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The Power of Silence

This post is the first in a new section of the International Clinician Educator’s blog entitled An Educational Moment. Educators will use this space to describe personal moments in time that elucidate important insights into educational theory, practice, or experience.


By Eric Warm (@CincyIM)

Clinical medicine and education echo one another, but the sound that we hear often comes from us.

When patients talk, the average chief complaint lasts approximately two minutes, yet on average, healthcare providers interrupt within 23 seconds.When we do this we hijack the agenda, and make it our own.

Perhaps we’d like to think we’re different when we teach.

The deliberate educator frames curricula around learning objectives — what the learner should leave with at the end of the experience. We don’t call them teaching objectives (what the teacher will say), because a teacher can say many things well and yet it means little if it doesn’t benefit the learner.

In our residency we long ago abandoned the typical PowerPoint-plus-lunch format (where an hour of lecture essentially turns learning objectives into teaching objectives), and have created many iterations of an academic half-day to activate our learners.2 Half-day usually begins with a brief theory burst, followed by a series of cases and exercises. We rarely do the same thing twice, but we always do something. Groups of learners remain together longitudinally for one year, mentored by a faculty member/chief resident pairing. We use growth mindset as our major framing mechanism, and tell the learners “don’t come here to show us what you know, come here to figure out what you don’t know and fix it.”

Residents read the cases and work through them together. Although we choose the initial learning objectives and want the residents to learn the few things we list, we know they have the capacity to learn a lot more when they ask the questions only they know to ask. We hope this is the difference between learning and teaching.

And yet, when I lean back in my chair and look at the many groups working through the cases I see the faculty and chief residents often doing the talking, and wonder if learning has been shifted to teaching, the way chief complaints are shifted from patient agenda to provider agenda.

Last year one of our astute chief residents, Elyse Harris, perhaps noticing the same thing, created an amazing learning experience that demonstrated the power of (our) silence.

The topic of the day was time management in ambulatory medicine. Elyse created a choose-your-own-adventure case that groups worked through on a computer. Each choice the group made added additional information to solve the case, but choices also came with a time cost. Some choices revealed more information, and some choices cost more time. The goal of the exercise was to solve the case in as few minutes as possible, and the learning objectives were to appreciate the time pressures inherent in office based practice, and to manage a case in a time limited environment. The big difference in these cases however, was that unlike other academic half-days, Elyse strictly forbid the chief residents and faculty members from interjecting as the residents solved the case. We had to be silent.

The first case began with a follow-up visit in the ambulatory practice. The patient was a young man who had been seen for abdominal pain and had a negative work-up in the Emergency Department the week before. The patient still had pain, but it was difficult for him to characterize. Unbeknownst to the residents (at the time) was that the patient was in a relationship marked by intimate partner violence. The residents began focusing on the previous work-up for the pain. Each choice cost time. Full review of ED record: five minutes. Review of the CT scan image itself and not just the report: two minutes. Asking the patient about recent exposures: two minutes. The time began adding up, and the residents had not gotten very far. More choices flashed on the screen. Do medication reconciliation? Four minutes. Take a social history? Three minutes. Perform a physical exam? Four minutes. The residents began to discuss what they should do, and a significant portion of them wanted to press on and get right to exam and labs because they felt this was the best way get to the answer quickly. A smaller group began to lobby for not skipping the social history because they feared if they skipped it now they would never come back to it, and they felt knowing a person might help to understand a vague chief complaint. The discussion centered on the value of the three minute time-cost versus the expected payoff. The smaller group eventually convinced the larger group to spend the three minutes, and the truth of the case was revealed. In fact, the only way to solve the case was through the social history, as any other path would have failed.

What was I doing during all this time? I was silent. I knew the answer, but I couldn’t let on. It was initially difficult to watch the group go astray without saying anything. I of course had many insights and lessons to teach. But then it was amazing to watch them learn the lesson through their own actions and choices. I imagined how this would have been had I been in talk/teach mode. I probably would have said “Well, you know, you really should take a good social history in every patient, especially people you are meeting for the first time…” and the residents would have probably responded, “Yeah, we know that, and we do it…”

What would have been gained with that interaction? Talking would have impeded learning. Silence enabled it.

It has been said that the greatest enemy of knowledge is not ignorance; it is the illusion of knowledge. How often do we think we are doing something (e.g. patient-centered or learner-centered activities), but really aren’t? In an ethnographic study of family-centered rounds, researchers found that despite family-centered structures teams create for patients, team introductions were often unilateral rather than bilateral, team momentum sometimes overrode families’ option to fully participate, and teams and families often engaged in information sharing but these conversations didn’t always result in collaborative decision making.3

I think the same findings are likely true in our learning spaces, even ones we’ve set up like our academic half-day. Teachers are known to themselves, but the students less so, teaching often overrides learning, and we have conversations but we often don’t know if they result in gains.

The Power of Silence, of listening before talking, may be a solution to these issues. The next time you are in a learning space, either as teacher or learner, take a few seconds to be silent and observe the flow of the experience. Who is talking? Who is listening? Who is teaching? Who is learning? How do you know?

References

1. Marvel MK, Epstein RM, Flowers K, Beckman HB. Soliciting the patient’s agenda: have we improved? JAMA. 1999 Jan 20;281(3):283-7. PubMed PMID: 9918487.

2. Batalden MK, Warm EJ, Logio LS. Beyond a curricular design of convenience: replacing the noon conference with an academic half day in three internal medicine residency programs. Acad Med. 2013 May;88(5):644-51. doi: 10.1097/ACM.0b013e31828b09f4. PubMed PMID: 23524926.

3. Subramony A, Hametz PA, Balmer D. Family-centered rounds in theory and practice: an ethnographic case study. Acad Pediatr. 2014 Mar-Apr;14(2):200-6. doi: 10.1016/j.acap.2013.11.003. PubMed PMID: 24602584

 

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