One of the unique aspects of education in the hospital setting is the nature of those being coached. The wards are a flurry of activity, with someone always wanting something for a patient: the nurses needing orders to be written; the social workers needing forms and discharge instructions to be completed; the pharmacist needing detailed patient data to release the appropriate pharmaceuticals; and the hospital administration pressing for discharge by 11 a.m., patients from the intensive care unit to be transferred immediately, and emergency department consults within the hour. The residents and students are working just shy of 80 hours per week—tired and hungry, their meals coming at odd hours, they struggle to satisfy everyone, all the while wondering what will become of their careers (“Will I pass the boards? Who will write my letters? Did I get my applications in on time?”). And after all of this, the student or resident has very little emotional voltage remaining to learn. This monstrous challenge before the teaching moment even begins is what makes teaching on the hospital wards challenging and unique, but it is also what makes motivation a critical component in ensuring performance.
The first step in motivating your learners is to acknowledge and deal with the sentiment that will hold you back if it is not consciously addressed: “Should I have to motivate students and residents to learn clinical medicine? I mean, seriously, it's only something as trivial as a patient's life!” Here's an analogy to answer that question. Should an NFL football coach have to motivate a prima donna wide receiver to catch the ball—even after he's been paid 5 billion dollars to do so? No. But if he doesn't, then the receiver doesn't catch the ball and the team loses. Should the attending physician have to motivate students to learn medicine? No. But if the coach doesn't motivate, the student's performance falls short and patient care suffers. So, should you have to motivate students to learn? The short answer: No. Must we motivate students to learn in order to be effective? Yes.
There is one word that will ensure your motivational effectiveness. To any given person, in any society, in any time in history, the most magical, motivating word is...her name.
And using people's names cannot be done enough. Take this example extracted from the wards:
“Paul, you had a patient with a hemoglobin of 9, Paul...and you diagnosed anemia, Paul. Fantastic. And Paul, the way you ordered a ferritin, Paul, well it was...inspirational! And Paul, the way you did the rectal exam, Paul, to exclude GI bleeding, Paul...I mean, what more can I say, Paul? Fantastic, Paul.”
The remainder of the team might be thinking, “Who is this freak?”; but not Paul. He's thinking, “This guy is great—I'm going to nominate him for a teaching award!” And that's the simple trick to winning awards. Just walk around the hospital or medical school calling people by their names for a year; you'll win an award.
Why is using people's names so powerful? It communicates that you care about the person as a person—as a unique person; not just a moon that orbits your planet. With this one word, it establishes the relationship requisite for the coach-player relationship. It says, “I see you as a person who is valuable to me; and I care enough about you as a unique person to know your name.”
The hospital wards can be a lonely place, with most students and residents feeling lost and over their head. Sum this up in one sentiment: People are not going to care what you know until they know that you care.
The best way to achieve that critical first step is simply to use people's names.
And if you are thinking, “That's fine and all...but I'm just not very good with names.” Well, here is the inside-the-actor's-studio tip number two: You don't have to be good with names. All you have to remember is one person's name. Begin with this student or resident each day, using the name as often as possible, and then end that segment of rounds by saying, “Paul, I've picked on you enough. Choose someone else on the team, but call him by name.” Paul will give you the next person's name. See? Easy. Just offload the responsibility of remembering names onto someone else.
The second step in motivation is to use physicality. Recognize that the students we coach have grown up with a very different perspective of entertainment.
As opposed to previous generations, for whom entertainment was “live” (the symphony had in-person artists playing, the play or musical had in-person performers, sports events were intimate enough that the players appeared in person), this generation has grown up in front of a glass screen. DVD players, TVs, movies, computers...these have been the source of this generation's entertainment. If at any time the entertainment went south or became uncomfortable, they simply changed the channel, left the room, or engaged in another activity (such as answering a cell phone).
Students will carry this psychological perception of entertainers “behind glass screens” with them onto the wards, seeing their attending (that is, the entertainer) as being behind a protective glass screen. It is the reason that a hospital ward team is spatially defined by an attending, surrounded by a 3-foot force field with all team members in orbit at a safe distance. Do not be perplexed when a student answers his cell phone during rounds or begins to surf the Web on his BlackBerry. He is simply changing the channel, and feels comfortable enough to do so because of the psychological glass screen.
After mastery of names, the next step in motivation is to break the glass screen. If you find yourself in a small conference room on the wards doing a quick talk, immediately move away from the whiteboard or chalkboard.
As you circulate about the room, you'll see the progress notes go back into the pockets and the phones back into their holsters. The energy of the room will rise, and this energy is what you need to fuel the motivation for the session. If you are on the wards conducting rounds, simply step across the semi-circle that surrounds you and assume a new position on the ward team. Even though the 3-foot force field will reset, it will temporarily bring down the glass screen and generate some much-needed energy.
Use the power of physical touch. A simple handshake for a job well done or a touch on the shoulder for encouragement sends the sentiment you long for: “I see you as a person. I am not a hologram, I am your coach.”
The power of touch is motivating, especially when well timed; it acknowledges great performance in a way that words cannot achieve and supports the player during difficult times (the pat on the shoulder) when things don't go well. And while shaking hands is a filthy custom, it is ours—so embrace it. It will remind you to wash your hands and ensure that your students do the same. Finally, despite the power of touch, it is worth noting that there are safe touch zones and unsafe touch zones. Further explanation is not needed.
Given enough time on the wards as a clinical coach, you will encounter those special students who have lost all pluripotency—there is no longer flexibility in the career decision, and the student has differentiated into, say, orthopedics (or some other career not remotely close to your own).
Sadly, many of these students will arrive with the mental stance that they “don't need to know internal medicine to do orthopedics.” So the question becomes, “What do I do with this student? Should I simply sequester him in the back, and teach to the students who might want to do medicine? After all, it's his problem, not mine. Right?” Wrong. This student, more than any other, needs a healthy dose of internal medicine—it may be his last trip through formal instruction in internal medicine, and the truth is that the more internal medicine he knows, the better an orthopedic surgeon he will become. But how do you motivate the student who doesn't want to learn internal medicine?
The answer is the hook. Every student has one: some reason that she will want to know what it is you have to teach. As an example, take this excerpt from the clinical wards:
“So Stef, you told me that you are going to do orthopedic surgery. Is that correct?”
“That's right.” Stef's face momentarily lights up, though the arms remain crossed.
“Okay, well listen, let me paint a mental image for you…. It's 3 years from now, 5 p.m. on Friday. You've had a busy day on the orthopedics service, doing some really exciting cases. And you're super excited because you have dinner plans with your family, and you're ready to leave the hospital. Can you see yourself there?”
“Yes.” Stef's grin begins to show the twinge of nervousness at the thought of being the resident.
“All right, well imagine that just as you start to leave the hospital, the pager goes off. The 62-year-old woman for whom you put in an artificial hip is now in atrial fibrillation with a rapid ventricular rate. Wow…what to do? So here will be your two options, Stef. Option 1, you can call me when that day arrives. As the med consult, I'll come see her, but it might take awhile. I have a lot of consults on Friday afternoon, for whatever reason, and it will probably mean that you are going to have to call your family and cancel that dinner….Or option 2, I can teach you in the next 5 minutes all that you need to know about rate control and clot control, and when that day comes, you can fix the problem yourself and be home in time for dinner. So which option do you want?”
“Hey, sounds good to me. Tell me what I need to know.” Stef's apprehension is turning to genuine excitement.
The unique feature of hospital medicine teams is the great heterogeneity of the team members. Some students will be interested in internal medicine as a career; others will have other careers in mind. Even among the residents there will be diverse career trajectories: some in general medicine, some in subspecialties, and some in careers that are not internal medicine (such as the preliminary interns). Each of these members will have a hook, and couching the instruction in utility—how the student will eventually use the information—generates the motivation that you need to ensure performance down the line.
But how do you deal with this heterogeneity? Doesn't couching the content in the orthopedic student's future career alienate the other team members? The answer is no. Despite our evolution, people have retained their herd mentality. When the lion stares down one antelope, the whole herd feels the same emotion. So it is with hooks on the wards—as the content is couched in utility for one team member, the other team members will begin to envision their own future and feel the same utility. The effect of motivation will be felt by all.
But how do you teach content that has no obvious utility? What if, say, a faculty member wonders, “I want to teach prion disease, and I just can't see how any of my students are going to use that. What do I do?” The answer is, “Well…don't teach that.” The truth is that in the grand scheme, the teacher's time with a ward team is short—it is impossible to teach all of internal medicine in this time frame, and something will have to be sacrificed.
You might as well sacrifice according to utility: Teach what people will use, and this will establish the motivation necessary for overcoming the monstrous time and energy challenges that oppose you.
Using visualization to empower interest and promote retention
As noted in the preceding section, one of the most powerful hooks is the ability to create a vision for how the student will use the skill or knowledge. That hook is important because it generates motivation for learning the skill and keeps the content of the coaching session focused on topics that have utility. When you consider that the mind has a difficult time distinguishing between what was imagined and what actually happened, the principle of visualization takes on even greater importance. The coach who can create a palpable vision of performing the skill effectively gives the student one “repetition” of doing that skill without ever having done it. It is the reason that great coaches in whatever venue—performing arts, music, athletics—have the same mantra: “See it before you do it.” It is the same reason that you'll find actors backstage and athletes in the locker room, all with eyes closed, rocking back and forth, seeing themselves doing the dance steps, or hitting the ball, or whatever task is immediately before them as they prepare to perform.
Teaching procedures on the internal medicine wards, though not as involved as on a surgical service, is the most tangible example of this coaching strategy. The time for the teacher to get the residents to visualize each step of the procedure is before they begin the procedure, as the “hard stop” is proceeding with the nursing and ancillary staff. The art lies in asking the questions that drive the vision:
“Can you see yourself prepping and draping the patient? Don't do it yet…just visualize it. Can you see it? Yes, good. Where will your procedure tray be? What will it look like? Is there anything not on that tray that you need? Now would be the time to get it.
“Can you see yourself finding the landmarks? Will you do that before or after your drape the neck? Can you see yourself putting the iodine on? Okay, now, can you see yourself loading the anesthesia syringe? Where will you inject? What will you do with the needle after you are finished with it? Where will you position your body as you insert the finder needle? Can you reach everything on your tray? It would suck to have found the vein, but have to change body positions to reach the inserting needle, huh?
“Can you hear the pager going off? Who will answer it? Yeah, maybe it's best to hand off the pager now before you begin….
“Now the inserting needle is in. Can you see the blood return in the syringe? It's dark red, isn't it? That's good, because that means you're in the vein. Now, how is the guidewire positioned? Can you see the little ‘J’ at the end? Probably good to insert the wire such that the ‘J’ is pointing toward the heart. That will make sure that the wire, and eventually the catheter, heads down toward the heart and not up to the head….Okay. The guidewire is in. See yourself holding it as you remove the needle. Don't let go.”
But visualization is not exclusive to procedure training. The more that teaching topics can be pursued with a vision of how students will use it, with as much detail created in their minds as possible, the better the retention of that topic will be. And retention is requisite for (top) performance.
It will matter little if the student masters the topic in the moment but cannot recall it at a later date. Long-term performance suffers without proper visualization. Visualization is the art of the attending physician.
It is important that all visions be positive. Positive visualization leads to positive results; negative visions lead to negative results. Students and residents, on average, are terrified of failure, and it is the prospect of failure or mistakes that dominates their thoughts. This is of great risk to their performance.
The analogy is the golfer who hits the golf ball into the water and then immediately proclaims, “I knew I was going to do that.” And he's absolutely right. If failure is on your mind (hitting the ball in the water), the body will accommodate accordingly. The coach's job is to ensure that the vision is positive—it is appropriate to get the student to visualize the pitfalls and potential mistakes inherent in a clinical task, but it is vital that the vision is created such that the residents can see themselves avoiding the pitfall or overcoming the obstacle.
You may wonder, “But do I have time to create these visions?” If you stay with the paradigm of teaching as much knowledge as you have, the answer is no. But if performance is the goal, then the paradigm shift to being a coach liberates you from the compulsion to teach all details, enabling the time to create the vision. Therein lies retention, and eventually performance.