It’s happened to all of us.
We facilitated a difficult simulation session with a resident physician who missed several critical actions in the case. The simulation debriefing unfolds simply enough, characterized as an opportunity to explore an important learning gap with the trainee.
Then suddenly it becomes clear… the learner seemed ‘off.’
Initially disengaged and reticent to participate, her reflections quickly shifted from a discussion of medical knowledge to one of emotion and self-concept. A bomb was dropped:
“I just don’t think I’m cut out for this.”
A Brief Overview of Identity Threat
In our previous post, we described how Malcolm Knowles’ theory of Andragogy — colloquially called Adult Learning Theory — could explain sudden shifts in a learner’s tone and participation in a medical simulation.1 Importantly, an understanding of self-concept and its implications for learner well-being are crucial when addressing disgruntled trainees.
Other theorists, including Voyer and Pratt, describe an evolving professional identity as a feature of self-concept for adults in the workplace. The related notion of professional identity threat explains why some learners ‘shut down’ abruptly in simulation sessions.
- Learners who are still uncertain about their professional identity may be especially susceptible to perceived challenges.
- They may generalize feedback about performance as a referendum about their current or future capabilities and belonging in medicine.
- Feedback that is discordant from their sense of professional identity may be triggering.2
The intersection of medical simulation debriefing, self-concept, and professional identity threat is complex and may fuel disgruntled learners.
(1) Feedback may threaten an individual’s professional identity.3 Feedback about clinical competence is deeply intertwined with a professional sense of self. Learners may react to threats to their personal and professional identities in many different ways. Some may attempt to avoid such threats altogether, limiting their pursuit and engagement in new learning opportunities. Ensure that your debriefing feedback is about observable actions and not the learners themselves.
(2) Psychologically-safe learning environments mitigate threats to professional identity. It is important for learners to decouple specific feedback in a simulation from their self-concept of clinical competence. ‘Prebriefing’ is an opportunity to set the tone of the learning environment and foster psychological safety during your session.4 Be deliberate in your choice of prebriefing language and make clear the safety of your simulation.
(3) The Basic Assumption protects professional identity. The Basic Assumption in medical simulation maintains that the learner is “intelligent, capable, cares about doing their best, and wants to improve.”5 Following The Basic Assumption may help learners separate their performance from their professional identity. Explicitly state The Basic Assumption to trainees to help them view simulation as a safe space, affirming of their learning goals.
Winning Over the Disgruntled Learner
- Professional Identity Threat: Learners may be reticent to participate in a simulation for fear that poor performance is disqualifying for their chosen field.
- Overcome this: Set the stage with a thoughtful prebriefing. Explicitly state The Basic Assumption during the prebriefing and remind learners when needed. What happens in the Sim Lab stays in the Sim Lab, free from judgment and evaluation.
- Professional Identity Threat: Learners may view feedback as criticism that undermines their worth.
- Overcome this: Elevate their self-concept in medicine by noting their successful past achievements. Demonstrate that you value their participation and engagement. Call on prior examples of their approach to challenges, reinforcing their professional identity as a competent problem-solver and provider.
An understanding of the intersection of self-concept and professional identity threat will make you a more effective facilitator and your simulations more powerful. When trainees truly accept that simulation is a learning resource rather than a denunciation of personal failure, the opportunity to “level up” is profound.
1. Knowles M. From Pedagogy to Andragogy. In: The modern practice of adult education; andragogy versus pedagogy. UK: Associated Press; 1970:53-70.
2. Pasquale SJ. Education and Learning Theory. In: The Comprehensive Textbook of Healthcare Simulation. New York: Springer; 2013:51-55.
3. Voyer S, Pratt D. Feedback: Much more than a tool. Medical education. 2011;45:862-864.
4. Rudolph JW, Raemer DB, Simon R. Establishing a safe container for learning in simulation: the role of the presimulation briefing. Simulation in healthcare : journal of the Society for Simulation in Healthcare. 2014;9(6):339-349.
5. Rudolph J. What’s Up with the Basic Assumption™? https://harvardmedsim.org/blog/whats-up-with-the-basic-assumption/. Accessed 2-18-2021.
About the Authors:
Kimberly Schertzer, MD is associate professor of emergency medicine and Director of Medical Simulation in the Department of Emergency Medicine at Stanford School of Medicine.
Sarah Williams, MD, MHPE is professor of emergency medicine and former residency program director in the Department of Emergency Medicine at Stanford School of Medicine.
Photo Credit: Pexels