TABLE OF CONTENTS

Acknowledgements
Contact Information

Prelude
Rationale for Another Teaching Skills Manual
Structure of the Toolbox
A Brief Review of Relevant Educational Theory
Teaching Ethics in a Clinical Setting: Finding
  Teachable Moments

Preview of Toolbox Features Yet to Come

Core Teaching Skills
Overview of Skill-Based Teaching
Goal Setting
Giving Feedback
Using the Group
 Addressing Emotion
Common Teaching Challenges
  (& Tips for Recovering from Them)


Unique Teaching Issues with Special Topics
DNR Orders
Medical Errors

Resources for Teaching
Annotated Bibliography
Domains for Small Group Teaching

        


     

Teacher-learner encounters can bring up emotions, much as encounters between physicians and patients can. As with physician-patient relationships, addressing the emotion when it is felt or observed can help.

RATIONALE:

Patient care is emotional work, but physicians are rarely given the training or opportunity to express emotions that accompany this work. Often people are even unaware of their underlying emotional state. Unaddressed emotions often appear elsewhere, either in anger, resistance, or a desire to end the encounter (teaching or patient) early. If emotions are unacknowledged, they can serve as a barrier to further learning. It is important to acknowledge emotions when they come up, so the work of learning and doctoring can continue.

PITFALLS:

  • Faculty may worry that exploring emotions of their learners could be seen as an invasion of privacy, so it is safer to keep the discussion at the level of content.
  • Talking about emotions can be seen as "touchy feely", when the work of doctoring and communication skills needs to be very concrete and pragmatic.
  • Often faculty do not explore learner emotion as they feel they do not have the training to deal with personal emotions once they are out on the table.

SUGGESTED PROCEDURE:

Name the Emotion. When making an observation about a learner's emotional state, often the teacher will have a hypothesis about what is going on. You can test your hypothesis by naming the emotion with the learner, and see what happens (e.g. "You seem sad today.") The learner can have a chance to clarify the emotion (e.g. "No, I'm not really sad, just feeling a bit run down.") or open up if they wish (e.g. "Actually, that last patient interaction really got to me.").

Explore. Often teachers will get a sense from a learner that something is going on. If your sense is that your observation might lead to some worthwhile reflections, you can explore the emotion with the learner.

FACULTY: How is it doing this all day long?

LEARNER: I don't have this experience all day long, you have consults. But I worry sometimes that I will have trouble, because this is what I love, I get a high off of it, everyone has the thing…best time to be a physician.

FACULTY: So, what I'm hearing you say, is that even if it makes you sad there is a certain degree in which the connection through the sadness makes up for the sadness and is what you like about being a doctor.

LEARNER: It's huge, it's huge.

GROUP MEMBER: It is an intimate relationship.

LEARNER: And people let you in and it's amazing.

FACULTY: But it is different for everybody and everybody does it differently. I think it is a real blessing to be able to say, to be clear for yourself about what makes you get up in the morning and say I really like to do this.

Give Feedback. Sometimes the learner will identify the emotion directly. Depending on the circumstances, faculty can help offer a perspective to the learner by sharing observations and feedback.

FACULTY: I know you were very anxious…

LEARNER: I'm still anxious! Whenever I give bad news.

FACULTY: If you are still anxious, where does that come from?

LEARNER:…the seriousness of the work we are dealing with …

FACULTY: Do you think this is typical of your encounter for you? What you just did here, do you that was different than what you normally do?

LEARNER: Well, my reactions with him I do with my own patients, but it is not typical with all of you here! But I often feel anxious when I respond to patients like this.

FACULTY: Well, for what it's worth - I understand that you have that perception - and that certainly you have that anxiety feeling inside. Earlier you said that you worry about yourself talking too much, which could be one way your anxiety comes out. This time, you appeared quite calm. You spoke slowly and left lots of room in the dialogue for the patient.

In another exchange with a different learner:

FACULTY: Okay, so you had a little trouble with the start-up and we just discussed that. But the point at which you actually called "Time" what were you stuck with there?

LEARNER: She seems emotionally upset, right, and I try to give, try to name that emotion: "I can see you're upset." And I don't see any response.

FACULTY: Okay…what kind of response do you want to see?

LEARNER: Well, I want to engage her in the conversation, so I can know how to help her better. Maybe it's just some time that I have to wait –give the emotion some time to digest, and let it out.

FACULTY: How long do you think she was crying before you said anything?

LEARNER: I don't think it was long. It was just getting to the point where I felt nervous.

FACULTY: Exactly, good, good. It was maybe ten seconds.

LEARNER: That short?

FACULTY: I understand that you feel anxious, that you feel nervous in front of this kind of emotion - she feels horrible. And she is sitting there with it and she has blanked you out of the room. So you can just be there with her, and let it go as long as it needs to go. And just touch base - not necessarily inquire anymore - but just support. Just with an empathic statement, something like: "This is obviously a bombshell for you." ......Okay, do you have a sense of how you might do that?

LEARNER: Well, again, I think I realize I set up too much goals for myself. I really just have to see how the patient responds.

FACULTY: Yes, try to touch in with her emotion right from the beginning, and then go on with the rest of the story.

Turn Insights into Practice. Connecting emotions, and our responses to them, to practice can help reinforce the importance of this awareness for clinical care. By connecting with a practical implication, the teacher can avoid the pitfall of feeling like they are inappropriately exploring learner emotions.

LEARNER: I think I have been, in my routine practice, I have a little bit of avoidance behavior, in terms of eliciting emotions. One way I use to avoid it is by focusing on the medical aspects, like what I did last time…[runs through various medical descriptions & analyses], trying to hide my emotions and trying to avoid what she is feeling right now. So I think that is most useful for me - that we do not need to avoid emotions.

FACULTY: That's great. You have a wonderful insight into what is making you have the behavior that you have. So now, let's try to translate this into the skills. Now that you understand what's going on, let's turn it into practice.

Flag for Further Thought. Not all emotions and responses will be able to be addressed or explored in the moment. However, faculty can still identify what might be happening and flag it as something to discuss at at a later time. Flagging it makes faculty thinking transparent (e.g. "we don't have time for this now, but I want to get back to it later") rather than just moving away from the topic or emotion without acknowledging it explicitly. Learners might assume that they shouldn't go there if the faculty just moves on quickly. Faculty can also ask the learner to think more about what the issues are. Reflection can often be more productive given more time. For example:

FACULTY: How are you doing?

LEARNER: I am learning.

FACULTY: Good. What did you learn?

LEARNER: Acknowledging emotions before going ahead with other exploration.

FACULTY: Great things to learn, great things to learn. I think you really did a nice job, and worked with that. Maybe at another time we can talk about why it was so hard - maybe think about that a little bit - why it was so hard to get out those statements, about acknowledging emotion. Because once you did clearly it felt very good to [the patient]. and sad situations.

PEARLS:

  • Addressing learner emotion by either naming it, acknowledging it, or exploring it, can help raise self-awareness within the learner about places where they have difficulty.
  • Identifying how emotions can impact patient interactions can help learners find positive coping strategies for their emotions, such as simply acknowledging they are part of a normal response to working with patients in difficult and sad situations.

REFERENCES:

  • Novack DH, Suchman AL, Clark W, Epstein RM, Najberg E, Kaplan C. Calibrating the physician. Personal awareness and effective patient care. JAMA. 1997 Aug 13;278(6):502-9.