Thread by @DrStevenTChen

I had a bit of an “ah ha moment” while attending in our #dermatology resident clinic a month ago.

The way I run this clinic means that when the timing is right, I try to have our senior resident precept the junior resident. I try to stay silent and literally say nothing.

1/

When this happened, we had a brand new senior and a brand new first year. Essentially both residents were settling into their respective roles.

In typical fashion, the junior resident presented the key points to the senior resident as I listened on.

2/

Jr: the patient doesn’t have a rash today, but the pictures look like wheals. He says that pressure causes it. Diphenhydramine doesn’t work that well. He doesn’t have dermatographism.

Sr: what do you think it is?

::both look at me to see what I’m thinking/about to say::

3/

Sr: well sounds like delayed pressure urticaria (then proceeds to discuss pathophysiology, treatment options, etc).

::both look at me again::

Me: stares back at them.... after a bit of silence - “it’s your patient! Do as you see fit!”

Sr: but you’re the boss!

4/

So what happened here? Why did my sr resident jump in with the answer? It’d be easy to say, “he’s not used to being a senior” or “he’s a bad teacher.” But he’s not. This senior resident is one of our best and brightest, and is an amazing communicator. So why the disconnect?

5/

I realized that he’s in a unique position. He gets to teach in this new role, but at the same time, still feels like he’s getting evaluated by me, “the boss.” For him, his teaching isn’t as learner centered because he’s worried about what I think about him as a learner.

6/

We as attendings have the luxury of not feeling judged at every turn, so we’re able to take our time and lead our learners through mistakes and a thought process. But when our learners are put into the position of teacher, there’s an interesting dynamic that is present.

7/

In the age of “resident as teacher” curricula, we can talk about adult learning theory as much as we want, but I think we may be missing the mark in thinking about the stressors our residents face that we’ve moved past as attendings. They are constantly being watched!

8/

I don’t think it’s a stretch to say it’s a bit of a performance. So what happens when your resident has stage fright? Furthermore, not all specialties are equal. In the derm world, we have less of a team structure, so the chance to hone these skills are even harder to find.

9/

So what do we do? I pulled my sr resident aside to give feedback on his teaching. We talked about using the Socratic method to lead the jr through a thought process. Our jr was on the right track, otherwise he wouldn’t have talked about dermatographism and antihistamines.

10/

So we discussed ways to use that info to gauge knowledge, & to help fill in the gaps by prodding them toward the right answer in a gentle & nonjudgmental way.

I also learned that my presence likely changes behavior. Maybe I need to extract myself more. Or just call it out!
11/

This is, I’m sure, a no brainer to all you wonderful #Meded educators out there. It was just a bit of a nice “click” in my brain as to why even our strongest residents may need a reminder that it’s ok to experiment & be wrong, especially in front of the attending.

12/

What do you think? Am I off base here? Did I totally miss the mark? Thanks for reading, and feel free to comment👇👇👇!

#dermtwitter #medtwitter #dermatologia #clinicalreasoning #residentasteacher #teachinghowtoteach #tweetorial #medthread