Psychiatry & Psychotherapy Podcast - Connection and Supervision in Medical Education: Exploring the utility of the Connection Index in postgraduate psychiatry training

Episode Date: November 10, 2023

What causes burnout among residents? There are many factors associated with burnout supported in the literature. We can break them down into environmental factors, personal factors, and non-modifiable factors. In this episode, we dive into the major factors of resident burnout and how the connection index can improve resident morale.  By listening to this episode, you can earn 1 Psychiatry CME Credits. Link to blog. Link to YouTube video.

All right, welcome back to the podcast. I am joined today with some colleagues from the University of Ottawa. We recently presented at the Association of Academic Psychiatry, and this will be a episode where we basically go through what we talked about. It was on the value of good supervision and connection in medical education. I am joined today with Lauren Hission. She is a fourth-year resident at the University. University of Ottawa. Lisa Johnston, she is a child psychiatrist who runs a day treatment program, dual diagnosis, and Mariana Yovanovitch, who is the child adolescent program director and who is heavily involved in medical education. Welcome to podcast. Hello, thanks. Thanks. Thanks for having. Lorna, I'm going to start out with you just jumping in to the kind of the introduction on the

problem that we're facing in psychiatry and go ahead. Perfect. I think I'm a PGY4 resident right now and I started my first year in the pandemic in 2020. And so I kind of noticed right off the bat that things were really different. I would hear that things used to be different kind of pre-pandemic and been noticing like a really large amount of burnout within my colleagues and when talking to people and other programs. And essentially, when we kind of look at who the bulk of residents are working right now in our hospitals, most of them have pretty much spent all or most of their

residency working as first-time physicians, either during COVID-19 or after the pandemic. And essentially, the impact of this on burnout has been high and is supported in the literature. So there been a lot of studies that have been looking at burnout rates. And one was published in 2022 that showed burnout in psychiatry residents specifically being as high as 78% and 83.3%. Now, pre-COVID, this number was way lower. It was more like 21%. And so we can kind of see that that's a substantial change that I think a lot of people have probably noticed themselves in their programs. Yeah, I've seen it as well in our program that I'm associated with. It's not just the residents, it's also the attendings. And I do a lot of coaching across the U.S. and the world, and it seems

like it's been a common thread pretty much across the board. Like, people are just really tired. And patients feel it, too. Patients talk about how it's really hard to get a therapist. It's hard to get a psychiatrist. And yeah, so go on. And during our meeting, too, we asked kind of the people who were in the room. And I don't think anyone said that, that, you know, they felt like things were going really smoothly since the pandemic. And I think everyone had identified similar, similar concerns and issues. So, yeah, it's definitely across the board. Yes, it seems like having to switch to doing a lot of the work virtually and folks mostly working out of their homes has reduced the amount of connection and sort of that face-to-face connection lacking compared to

pre-pandemic has been one of the major themes. And there's a lot of factors that can contribute to burnout, you know, environmental factors, you know, of the workplace itself, personality factors of the people experiencing the burnout as well as more non-modifiable factors. If we look a bit closer at environmental factors, these can be things like the number of hours that are worked per week, the number of on-call shifts per month or weekend on-call shifts.

So these can be big factors. that can contribute number of patients seen per day or clinics per week. And so these are all kind of aspects of the day-to-day work life that can certainly contribute, but also in the environment are the relationships with the people who you're working with. So having difficulty maintaining positive relationships with supervisors has been shown to be related to burnout, as well as occurrence of psychological abuse or poor faculty supervision, contributing to worsening learning experiences.

So all of these have been shown in literature to worsen burnout. In regards to personality factors, things that have been shown have been things like high neuroticism or use of avoidance as a coping technique, coping with self-blame, use of substances, venting, lack of physical exercise. So these are our other kind of more personal aspects that can contribute. And then there's just the non-modifiable factors. So things like your first two years of training are a really high-risk zone for burnout. So first-year residency, second year, if there's a history of receiving mental health in the past,

so any kind of previous psychiatric history, being female, unfortunately, is a risk factor. And then being just in general, younger, younger age and not having children. So these are kind of the main things in the literature that show burnout factors. there was a narrative review actually of studies published between 1990 and 2015 that was looking at all of those types of factors that are within the learning and work environment and the individual attributes of residents and trying to kind of see what are the main drivers. After reviewing all of these studies, they showed that ultimately those factors within the learning and the work environment, rather than those individual attributes of the residents

were actually the main drivers of burnout. So I found that kind of interesting. You know, it's less about that person and who they are and how they can change and more about what's going on around them in the organization as a whole. I think that takes a lot of the shame out of it. When I read that study, I was just like, oh, so you're saying that just targeting the physicians, you know, or the providers,

Like, that's not necessarily the solution, but it's commonly presented as a solution, you know, like, oh, here, let me add something to your schedule. You know, let me add like an extra learning communication skill thing, you know, where it's like, no, actually, if you change the environment so that you have more support staff, you make the physicians less busy, less busy work, things get better. Yeah, totally. That brings us into the next study, which was essentially the systematic. review and meta-analysis that looked at all different types of interventions that can be done for burnout. And essentially, they showed that any kind of physician-directed intervention. So these are the mindfulness-based interventions, the stress management skills, workshops. These were only associated with a small reduction in burnout scores. So it didn't have much of an effect, whereas the

organizational directed interventions. So these are actually looking at workloads, schedule, teamwork, camaraderie, they were associated with a moderate reduction, so a larger reduction in burnout scores. And even furthermore, you know, specifically the mindfulness-based interventions, a lot of people have looked at this through systematic review and meta-analysis and to find that it's actually really small reduction, burnout, and overall low quality of evidence. So it's something that's often pushed on residence. It's often that, as you say, kind of extra time added in terms of workload, but the evidence doesn't support that it actually works.

Makes you want to give some of that information to those, planning those, because I think we still get a lot of, you know, emails and messages from all over the place that that burnout is, is a personal responsibility. And if you do X, Y, Z, then that's going to make a huge difference. And, I mean, the science doesn't show that, right? It shows that those are small things.

And when we look a little bit closer to in the literature, there's this other study that was completed on Reservoir, across multiple specialties that showed that if they were personally mistreated by people they were eight times more likely to report burnout and four times more likely to report symptoms of anxiety and depression. So we can just see how important those relationships are in the team. There was this other study done on frontline workers working in New York City during the first year of COVID pandemic. And they found that if they were feeling valued by their supervisors, this was associated with a decrease in burnout odds, which is kind of amazing when you think about it. You know, you're on the front lines.

You're really high risk of burnout of having been overburdened with, you know, not only the physical risk, but emotional risks and the toll that that takes on you. But, you know, if you felt value by your team, felt valued by your supervisor, that was a protector for you. Yeah, I think the difficulty with that is you don't always have a choice in who's supervising you, right? So as a resident, you're kind of in this precarious position. And I've spoken to residents who literally have zero people in their residency program that they feel is warm, compassionate, understanding of them. And so they have to find it outside of it. So it's like, okay, you as a resident, you may need to get through to graduate. and you may need to also seek out supervisors

who are outside of your program, who are people that you can feel connected, warm, you know, essentially like compassion, right? And by the way, like, I've been in practice for over 10 years. Like, this is something I still pay for, you know? When you get out of residency, you pay a whole lot more, I guess you're paying in residency by just making less. But when you become an attending, you know, you, I don't know,

like for me, I still value it so much that I pay people very well to supervise me and to just, you know, it's so important. So, okay, Lisa, Mariana, anything jumping out at you? I was just a bit struck by how, you know, it would be really challenging while you're in a residency program to even kind of like find the time or nowhere to look for some of that extra supervision. If it, you know, if it wasn't built in and especially if you're feeling kind of burnt out already, you know, would you have the capacity to take that on, right? So that's what struck me about that. Yeah, like me saying that could be another level of shame. Like, you should be able to find a supervisor outside of your residency. Like, it's rare, right? Like, it's like, it's a gift when you find a good

supervisor. And I always tell residents, like, when you find a good supervisor, like lavish your gratitude on them, because that's honestly how they're usually paid. They're not paid more. to be at an academic center, believe it or not. Okay, Lisa, go ahead. So I had two thoughts, and one of them is that I still have mentors from my old, like from my residency program that I still reach out to, you know, if I'm needing that extra support or have those questions. So it is really helpful to have that network that you can go to.

And then the other thing that struck me was just how, too, with the pandemic, I think we all got into the Zoom world, and it was harder to find those times to connect. Like pre-pendemic, if you're working with a resident, you might have a little downtime, and maybe you sit down and have a bit of a conversation or go for coffee or something like that. And I felt that with COVID, everything, you know,

that was virtual, then you're back to back to back. There really isn't that space or you hang up the meeting. And really, I think that all of that, support, I can only imagine how difficult it would have been to be a resident starting in a brand new city program, everything to then be kind of isolated with only Zoom and then people who are exhausted and logging out and not finding those little moments to connect and to check in and things like that. Oh, absolutely. It's like the small bump in. I mean, so I lead an IOP partial from another state now, you know, and I like, I used to have during the meetings the before

and the after where you're just having casual talk and such like that. It just doesn't happen over Zoom in the same way. Yeah, so I absolutely agree with you. It's a different world that we live in. And I think even taking a step like supervisors, the effective supervisors on relationships are really powerful. But there's also like a lot of other people on the team as well. But I think the study also just lent to that kind of specificity or the importance of that specific relationship between resident and supervisor because they looked at the satisfaction of residents with the social support that they received from supervisors, peers, nurses, patients. And they actually showed ultimately that the best predictor of burnout was dissatisfaction with that emotional support received

by supervisors. So it is this like special relationship. Even though there's a lot of people you're working with. There's a lot of people on the team. There's something about that dynamic. There's a literature review done a while back now in 2000, and they reported actually that the supervision relationship was the most important factor in effective supervision. So more important than the type of supervisory methods used. And I mean, this makes me think about, you know, that kind of educational alliance, you know, in the same way of there's the therapy. Approprietal alliance, you know, when you have that connection between your supervisor, when you have that safety, kind of even doesn't matter what way you're teaching, but ultimately the supervision will be more effective if that's there. Another study showed that working in good team culture was ultimately associated with less clinician exhaustion. And I mean, this seems like a no-brainer in a way. You know, of course, if there's a good team culture, camaraderie, people, people are going to want to come to work and probably feel less.

exhausted. Yeah, absolutely. All that stuff just makes complete sense. And that's, you know, part of the motivating force behind the connection index, which we'll get to in a bit and why I think it's so important. And there's other studies, too, that are looking at, you know, just the specific factors of the Maz, Maslack, Maslok burnout inventory. These are the personal accomplishment, emotional exhaustion, depersonalization. These are those three aspects. that are always measured when looking at burnout. And they look at how they are associated with that supervisor training relationship. One study actually found that interventions that were done to improve the connectivity

between residents and faculty. So this was with use of like movie cinema nights or hikes, you know, these kind of extracurricular activities that are taking people out of the clinic, out of the office, showed to improve residents' perceived personal accomplishment. So that's that one, you know, sub-scale of the burnout inventory. And within personal accomplishment is a lot of like meaning and purpose. Like I'm finding meaning in work. I'm connected with people.

And so, yeah, it's interesting how that specifically jumps up there. Okay. Yeah, out of the other ones for sure. And there's this other study done in Brazil that looked at the relationship between residents and their preceptors, as well as. kind of looking at the relationship within the climate of the institution as a whole. And they saw that that was more so correlated with the emotional exhaustion and depersonalization. So those other aspects of burnout.

And specifically in the study, they kind of showed that that feeling of always being short of what preceptors expected of me or the feeling more pressure than helped by my preceptors, that was quite highly correlated with emotional exhaustion and not feeling a collaborative climate in the institution and not feeling like I belonged and my institution was correlated with that depersonalization score. And ultimately, they thought that interventions that could be aimed at improving the quality of relationships within an institution may have a potential impact for improving burnout. I remember how hard it was in residency that you'd have a new supervisor fairly frequently and each person had their own way of doing things and just that like adding on top

of everything else that needing to adapt to that supervisor. And I always found that I valued the ones that like gave me space to to have my own style, recognizing that as long as I had the information there, as long as I had done all the things I needed to do, it didn't really matter how it was done. But then sometimes you have supervisors who are really rich, about that stuff. And it's just like another, there's so much in residency that you have to do and that if you don't have a place

where you feel like you can, you know, talk to your supervisor that you feel supported and all that stuff. There's just so much that piles on. Yeah, absolutely. And when we kind of pull together all of the research from this literature review, we can really see that the relationship

between supervisor and residence is a really important kind of environmental mitigating factor in burnout. You know, as we know, culture in institutions comes from the top down. And so if we kind of think about if there are large cultural or interpersonal connection issues in a program, you know, that could potentially be the source of a problem. There's a big burnout problem in a particular program or institution. We can also see that more individually driven initiatives versus individually driven ones are more effective at reducing burnout. And as such, we can kind of consider targeting this interpersonal connection, perhaps, between residents and supervisors as a potential avenue to explore when wanting to actually look at improving burnout, which lends us into talking a bit further about the connection index.

Yeah, so shall I pull up? Shall I pull up my hand out and get through it? Lauren, you did a truly excellent job on that review, and I think you added some studies that I've never even seen, some newer studies, so I really appreciate that. Oh, cool. Thank you. Okay, so I'm going to go through and kind of talk about the Connection Index. So, yeah, kind of building off of what Lauren was talking about,

the importance of connection. connection, I had this idea that I needed to be able to measure it, right? If you can measure it, then you can maybe make an improvement. And if you can make an improvement and you can measure it, then it's like you can show like, hey, this is really important. So I thought this is super important. Why don't we focus on this? So in the initial study, I had 61 questions. We tested every six months in my program for two years. We had 100% response rate, which I can contribute, which I can say is a lot of hounding. And it's also a trust. The residents trusted myself. They trusted Dr. Pro, who was heavily involved in this. And we were

able to look at seven domains. So this is more than the Connection Index became, but I just want to kind of outline how we came to the Connection Index. So we started with seven domains, empathy, education alliance, psychological safety, effective feedback, subjective emotional experience. And we also had a bullying harassment and prejudice and bias domain. So through factor analysis, we showed that all four domains of empathy, psychological safety, educational science, and feedback flowed together, meaning all the fish are swimming in the same direction. If you're high in empathy, you're going to be high in feedback. If you're high in feedback, you're going to be high in educational eyes.

If you're high in educational eyes, you're going to be high in psychological safety. So it's not like these four different domains. There was never a case that you could be high in empathy, but low in feedback. And so really that changed my conception of feedback even. Like what is good feedback? But knowing your person that you're training, knowing what they know, knowing what they don't know, knowing how to give that information in a way that is non-shaming, what is psychological safety? Psychological safety is the ability to speak out if you disagree with your supervisor, right?

So it's like, do you have too much fear that you can't overcome speaking out? So there's some people who are just going to have a harder time speaking out in general, but if you have a really good supervisor, they create space for you to disagree. if you had asked questions for you to put words to things. And lo and behold, that supervisor also is high in empathy, right? And so all of these four domains flowed together. And I think that's really, really important. We reduced all of those questions, 61 questions, to 12.

So that became the connection index. So it's a lot faster to fill out. Like imagine these residents filling out tons and tons of questions. So we were reduced it to 12. And they were all highly related, which means, once again, when you scored high in something, you scored high in all of them. So we used something called the Nine Criteria Framework. My mentor in this, Dr. Cashner was a statistician genius, one of the most published medical education researchers out there. Interesting side note.

He saw me give a lecture on Connection. at the VA, and he was like, we need to do research together. Let me help you. And so we started meeting. We had a close friendship from a number of years. Okay, so Dr. Kassner and I worked hard on this with a bunch of residents and medical students, and we eventually looked at, you know, different statistical measures that showed that this was valid. I won't go into all the details. There's a published article that we have in academic psychiatry about that. It will overwhelm you.

I was impressed when I've gone through it. All, like, just everything that you guys pulled from to come up with the questions and all of the analysis that was done. It's really quite, quite impressive. Oh, thank you, Lisa. I appreciate that from a fellow academic psychiatrist here. Yeah, so I think it's worth kind of going through some of the, questions like just to reiterate what psychological safety is. It's like things like I would voice my concerns or questions with this person. I felt free to express things that worry me.

I feel free to ask for more information about his or her decisions or actions. So that's psychological safety. So before this measure was created, you could only measure psychological safety of the group. So there were no studies that I could find of individual psychological safety. And so this measure allows you to pinpoint a leader and say this leader is creating this dynamic. So it's not like this amorphous, like this whole like culture thing. It's like, no, there's like a specific person and not to get ahead of myself. But what we found is that like I did this in different departments and we test it once. And then the chair would come back and say, ah, I'm worried that like if we take,

test it again, they're going to get very different scores. No interventions tested again, they get the exact same score overall. So it's out of seven. So maybe they got 6.5. The first time, they get 6.4 the second time. So it's like very consistent unless there's a concerted change that occurs. Okay. So what we found, I'm not going to read all the questions, but what we found was that the stress that occurred within the encounter with the supervisor decreased like a linear line the more connected they were. So if they were connected, seven out of seven, it was a whole lot less stressful than like four out of seven, right? Shouldn't be a huge surprise. It was like a linear line, okay? Whereas prejudice and bias had a drop-off. So this was really interesting

me. Like, a resident would not report any prejudice and bias in an attending until they scored below a four. It went, it went a step up, right? And so that's really important because when we were thinking about a correlation, we usually think about just a linear line. But in this study, we thought of things as like, are there step-ups or step-downs? And we found that with burnout, there was really not a lot of difference between a four and a five and a six. But when you got to a seven connection, so the top most connected you could possibly be, there was a drop in burnout. Specifically, emotional exhaustion dropped about 0.6, which is the difference between something like,

I feel emotionally drained from work a few times a week to once a week. Like, that's how big of a drop it is. Okay. So interestingly, as our program studied this, this was pre-COVID, right? And so I'm sure it dropped during COVID. But the connection scores went from a 6.0 to a 6.65 on average in our department. Now, how did that occur? well, we talked a lot about it during those two years as attendings.

They knew that they were being measured. We talked about connection, the value of it. We talked about supervision. We excluded a couple supervisors who were scoring below four from supervising at all. Because we were like, okay, now we have the data. They're just not connecting. One of the supervisors would just have the student read the DSM to them during their supervision time. Literally just sit there and read the DSM to me.

So this supervisor was no longer allowed to supervise residents. Okay. That must also, I'm just thinking if you knew, you know, everyone knows who those people would be. And so I imagine, too, like just adding that relief, like, I'm not going to have to do that rotation, right? As I'm preparing and learning what my schedule is going to be like, there's, I imagine a sense of dread, right? like I hope I don't get this supervisor. I hope I don't do this awful rotation. And so then knowing that

that then we've got a group of people who's interested and they care and they want to see, you know, residents succeed. I imagine that also takes the weight off of everyone's shoulders. Yeah, and think about it like this as well. It's not like the chair. It's not like the program director didn't hear stories about this bad supervisor over the years.

But once you put a number to it, and it's like, no, this person's scoring below four, this person has some prejudice and bias and bullying harassment. This person is like every resident scoring below four, then it's like you can't ignore that, right? Like you can't just say, oh, I think it's all in the residence's head. It's like, no, there's a data point. It's a valid measure. Like, it's more than just a story, you know? The other thing I like about this is because it is so short is that it's easy to do it after like many clinical encounters or even a small amount. So even if you're on call with a person, residents could fill it out for what that call shift was about.

So I think that it's nice because it's pretty quick to then gather a whole lot of information and feedback as well to use. Yeah. When we measured it in other departments, I wanted to get an idea of how close these two people work together. Because if you only like did one case ever with this person, I wouldn't want that to be weighted in the same way as like someone who spent like 30 or 40 cases, right? So when we did in like surgery departments, I would ask how many cases did you do? When we did in like the, you know, OB department or anesthesia, it was like, you know, so we use different ways. of judging the closeness that these people work together. Because if there's like an outlier and it's like, oh, you had one case with this person, you had one bad experience, it's like, okay, I don't want that to like color this attending's persona who, you know, after 30 cases, he gets along with everyone, you know? So I definitely think intensity matters to some degree. But yeah, I think you're right.

It could be after just one call. Like you could just, you know, see how things are going with this attending. especially if you're like a program director and you have the ability to coach new faculty and I would say as well like if you are the chair or the program director and you take on a punitive shame inducing role basing off this connection index you are like losing the spirit of this right and so I never like there was one time the GME brought me in to to measure a program and And then I learned, after measuring it, they wanted to use this for a legal case. And I was like, no way.

Not giving you the information. Shut it down. Deleted the files. Boom. Sorry. You can't subpoena me. And like another time, this department just wanted me to come in and run it and then give the individual people their feedback and to not give it to the chair. So that or not give it to HR.

Like I would never give it to HR. This is not punitive. This is a growth measure in my mind. Okay. So, yeah, if you're a chair using this, though, you have to then be connected to the person that you are working with and be like, hey, there's no shame in this. We're all growing.

We all have a starting point. We're all trying to get a little bit better. And this is a value that we have. And we're, you know, like, I am concerned about your connection with me, right? Because like if you're the chair of a program, I was going to say you can do another connection index too, right? The connection index would be the faculty member with you as the chair, right? And that would be your rubric for how successful you are as a leader.

I would say it's the same for me at this point. I have some psychiatrists that work for me, some therapists. It's like for me running the connection index is like looking at their connection to me. And if they're connected with me, like we build culture and we have a great time. And that's, and one time I was. supervising a nurse practitioner. And she had this boss. And it was just he, he would rant, he would belittle her.

He was very meticulous. And it just went on and on. And finally, I was like, look, there is no amount of psychological stabilization I can do for you other than leaving this job. She left the job, got a much better boss. And things just went blissful. You know, like that was the issue, right? Okay. I'm going to talk about this qualitative study that I did.

We looked at 16 medical students. We videotaped them. We looked at themes that came up. We had them rate the most connected and the least connected attending. We had them go through the questions, and as they went through the questions, we had them talk about why they answered in a certain way. And so I wanted to look for themes of what were the commonalities in people who are highly empathic, people who are highly psychologically safe or people who were not. So this will kind of give a little

bit of meat to like what are some of the common things that you might find in a highly empathic attending. And just before I start, like one thing that came through was like the best of the best attendings often fed their medical students or residents. So if you want to do a one quick win. And that would be tricky during the pandemic, right? We didn't get that opportunity to go and, you know, socialize in a food environment. Absolutely, absolutely. But feeding people is important. Feeding people just having a cup of coffee.

It's like you guys remember what it was like to be on that surgery rotation when that was not valued. You were not allowed to eat. You had to like eat in the corner. You know, you had to find a closet. You could quickly eat your cliff bar before the next case or something like that. And then you met that one resident or fellow who was just like, hey guys, let's go get some food, you know. like here, hey, let me put it on my card and you were like, ah, like, this is such a gift from God here, you know, it's like, what's going on? So food, food was one commonality that just,

before I even start, I'll just put that out there. Okay. And it's something easy too, right? Like, that's not difficult. I think when you're working virtually, it's a little bit different, but, but if you're there, something to remember Adam, the schedule, so it's not something that's really challenging. Not, okay. So I gave this talk. Sorry, it's simple, but maybe not easily, but. Oh, I know, I agree with you. It's like something that you can do.

Okay, I gave this talk with dermatology grand rounds, and I had a bunch of attendings there, a bunch of residents, bunch of fellows. Every medical, like three medical students came to me afterwards, like a month later and said, after you gave that talk, they started feeding us, and the rotation was just so much better. And it was like, it was amazing.

Yeah, like, they were like, yeah, they brought cookies in. they brought, you know, food for lunch. They made sure we were full. Like, just that one comment made all the difference. Okay, so let me start with the empathy domain. Highly empathic, connected supervisor, was mentally present, paid attention, engaged, understood the concerns or made an effort to do so, got to know the student on a personal level, acknowledged the student's presence and their work.

Very basic things, right? Do you know your student's name? Do you know a little bit about their life, their story, what they want to go into, what they want to do after residency? Do you, like, show up mentally, like, not have your phone on? You know, give them the same attention you would give a patient, you know, where you're, like, trying to give them your undivided focus. Okay. So that would be the high empathy domain. The least connected supervisor.

This was the empathy domain, the commonalities, not mentally present. only concerned about their own matters. It's very self-preoccupied. Didn't know the student's names. No questions about how they were doing. Made the student feel non-existent. No respect of their time. And the students feared making mistakes.

So that was the low empathy commonalities. in the psychological safety domain, the most connected supervisor had these commonalities. They were safe to ask questions even if busy or the student thought they were stupid. The senior encouraged the student to learn from and even question their decision-making, and senior cared about the student as an individual and allowed them to express their worries and their thoughts. And I was just thinking about this with like conformity before this episode is released. I'm releasing this episode on the Holocaust, ordinary men, conformity, and how like conformity led to this just absolute horrific horror of horrors, right?

And I'm thinking like one of the best ways to teach people to not conform, not to conform is to allow them to have some psychological safety to express like, hey, I'm concerned about the way that we're doing this. And if you shame them right away, then it pushes them back into conformity. But actually, it's really important to value people's individual meanings,

you know, like concerns, and not just kind of like, say, get in line, this is how we do it. Not only that too, but I think just even like to reflect to reflect back and and even question what you're doing because, you know, we're all out there to learn and there's always new information out there. So even just for patient care to like go, oh, is this the right thing right now, right? And so being able to have learners ask you questions,

I think also is really helpful for like learning as, you know, as a physician too. Yeah. It's, I agree. There's like a humility. in becoming an always trying to learn something new, trying to grow. Sometimes if someone is too far in that domain, someone will see like, oh, this person doesn't know anything or this person, especially if that student is a little bit more narcissistic themselves,

they're like, I don't know if I can respect this person because they're so wishy-washy. And it's like, no, actually they're like trying to value everyone's perspective, they still probably know a whole lot more than you. but they're just open to being wrong. I think it's so important to be open to being wrong and to grow and to learn. Otherwise, you get stuck and rigid and you're like, you practice the same way that you graduated.

And also what a great thing to role model too, right, to our learners is that it's okay not to know and it's okay to ask for help and support from other people, right? Because we're in a profession that emphasizes lifelong learning. and we're in a profession that is always evolving and changing, right? So I just think that that too is such a great thing to show learners. Yep. Yep. Okay, so the least psychologically safe attendings had these things in common. They feared voicing concerns or questions would be seen as useless or stupid.

When they did express questions, their senior was condescending, hostile, or saw them as an attack on their judgment. The student referred to as medical student, not their name. Senior talked without breaks. No explanation of, no explanation for the student was given. And the senior was disengaged.

So that's the psychological safety domain. Any comments on that, guys? I mean, it's bringing me back to the resident rotation. So I definitely can relate. But I think to you again, like these are just some, you know, if you're going through that list, like just get the name of the person you're working with, right? Like, like that's, it's incredible how condescending that is to not know the name of the person that you're supervising, right?

And it's such an easy thing to start with and write down. You probably have it in your calendar. Yeah. Yeah. I was just going to say I have lots of, lots of memories as a med student, you know, being shuffled into the corner and, you know, maybe getting a nod from the attending or the patient, but you're just, you're kind of there to see and not to, not to say. I wasn't even med students sometimes. I was just, you know, corner statue at times. And, you know, even, it's like,

yeah, it could be even worse than that for sure. It's a little bit dehumanizing, right? Absolutely. But you just think, like, even in those situations, like, let's say you're in a are and it's busy something's acute. And so you do need the med student to go do, you know, to be there in the corner, but even just explaining that respectfully, right, like using their name and saying, thank you so much, like this is what's going on. You know, while we're doing this, maybe, you know, giving them a learning task or something like that. And then being able to follow up with that afterwards, I think that's such a huge different

experience than that like, yeah, statue in a corner. keep your mouth shut, don't say anything, a kind of experience. So again, just like recognizing that there might be times where a learner can't be as involved as everyone would like, but treating them respectfully about it, I think would go a long way. Yeah. Okay, let's talk about the feedback domain.

So the most connected supervisor, this is the positive things that came up when asking the feedback questions. They said they taught at the level of the student, which by the way is really hard to do unless you know the student. Because if you have a struggling student versus a student who's maybe thought about this for the last three years because it's the specialty they want to go into, like to teach them at their level takes a lot of nuance. Invested in teaching and making sure the student learned, voiced.

thought process out loud, gave the students assignments, encouraged the student to reteach other students, encouraged student to take ownership of their patients, gave them the autonomy and responsibility, and gave specific feedback. The specific feedback was pretty key. It's like, you should read more. It's like, that's very general feedback. It's very shaming. It's like, you need to read more. Rather than here is a specific chapter about catatonia that will help you with the specific patient and some of your gaps. And then after you read it, let's talk about it tomorrow. So it's like here's a specific area that may be a gap, something that you can learn from it. And then let's talk about it. So it's like you're checking in on them. I think that's really good

education type stuff. Okay. Any thoughts on that, Lisa or Lauren? I was just thinking that you could then talk about it over lunch or a coffee. And I mean, it kind of ties back into feeding people and sharing, sharing those moments. And I think that that then gives the space for some of those either other teaching moments or even those reflective moments on, you know, that can increase the psychological safety, you know, to have, when you're not in the office, you can maybe be a bit more vulnerable and kind of reflect back on a case from the

day before and, oh, you know, I was thinking this and I liked, I appreciate you brought up that point, kind of lends for space to have those conversations. So I was just, again, thinking about the food. Yeah. Yeah. From my like supervisor lens, one thing I've noticed is that kind of following that structured feedback actually makes my life easier to you. It's, I find that it's, you know, usually faster to give that feedback to residents, you know, where things are shifting now with like the competency-based education and doing, you know, a lot of small chunks of feedback along the way. It's really nice to have that structure in terms of how to, how to give that feedback and, you know, picking one area and then having that like follow through. I find that it's really helpful and it's made

my life easier as a supervisor to, and I'm hoping that it's valuable for the residents. And certainly, you know, literature would suggest that it is. But it sounds like an onerous tax. I guess just coming from the supervisor point of view, it sounds like, oh, this is going to be more work. But I personally find that it's faster. It's easier. And I think a lot more valuable. Good. Okay. Here's the least connected supervisor feedback section. concerned with showing how smart they were. So imagine a supervisor that's just like thinking of themselves there. Exposes the student's lack of knowledge.

Only gives criticism. Couldn't give feedback because they weren't paying attention. Mistakes weren't used as learning opportunities. Gave generic feedback. Gave feedback based off of others' observations, opinions. So that's more of the least connected supervisor. I've definitely received a lot of that. The generic feedback over the years,

and you're right in terms of it being kind of connected as well to that empathy piece, because then you're almost thinking, like, do you even know me where I'm at? Like in this rotation, have been connected, have you been paying attention? Because, you know, you're just kind of told like, oh, yeah, keep doing what you're doing, or, you know, keep reading around cases. It's never, you know, sometimes it's hard.

You don't, you're not getting that specific feedback. And then, and then you're not sure what to do with that more general feedback. So I can see why that that would be something rated when highly, you're less connected. And I think it feeds back nicely to that feeling valued, right? And so if it seems like the person's not even paying attention or not even like looking at the work that you're doing, then I imagine that that will decrease your sense of value, whereas if someone's taking that time to look through the stuff that you've done, it shows that, like, you know, you've been doing valuable work, and this is an important

work. It's not just that work that, you know, doesn't matter. It's not just busy work kind of thing. Which totally would change the domain of personal accomplishment, right? Meaning, I'm showing up to work. People value me. if I wasn't here, they would miss me. I'm part of the team.

What I do is meaningful. What I do is changing patients' lives. All of that kind of like feeds into that perfectly. Yeah. Okay. The last domain, Education Alliance. So the students said this about the most connected supervisor. The goal was to teach and they took time to do so.

They taught and gave tasks at the students. level, didn't make the student feel small or stupid, used mistakes as learning opportunities, did not lose respect for the student after mistakes, gave specific goals, tasks, and responsibilities to the student, discussed their learning goals and objectives, made the student feel a valued part of the team, was looked up to as a role model. So things you would desire. from a good supervisor. Okay, here's the least, the least connected supervisor, Education Alliance.

The supervisor dictatorily gave orders without explanations, shut down the student's questions or input, looked down on the student's mistake, yelled at the student for unspecified tasks and skills not taught, called medical student or the wrong name consistently, didn't give autonomy or responsibility over pay. patients, concerned with finishing their tasks rather than teaching, ignored the medical student, blamed students for shortcomings outside the role of the team, expect the student to read

the senior's mind, and sought to bring people down rather than teach them. So things that we don't want to do. Okay, check. Okay, so summary, the connection index includes empathy, psychological safety, feedback, education alliance. When scoring the results, you could look at less of like a linear line with, if you compare it against other things, but you could look at like if there's a step up or step down, which I think that's a little bit of statistical nuance. Any good statistician could help you figure that out. And attention and ability to understand the student is a theme of high

connection attendings. I think it's wise if you're in leadership. and psychiatry to have this measure, and then you can use it to do coaching based on good and bad scores. I think if someone scores above a 6.5, you don't have to try to get them to a 7. You can just celebrate them. You can, I don't know, like encourage them, try to find ways of feeding them. and yeah, I think this is the end of my portion. And I said, we'll kind of open it up for any sort of discussion. I'm curious a little bit of how that remediation goes, like when someone doesn't score the six and a half and they score lower.

Do you work on each kind of different aspects separately, or I know they flow together, so is it more of like a general type of discussion feedback? What do those conversations look like? I usually start by like asking them what's going well, what parts of it do they enjoy. You know, if there's any like wins that they could see that they could make once I, you know, if I'm going through, I may go through some of the qualitative results on what we found like really good supervisors are doing versus like really bad supervisors. And so I'm eliciting from them in the coaching. kind of like, where are some areas that they think they could grow in,

where are some areas that they think they're doing well in? And then how do we kind of like, you know, judge if those areas that they're not doing well in are changing by the time we talk next time, right? So there's that. And then there's also like, when you're talking to someone, it's like, oh, you know, I'm going through child custody battle and I'm going through divorce and I am, you know,

my family overseas needs lots of money. and they're, you know, my dad is dying of cancer. And, you know, so sometimes it's like, it's very situational that they're just not showing up. They're not present. And so then as someone like myself, I'm like, how do I reduce their stigma of getting the treatment they need? You know, they're not seeing a therapist.

They're not exercising. They're not taking care of themselves. Or they just need empathy for me as well, you know, like, dude, like, you're doing a lot. You have a lot on your plate right now. Your stress scores are way up because you. you're going through tons of stuff. And so it makes sense that this is just not the priority right now. And so how can you do some more self-care?

How can you create some balance in your life? A number of attendings I met with, it's like duty after duty gets piled on them to the point that they're just, the margin is gone to teach. And so it's like, how can you get some of your schedule back? How can you create boundaries? And then, you know,

the complicated issues that come along with, that of like, well, I'm, I fear if I stop doing some of this stuff, my group of attendings that I'm a part of will look down on me, you know? And so it's like, okay, how do we push through that? So it's very, it's very nuanced discussions. It's very individualistic. And some of the discussions will surprise you. But I think having a score kind of allows you to have a benchmark of how things are going. I would meet with some attendings, and they would have so much fear that they had scored so low,

and they scored like almost perfect. And they had no conception that they were actually doing awesome. And so it's like, hey, you're doing awesome. Like, keep doing what you're doing. And they just felt so encouraged. And then I had this one attending who was like, he thought he was awesome,

but he had like force across the board. And, you know, it's like, it took everything in me to try to create a alliance in a short amount of time. to create some buy-in that like, hey, it sounds like, you know, with the patients, you're doing awesome. And I knew this guy. And I knew that his patient care stuff was like, awesome.

But he was horrible with the residents. And so I was like, how can you take some of that same energy that you give to the patients and give that to the residents so that you are, you know, as effective as you can be? And so that made all the difference for him. So yeah, there's some just things I've learned from doing this, I guess. One of the things that I really liked with the, like, qualitative piece is that a lot of the feedback on things that the, you know, supervisors who scored highly were doing, can easily kind of be, if you're wanting to look at yourself and how to increase that connection, you know, just looking at, like, have I made space to go through objectives with the learner? Have I, you know, made space each day to

maybe check in on how they're doing and, and how their learning goals are, you know, moving along, things like that. So, so I really like looking through that the data from the qualitative stuff and going like, what could I add in to what I'm doing? And, you know, can I schedule in a little bit of that time to do that. And then, you know, again, it's things that are not, that are fairly simple, but not always easy to incorporate. But if we're aware of them, then it might make it a little bit easier to just take those few moments here and there to, to do some of that. Yeah, wonderful. I really appreciate you sharing that, Lisa Johnston. I think that's a really good, really good point.

Some of these things are like just if you change just a little bit, right? I'm remembering Dr. Lee who was my program director, he would do something like, what's the high point of your week and the low point of your week? You know, just to kind of check in with people.

Yeah, so it's like it could look different for different people. And, you know, like some residents don't want to be vulnerable about the low point. And so it's like noticing that and being like, hey, level of self-disclosure can be like four out of ten. It doesn't need to be ten out of ten here, you know? So it's kind of reading what the resident wants as well.

And one thing I always said to medical students who rotated with me was like, hey, I've never given a bad medical student review. So just let you know, like, I'm going to give you a good review. Okay. Now, that being said, I'm going to give you feedback when we're working together on things you can improve. I don't want to be in the way of you're graduating. Like, I am not a forensic psychiatrist, right? I'm not like, that's not how I'm wired. You will get a good review. But I want to be able to like have an open dialogue about things. And then we'd go see patients together. I'd have them interview in front of me. And I would watch them. And I was super into psychotherapy. So I was giving them feedback on like the interpersonal, the relatedness. the connection. And that year is my senior year of residency. I got voted. This is like the best accomplishment I ever had in my life, I think. It's like number one psychiatry resident for teaching medical students as voted by medical students across all residences. And so I was doing, I was doing that interpersonal feedback, that psychotherapy training, watching the medical students, spending a lot

of time with the medical students, getting them excited about reading about psychiatry articles, you know, and taking, you know, going out to coffee, going out to lunch, you know, with them and just enjoying my time. So it's interesting that you say that because why we, you know, presented this at the conference and had group discussion afterwards. And one of the concerns that came up was around, you know, they were worried that, then supervisors wouldn't be pushing residents as much for fear that they wouldn't be scoring highly. But what I love about what I love about this is it is I think the scoring really does take that into consideration. Like did they give me autonomy, right?

Like what was the feedback specific? And I think that that there's probably, you know, a very large, we're all in this because we want to learn and we want to be really good physicians. And I think that that giving that feedback is really, really important. And so it's really cool to hear you say that, like, you know, I did all this feedback. And then, you know, I got this award for it. And I think that that's really what learners are looking for. They want feedback and they want experiences. So I actually think that this helps push supervisors to, you know, push learners to the edge of their learning kind of thing rather than doing the opposite.

Yeah. You don't need to shame a resident into being a great attending. Like that's just not how it works. You know, it's like, especially in psychiatry where so much of what we do is very relational. It's like, how are you going to build a good resident? It's going to be very relational. And, yeah, 100%. Like what I heard, even when I went into other disciplines like surgery and anesthesia, it was like the great attendings were often the best teachers and the ones that had like a demand on them that was very high.

But within that demand was connection, was like an excitement. Like, hey, we're going to learn about this. You know, like there was this one cardiac anesthesiologist. And so, you know, residents would come on and have no clue how to do these very difficult cases. But they were just so excited to learn, you know. And it was like they were learning a lot, right? So I think, yeah, there definitely could be a misunderstanding like, oh, this is going to be kind of like the end of pimping and the end of learning, right? And I guess,

no, it's not the case. Not the case at all. And I think this fits in really nicely, too, with the whole growth mindset literature out there, right? And how, you know, we just, I don't know it yet, right? And it's okay that I don't know it because I'm an R2. And so I wouldn't know it yet, because I'm still learning, right? And so really taking it. making that open, you're not going to know everything and let's learn it and let's work together to help you learn it. So I really, I think it just fits in really, really nicely with a whole bunch of learning modalities that we work really well. Yeah, absolutely. Lauren, any kind of like thoughts rolling around your head? Well, when I was just thinking, reflecting on a bit too, is about how,

like I think connection isn't just about being really nice, you know, and it's not about just, you know, superficial niceties. It's actually, it's actually about genuinely caring. It's about giving that specific feedback. It's about kind of like creating that sense of joy too in learning, you know, and allowing the learner to kind of engage in that with you. And I think that that can be something that people can kind of get distracted with, maybe being like, oh, well, if it's just about being nice,

then yeah, we lose what we're here about. but no, it's kind of both. And it's even steeper than just being nice. It's really, it's caring and it's connecting. Yeah, absolutely. I think it's, yeah, it's not just being nice. I think highly agreeable attendings can have the potential issue of not bringing a student to the edge of their knowledge. or like this one attending I worked with,

he was so fearful that he would have nothing to bring and he would be found out as not knowing very much. He'd been doing what he'd been doing for 10 years. I mean, but he had this kind of like internal self-concept which led him to not teach at all. So he never like taught anything. So different attendings are going to need to grow in different ways in order to connect the best with the people that they're working with.

In a similar way that, like, you know, psychotherapy is a journey, right? It's like we all have a starting point. It's like, well, this person was in psychotherapy for five years and they're still dysfunctional. It's like they are where they are today, which is probably a better place than they would have been otherwise, you know? So it's like, I don't know, people are in process. Like, that doesn't bother me at all. the people I work with are in process. You know, it's like figuring out where the gap is.

Therapeutic alliance is always like coming to common goals, things you can both agree in. And sometimes that takes time to delineate and it takes a little bit of extra effort. Yeah. Okay. Lisa, any final things? We'll kind of pull this together.

Any final comments that you heard from the audience, I guess, that are worth bringing into the discussion? I think just that this seems like it would be a really, really valuable tool. And much like the, you know, I found that the qualitative stuff is really helpful. One feedback or, you know, feedback that we got from the group was that just even adding like a little like comment section if residents wanted to just add a little narrative that might then even point them in the direction of why. the score was the way it was. So are there things that the supervisor should keep doing because those are working really well? Are there things that the supervisor might consider changing because those maybe aren't working so well? So that was just something that some institutions

were wanting to consider adding is just a little narrative feedback section. Right. And what I would say is that's a great way to do a little quantitative, qualitative study, right? Keep that data. Okay, this attending is scoring fours and here's the feedback. here's the commonalities of that feedback. That's a nice quantitative, qualitative study, yeah. And you know what? Like, if you're a program director, you don't need an IRB for that

because you are not doing this as a research study. You are literally collecting the data for years for program development. And when you are doing program development, you do not need an IRB. So despite this being used in research in the past, and despite maybe after you collect the data for a couple years, you decided to use it for research,

I would just say, do it in a systematic way that leads to program development, have it be a program development initiative, and then you can get a retrospective IRB if you decide to do some research. And if any of you are listening to this, you can go to Psychiatrypodcast.com, you can send me a message. My email is DR at David pewter.com. And this is free. I'm not looking to make any money. off of you using this measure ever. I just want this to be a way to improve medical education.

There's a manual. There is my research study I can send you. So, yeah, I will leave it there for today unless you guys have any other thoughts. No, just thank you so much for taking the time. It's been fantastic to chat. So fun. Thank you. All right, we'll leave it there for today.