in the assessments or decisions made about the students they coach. I’m not sure how feasible it is to have a separate coach and evaluator in medical education, I wonder if this may be an option to consider when aiming to improve psychological safety and the learner’s willingness to show their mistakes and take risks? Dr. Trier explained that creating this environment where learners are comfortable sharing mistakes, asking questions, and voicing concerns actually improves patient care outcomes, showing how important it is to create psychological safety.

Here’s the article link - https://bmcmededuc.biomedcentral.com/articles/10.1186/s12909-020-02119-z

Best,

Samantha Ables

Name
Samantha Ables

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