Just as with patient care, not all your teaching encounters will go smoothly. The goal in both situations is not to be perfect, but rather to be aware of potential challenges and to develop strategies for addressing them when they (inevitably) come up. We have identified a few of the most common challenges that we have faced when doing skill practice work with medical trainees.

Resisting the Role Play. There are very few learners who embrace role play work right from the beginning. More often, learners will challenge the relevance of doing role play work. Some comments you might hear include:

• "This just seems unreal. I can't act like I normally do with my patients."
• "If I had a relationship with this patient, it would be different, but this is an artificial situation."
• "This is ok, but in reality I have to also deal with writing orders, following up on medications, and a waiting room full of other patients!"

One way to respond to this challenge is by anticipating it and addressing it upfront. Before you begin a skill practice session, ask the learners what they don't like about role playing. Once those concerns are out on the table, ask them to imagine why it is that we still ask them to do it. You can be upfront by acknowledging the limitations of the context Ñ it is artificial and the learners will not have developed a relationship with the patients yet. You can also reinforce the safety of the situation and characterize the skill practice as an opportunity to practice new skills, take risks, and make mistakes. Once the learners have had some practice with the skills, they will be able to try them in real patient care contexts.

You can also ask how they learned other clinical skills. "Think about the last new clinical skill you learned. How did you learn to do it?" Most likely, they will say things like, "By observing someone do it," "by practicing," "by walking through the steps in a 'dry run' before I did it with a patient for the first time," and so forth. Often learners assume that communication skills should just come naturally and that they are somehow different from other technical skills they have learned over the years. Reinforcing the connections can help the learner appreciate the need for a dry run with the communication skills also.

Finally, you can simply ask the learners to humor you. Often no amount of negotiating or arguing will help the learner feel good about heading into a role play. Just asking the learner to try it and see how it works, can be your most effective route.

Questioning the Content. When teaching communication skills, often faculty will bump up against pre-existing beliefs in the learners that run counter to the approach being taught. This learner resistance is not to the process (as above), but rather to the content itself. This also is to be expected, as many of our communication strategies ask the learner to turn a usual practice on its head. Some ways this challenge might appear as follows:

• "How do we know this works. Have they been tested in an evidence-based way, or do we have surveys to show that patients like statements of understanding?"
• "I think most patients would just get annoyed if you tried to ask them anything before giving them the test results."
• "How can you say that so it doesn't sound fake? It just sounds so contrived, or psychobabbly to say that."
• "But I won't be there throughout her treatment. Isn't it misleading to promise her that I won't abandon her?"

Many of these challenges from the learners reflect misconceptions about what the skill is asking them to do. In those cases, identifying the misunderstanding and clarifying the expectation can be helpful. For example, in response to a discussion about how exploring with a patient before you give bad news is likely to be harmful or just annoying, the faculty member clarified:

FACULTY: The other thing I want to mention is social chitchat. 'how you doing' 'how's the weather' 'how was the game last night' Those statements have nothing to do with anything. That you usually don't want to spend a lot of time on, but it has its role. So the other thing is 'how have you been doing since the last time I saw you,' and that's not chitchat that is exploring the patient's expectations and finding out where they are right now.

Faculty can also encourage learners to find the words to say that will feel natural and not forced. By returning to the goal of the communication skill (e.g. to show support, to encourage, to explore, to diagnose, to align with the patient, etc.), the learner can identify a way to accomplish the goal but through her own words. Acknowledge that the statements can feel awkward at first. Encourage the learner to try them out. It is possible that feedback (explicit or implicit) from patients will help reinforce the skills once they are employed.

Limited Self-Assessment Abilities. Since one of the teaching strategies we emphasize is checking in with the learner and asking for an assessment of his own abilities, this works best with learners who have good insight into their strengths and limitations. However, not all learners are good observers of their own behaviors. Others will have different assessments of the patient encounter than you have. Finding middle ground with these learners is a teaching challenge. Some challenging learner behaviors include:

• Saying an encounter is "going pretty well" when you think it is not going so well.
• Having difficulty naming an emotion the patient is experiencing, or that the learner is clearly experiencing, in the encounter.
• Missing the teaching point

These are challenging teaching situations because they risk setting up a conflict between the teacher and the learner. You have a different assessment and you want to communicate it. You have a few options. You can use the group (e.g. "What observations did you all have from this exchange?"). Often group members will identify some of the teaching points of interest, which keeps you from having to set yourself up as disagreeing with the learner. You can ask the learner to explore her own observations (e.g. "How did the patient seem during the discussion?"). By asking the learner to consider a few more data points, sometimes you can elicit some new insights into the encounter. In other circumstances, or after those two options have been tried, you need to be direct if it is a point you want to get across. Keeping your observations and feedback tied to specific behaviors can really help your feedback not seem personal (e.g. "I noticed that you seemed to be pulled back into your chair for much of that discussion. Did you notice that?").

You also want to promote the underlying issue here which is developing the learner's ability to self-assess more accurately. By giving direct feedback and asking probing questions, you can help the learner's self-assessment ability to develop. Your teaching will be most effective if you can meet the learner where she is, even while engaging her in the next steps to move forward in her own development.

Group Dynamics. A common challenge for teachers is managing group dynamics. It is rare to have a group that works well together right from the beginning, all contributing equally, respectfully, and fairly. More often, you will have a few silent group members, or a few dominators that set the tone for the whole group. Addressing these issues early and often can be the best strategy toward redirecting the tone and setting expectations within your group. You can try invitations and direct questions to the group to draw others into the discussion (e.g. "That is an interesting idea Steve, what do the rest of you think?").

A group member might pose all his questions to you, in deference to your expertise. To answer him directly will go counter to your goal of engaging the group, so you can always turn a question back out to the group for their thoughts before you answer (e.g. "What can you do when the patient starts to get hostile and you are trying to be empathic?"). Your response to his question will re-engage the group in the discussion and it will also model for the group that you value their contributions, and demonstrate for them that you will be in the role of facilitator rather than expert-lecturer for the day.

If a dominant member does not take any of your cues, you might talk with her separately outside the group. Emphasize that you appreciate her insights but that your main concern is in giving everyone an opportunity to share their ideas. One of the primary challenges of teaching is that you are often asked to attend on multiple levels. You will be paying attention to course goals, content areas, skill practice, as well as learner responses, group dynamics, your own responses, and time management. Doing all of this well takes time and practice. There are several strategies you can employ to help you get there:

• Sharpen your observation skills. It takes practice to attend on multiple levels. When you begin, it is likely that you will focus on the content of the teaching lesson. As you move forward, consider consciously chosing one additional thing to pay attention to during the session (e.g. "Are all group members participating?"). Over time you will add more and more elements.
• Develop and test hypotheses. Get curious about your learners. Once you have begun making observations, start developing ideas about what might be going on (e.g. "Tom seems really withdrawn today. I wonder if he had a tough call night last night."). The next step is testing your hypothesis by asking about it (e.g. "Tom, how was your night last night?").
• Be transparent. You can let learners know what is going on in your head as a way to enlist them in the process (e.g. "I'm just conscious of the time and I am wondering how we can fit these next two pieces in before the break.").

These, and many other, challenges will come up during your teaching sessions. When you encounter them, it is not a sign that your skills have failed. It is simply the nature of teaching something as complex as communication skills and ethics to a group of learners as diverse as physicians-in-training. Developing the abilities to recover from these challenges when they occur is the goal for you to be successful in your teaching.