Simulcast Journal Club August 2018


Introduction :  

Simulcast Journal Club is a monthly series that aims to encourage simulation educators to explore and learn from publications on Healthcare Simulation Education.  Inspired by the ALiEM MEdIC Series, each month we publish a case and link a paper with associated questions for discussion.  We moderate and summarise the discussion at the end of the month in pdf and podcast format, including opinions of experts from the field. 

In order for the journal club to thrive we need your comments!  Some participants report feeling nervous about their initial posts, but we work hard at ensuring this is a safe online space where your thoughts are valued and appreciated.  To ensure this, all posts are reviewed prior to posting.  We look forward to learning from you. 

Copy of Journal Club(3)

Title :  “A Vulnerable Moment 

It had been 2 years since the simulation centre had opened and the champagne from the evening’s celebration was flowing freely.  Nitin sat on the couch sleepily, one arm around a Sim Man in a party hat and the other holding his glass. 

Across the way was Nimali, ever the educator, exploring with her fellow staff members the things they’d all learned together over the last 24 months.  He could only hear the occasional murmur over the sounds of John Legend playing through the speakers, but the words “Name the dynamic” filtered through with clarity. 

“Name the dynamic.” he smiled wistfully at Sim Man. “That’s not always easy to do, is it?”.  Sim Man, for his part, made no comment. 

Minutes later, Nimali walked up with a smile and jumped down on the couch between them. 

“And what have you learned this year?” she asked Nitin warmly. 

He gazed at her for a moment, and paused. 

“Emotion before cognition, I guess?” he stuttered.  He stared hesitantly at her expression, it seemed framed with curiosity, compassion, and perhaps…. Just maybe, a hint of understanding?  He took a breath. 

“I’ve learned that you care about people, Nimali.  This stuff isn’t just words to you, you actually want people to thrive.  I’ve learned that you show your vulnerabilities to help learners with their own…” 

He cautiously edged his hand closer to hers. 

“In this last year…. I’ve learned that I love you.  I’ve loved you from the moment you explained to me the basic assumption and I realised you genuinely hold it for every person you meet.”  His speech quickened, gaining confidence and honesty. 

“I don’t know how you do that, how you can be such an expert yet so generous with your spirit.  I struggle with that sometimes, I judge people privately a lot… but you…. I’ve never heard you say an unfair thing about anyone.” 

Gently, cautiously, scanning her face for any hint of repulsion or interest, he placed his hand on hers.  

“You’re my safe container, Nimali Jones.  I couldn’t love you more if I”. 

But his words were cut short as Nimali leaned forward and kissed him on the lips. 

 

The Article : 

Bearman, M. and Molloy, E. (2017). Intellectual streaking: The value of teachers exposing minds (and hearts). Medical Teacher, 39(12), pp.1284-1285. 
Discussion :  

In this month’s case study, Nitin allows himself a moment of emotional vulnerability in order to get close to someone he cares about, but in doing so he also takes a risk.  In Margaret Bearman and Elizabeth Molloy’s 2017 article in Medical Teacher, they explore the benefits of ‘Intellectual Streaking’ whereby a facilitator is open and honest about their own knowledge deficits.  As with Nitin’s romantic overture, it is a move that has potentially significant benefits to rapport building, but done poorly may also have some unexpected drawbacks. 

 

So in this very special second anniversary of our online journal club, what do you think of Intellectual Streaking?  Is it a sophisticated move that rapidly creates rapport, or can it shatter the respect your learners have for you? 

 

And on a final note, thanks for sharing the last 2 years with us as we’ve grown as educators in a wonderful online community of practice. If you’d like to share something you’ve learned from journal club since we started, please feel free to let us know! 

 

Ben 

 

References : 

Bearman, M. and Molloy, E. (2017). Intellectual streaking: The value of teachers exposing minds (and hearts). Medical Teacher, 39(12), pp.1284-1285. 


About Ben Symon

Ben is a Paediatric Emergency Physician at The Prince Charles Hospital in Brisbane and a Simulation Educator at Lady Cilento Children's Hospital. He currently teaches on a variety of paediatric simulation based courses on paediatric resuscitation, trauma and CRM principles. Ben has a growing interest in encouraging clinical educators to be more familiar with simulation research.


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22 thoughts on “Simulcast Journal Club August 2018

  • Shannon McNamara

    Ben, thank you for making me laugh with this one.

    Intellectual streaking is an interesting phrase for this strategy. Full disclosure: I can’t access the full text article. From what I can see, I do agree that this can be a useful tool or a disasterous tactic.

    In general, I think transparency about uncertainty and error mitigation strategies are powerful tools for medical educators. When framed in a patient centered and proactive manner, this vulnerability can be humanizing and empowering for learners. On the other hand, if addressed in a nihilist or cynical manner without proactive strategies to overcome systems failures, human error or knowledge deficits, exposing vulnerabilities can be toxic. “It’s ok to mess up, they would have died anyway,” is not helpful. I don’t think I would ever call it streaking.

    • Ben Symon Post author

      Hi Shannon, thanks for the retweets and your post. I was wondering if you could unpack a little bit more about what you mean by addressing one’s own errors in a nihilist or cynical manner? It sounds like you have witnessed that in the past?

  • Melanie Barlow

    I think this is a great concept for discussion and completely agree with the article in that we ask our learners to be vulnerable both in the simulation and in personal reflections within the debrief, yet don’t hold the same expectations of our educators. As facilitators and teachers we tend to hide behind the veil of being the ‘expert’ and don’t in fact role model vulnerability. I love the work by Brene Brown who suggests by embracing your vulnerability your world will be open to new possibilities. The same as educators, by showing our vulnerability, our learners will feel more comfortable in sharing theirs. I have found this when debriefing the debriefer. If I ask a question that doesn’t make sense, or is ‘dirty’ and I see a look of confusion on my learners face, I have openly acknowledged my error and rephrased the question. By doing this I have received really positive feedback and shown that no matter your experience level, no one gets it right all the time and this is ok!
    I do agree though that showing too much vulnerability and emotion can diminish the confidence levels of the learners, so yes, there needs to be balance: The Yin of vulnerability and the Yang of maintaining the learner’s confidence.

    • Ben Symon Post author

      Hi Mel,
      Thanks so much for joining us on Journal Club. Hope the Boston summer is treating you and the family well!
      I agree with both you and the article that there is a level of hypocrisy in how we present ourselves as experts sometimes, and that role modelling acceptance of our errors can be highly valuable. You mention the Yin of Vulnerability and the Yang of maintaining Learner Confidence…. any practical tips on how you detect that fine line?

      • Melanie Barlow

        Hi Ben! Boston is great. For me I really like the move of ‘normalisation’. It shows the learner that we too find things difficult at times and/or make mistakes (so showing vulnerability) and it also provides an opportunity to demonstrate the reflections, learnings and strategies we have put into place as a result of these mistakes (demonstrating reflective practice, competence and critical thinking); thereby helping to maintain/achieve learner confidence.

  • Glenn Posner

    Great vignette, Ben! This topic is helping me understand my own frame in that I don’t present myself as a “high status, knowledgeable expert” when I’m debriefing, but as a partner with particular expertise in facilitating a safe conversation, perhaps even a detective, trying to understand the mystery of why certain performance gaps were exposed. I can embrace the term “intellectual streaking” but I submit that this exposure of vulnerability is just a subset of normalization – “personalized normalization” (did I just make that up? I’m too lazy on a Saturday morning to do a lit search!) where the facilitator not only tells the participants that “this happens to learners all the time” but specifically, “this has happened to me”, or “happens to me all the time.” I will now personally normalize my own intellectual streaking and say that I reveal my own mistakes often, but I don’t think I was recognizing it as a risky maneuver for some potential benefit, but I do it in order to paint myself as just another healthcare provider at the debriefing table, engaging in problem-solving to glean some valuable take-home messages from a fun sim case. I’m excited to hear what everyone else thinks of that. Thanks for prompting this conversation.

    • Ben Symon Post author

      Hi Glenn, glad you enjoyed the Vignette, and thanks for promoting the case on twitter! I think it’s very fair to reframe intellectual streaking as personalised normalisation. It definitely seems to me to fit within the definition of both the action and underlying function of normalisation. I think intellectual streaking can be a specific power move to decrease your threat level as an expert. While I agree with the Sherlock Holmes style stance of a classic debrief with good judgment, I’ve been amazed at how strong social hierarchies can be, and how rapidly I’m put on a pedestal as a facilitator no matter how much I protest. I think this is a very specifically useful technique for flattening that implied status difference.

  • Janine kane

    First comment ever in this space and feel comfortable now based on the above text! I write the scenarios, prebrief, do scenario debrief etc a one woman show. It works though and I believe it does because I share some of my own experiences with the students over a few hours before we even set foot in the sim space. I ask them about their own fears and expectations about the clinical arena and explain what Sim is and how this will help them. As a result I have developed a relationship with my students before we start and they can see that I have made mistakes and it’s ok to do so as long as we reflect, talk and learn from those things we don’t get quite right. Sharing our own vulnerabilities with our students and peers leads to a more open and honest experience for everyone.

    • Ben Symon Post author

      Hi Janine, great to have you along for the first time!
      Sounds like you’re running an impressive one woman show that sounds both challenging and rewarding.
      Your comments remind me a little of Susan Eller and Mary Fey from last month in that you all highlight the importance of rapport building pre Sim. What sort of techniques do you use to make people feel comfortable?

      • Janine kane

        Hi Ben, thank you for responding! I have a 3 hour prep for prac session I run for each of my stage 2 student nurses. This is compulsory before students are allowed to then move into the sim program, again all before they hit their first hospital placement. It’s quite simple TBH. I put them in groups of 4-5 and ask them all to write down one fear and one expectation about going to prac! The ensuing discussion can take up to an hour and a half but I get to find out a bit about my students and they get to know me. Without doing this sim can go pear shaped! I’ve been doing this for 4-5 yrs and is a great intro to building confidence and communication with students before we begin the program. Thanks again!

        • Ben Symon Post author

          Wow Janine, that’s a really interesting prebrief strategy. Do you find the fears and expectations revealed are surprising or do they start forming a pattern?

  • Sarah Janssens

    Wow Ben, great to see someone got a great photo of you going to the baseball when you were in Boston! (someone had to say it – may as well be me!)

    It occurs to me that there are 2 types of streaking – 1) sharing your imperfectness as a clinician – (easy to discuss past mistakes in front of colleagues, but less so in front of your patients!) and 2) demonstrating fallibility as an educator in front of your learners. I think the latter can be the more dangerous form if it occurs too frequently, and the former useful if accompanied by the story of reflective learning that occurred after these errors.

    As I was reading the article, it made me think of my ultimate form of streaking in simulation – “registrar’s revenge” sims. (I can’t recall who gave me this idea but it definitely isn’t mine) I call it the ultimate, because the risk is you show your learners that you cannot do what you have been teaching them to do all year! The risk seems to me worthwhile, as not only does it demonstrate your willingness to put yourself in their position, but they too see what its like to walk in your shoes as a somewhat imperfect educator!

    For those readers who are not familiar with this concept, each year we ask for some volunteers in the registrar pool who write, run and debrief a sim for me and the sim team to be learners in. In somewhat increasingly difficult (and outlandish) scenarios they might see me jump on the chest instead of staying hands off,(d’oh!!) and we debrief together, sharing our thoughts on the challenges of managing preterm undiagnosed twins with a brown snake bite (yes they are getting crafty those registrars!!). It really is an enlightening and fun way to end the year, and this article makes me consider if I am to truly bear all we could do it earlier, so that the rapport built by the experience isn’t lost as our learners move on to the next rotation.

    Thanks simulcast team for a chance to reflect on how helpful being vulnerable can be.

    • Ben Symon Post author

      Hi Sarah! Yeah I’m quite proud of that photo thankyou very much, I hoped you’d notice I’ve been doing a lot of squats.
      I agree that Registrar’s revenge are a great way of showing openess and a willingness to be vulnerable, and it’s always entertaining to me who runs a mile in the consultant group when they come up. I’d counter-argue though that a lot of the time Reg Revenge mocks don’t value psych safety very much, even though consultants are an extremely nervous group when it comes to demonstrating their own fallibility.

      On that note it intrigued me that you think clinical imperfections are easier to expose that educator flaws. Instinctively I’d think it’s the other way round. Why do you think this is?

      See you soon!
      Ben

      • Sarah Janssens

        I think just like it’s hard to admit error as a doctor to your patients, it’s hard to admit error as a teacher to your learners. Perhaps it’s a distance thing, or that trust thing? See you soon but please keep your clothes on!

  • Susan Eller

    Hello Ben,

    I was curious to read the article, and now wishing it were a little longer. I think that there is definitely a need for balance between the exposing your fallibility and maintaining credibility. I think that for more novice debriefers, they may want more in terms of how to achieve that balance. I have to laugh as I write that, as I am not sure that I could articulate how to do it.

    It is also interesting on the perspective of the learners. We just finished an instructor course at our institution, and I corrected myself a couple of times as I thought my phrasing was unclear. When one of our participants asked how do you re-phrase a question and I gave some examples similar to Melanie’s comments about dirty questions. I also reminded them that I had re-phrased during the course, but they did not remember that – they said it all just flowed so smoothly. So it was interesting to me that although I had tried to be intellectually transparent, that was not what they remembered, they remembered the flow and the content.

    • Ben Symon Post author

      Sounds like your standards are so high Susan that when you fall below them you’re still floating in the clouds above your learners :p

      I would have liked a longer article too, although I think they cover their point efficiently and articulately and it’s a lovely, lyrical read.

  • Ben Symon Post author

    Thanks to all for your comments so far on this topic. It seems to me that everyone’s keen on vulnerability as a tactic for rapport building and learner engagement, as well as to enable our learners to truly take a leap of faith and explore themselves in a more honestly reflective manner.

    One thing that interests me is that none of us have really been able to name what constitutes that ‘going too far’ zone, whereby vulnerability from an instructor can lead to a loss of confidence in them.

    I’d love if anyone would be interested in unpacking that breakpoint on a deeper level.

    Personally this interests me because in the past I’ve made a couple of blog posts that have been very, very personal in order to engage the audience on a particular healthcare issue that concerns me. The social media response was strong, and I found that experience very affirming in terms of the ‘risk vs reward’ of demonstrating vulnerability in our writing.

    I’d have to say though that after a couple of rounds of that, I think I embraced the notion too strongly. I gave a rehearsal talk to some mentors in order to gain feedback prior to a conference presentation, and the feedback I received was very valuable. In particular, there was concern that I had been too specific and too vulnerable about exposing my negative emotions during a particular term, specific phrases noted as making my audience uncomfortable included “I started to hate my job, and I started to hate myself.”. The wise messages I received included “This same message could come from a place of strength.”. Which allowed me to frameshift my talk from one that was bordering on personal therapy to one whereby I could share learning and growth with an audience while still allowing some humanity.

    In retrospect to me, I learned a number of things from that process.

    1) I think demonstrating personal vulnerability and intellectual streaking is of most benefit when it is shared in the interests of the learners, rather than shared because it’s of interest to the educator. This might be obvious, but I’ve often seen emotional vulnerability used as a tool for the educator ie as a shield of self deprecation to protect an insecure speaker. I will sometimes see educators critique themselves with such fervor that it seems to be a pre-emptive strategy to avoid the audience doing it for them. This shows their humanity, yes, but it also draws the audience into an uncomfortable, involuntary role : they are being drawn into a protective and reassuring role for the educator, when they should be focused on learning.

    2) Showing personal vulnerability as an educator involves risks not only because you can drop too far down the authority gradient, but also because personally, you’ve just let your guard down by exposing some personal flaws. That sets you up not only for ‘losing face’, but also for personal hurt when it is not embraced in the way you expect it to, because from a defence point of view you can feel really exposed in that moment and you can’t take it back.

    3) Written vulnerability is easier, less risky in the moment, but more risky in its accessibility and permanence. Because there is more distance from you and the audience, it can be really successful and in some ways I think you need to gamble more to let them in. I think one post I wrote was specifically successful because it let people in on a deep and personal level, while still being focused on the learning points at hand. Which you kind of need online.

    4) I think that there are still some cultural variances in the level of vulnerability that can be demonstrated. Social media in Australia for example, not infrequently features stories from people sharing quite personal stories of depression in the workplace, suicidality etc, there appears to be a strong thirst for that human connection. I’ve repeatedly been warned in Australia that a couple talks I’ve given might not go down in America as well, because the established experience is that ‘Americans respect strength’. I’m not saying that’s necessarily a rule, but I think we do have different cultural expectations in different countries. Australians in particular, appear almost pathologically concerned with tall poppy syndrome and avoiding appearing like a ‘know it all’ to the audience, because particularly in Australia, humility to the point of downplaying your own successes is often rewarded with acceptance.

    In summary, to take the article’s metaphor to its crude extreme, there’s a difference between an intellectual streak and an intellectual d*ck pic. Vulnerabilty can be a somewhat intoxicating experience due to social media reward of that behaviour, but particularly in a face to face environment, I think it’s most effective when utilised in a considered manner to help the audience rather than the educator.

  • Ian Summers

    Intellectual streaking.
    And then the case: Mills, Boon and imminent disrobing.

    Ben, what’s going on? The naked truth please.

    I shall try and stay in theme, which means a little doffing.

    The article, or viewpoint, is wonderfully written, thought provoking and just the right dose of entendre to capture the eye and imagination. No surprise given the authors. I wonder if this was simply called: “Expressing vulnerability: role and validity as a teaching method” whether it would have attracted the same attention. But once caught, the reader can’t help but reflect on the central messages. Job done.

    Two comments:

    1.)this article focuses, as it should, on the participant benefit of teacher expression of vulnerability. There is a second benefit, that to teacher. Imposter syndrome depends on our ability to place the expected standard just out of reach of our perception of our own talents. What if we are exposed as the fraud we know we are! Terrifying! Imagine, instead of facing the true awfulness, the public reveal of our Emporer’s new clothes, naked, shamed in all our inadequacy (!), we let just a tiny revealment of our humanity shine through. What if we had made mistakes, learned from them, shared them? Could this help us by taking off the pressure of our own expectations? Could the expression of imperfection reduce the terror of standing in front of an audience: now allies in reflection and learning?

    2.)How far is too far?

    Pointless venting. War stories, tragedy without reflection and learning.
    Dominance of our voice over theirs, emotional distress, self-flagellation. False emotion, manipulation. Breaching confidentiality.
    Dishonesty and deception. The Fargo factor. This is a true story events depicted took place….

    Pick your stories, determine your comfort with the past, determine the point, the message and the effect of your words. Use sparingly.

    Like all good (intellectual) strips: leave a little to the imagination, choreograph for effect and light carefully. And be fitter than security.

    Thanks Ben and team and the thought provoking comments of those that have contributed and in anticipation of those that will.

    cheers, Ian

    • Victoria Brazil

      This is an amazing discussion.
      Feeling vulnerable just entering .. attempting to keep up with the erudition and insight
      ……
      I think streaking is perhaps a poor analogy, as i’m not sure most of the naked folks running across the cricket field are exposing vulnerability… they are mostly showing off, drawing attention and causing trouble.
      (..at least one of the Chappel brothers took to a naked bottom with his cricket bat )
      Suspect we run the same risk as educators

      And Ian and Ben’s last comments get to the heart of this issue … why show vulnerability.?…
      If we can really articulate ‘why’ – how much is too far might be easier to spot..?
      If its to gain rapport/ extend real empathy to learners – great stuff.
      But yes the risk is narcissism or even ‘faux humility’ …
      eg “… that happened to me once too……etc etc .. though of course i heroically saved the day”

      I think we also see this in stories told in talks on stage…. making the audience feel deeply is powerful, but has to also have a point

      Thanks again for the great chat

      vb

      • Eve Purdy

        I’m glad you brought this up Vic! I came on the blog to rant a bit about the language they chose for the theory. I agree that it does not at all get at what they are describing and is just a bit sensational – click bait if you will.

        The history of streaking is interesting though. Apparently the first recorded streak was that of a bunch of Quakers in the 1700s in England who ran through the streets to “show the naked truth” of the gospel. The trend really got going though on American Campuses in the 1970s and took off from there. The rates of streaking significantly dropped off at the end of that decade. Now we just see the one off streaker at sporting events or concerts. The practice has largely been written off as a weird thing that people do but it might actually fit into an important political and cultural milieu. Why did this start happening? Seriously, though…wtf?!? For more on this check out this historian’s account. http://www.billkirkpatrick.net/scholarship/streaking/

        There are any number of reasons that one historian Kirkpatrick tries to explore. He writes:

        “While many Americans were longing for the Age of Innocence of the (white, patriarchal) 1950s, the university continued to lead the way in altering the gendered and racialized relations of power on campus and in American society at large. And it was at precisely this socio-historical juncture that young white men began stripping off their clothes and running in public.”

        Though not all streakers are men, the practice largely started (and mostly continues) to be performed by this gender. Kirkpatrick theorizes that the practice of streaking was performed as a way to re-territorialize campuses by young white men just after an era of profound change and revolution.

        So even though I don’t think the term is a useful way to think about showing vulnerability effectively in the debrief room I think can we take lessons from the history of streaking to help us understand when things go wrong. If stories and anecdotes don’t bring us closer to learners or learners closer to each other, rather they act to re-territorialize something we feel we are losing then we just aren’t doing it right.

  • Jenny Rudolph

    Hello everyone I really enjoyed this discussion because I think that modeling fallibility (as my colleague Walter Eppich dubs it) can be very powerful not only in building rapport but transforming power relationships as others have noted here.
    My interest is the boundaries of “fallibility“ or “intellectual streaking“ with respect to allowing the learners to keep learning. I’d like to describe my gut sense, and my understanding of the literature on “creating a safe container“. My take is that the container has to be non-reactive and durable enough that learners can rely on the holding environment to not unravel or disintegrate.

    Imagine that learning is relational and dependent on “being held“, not just a cold intellectual activity. Vulnerability and fallibility by teacher/educator/instructor needs to be a “dose” that does not threaten the perceived integrity of the holding environment.

    So I’ve noticed that when I admit I’ve made a mistake with a lightness or humor but clearly “keep my balance”, learners seem to respond very well. I believe it would be a different story if I appeared to be ashamed or deeply discombobulated myself because then that threatens the holding environment that I am creating.

    Would be curious to get peoples take on what I’ve said here and being seen to make a clinical error either in Sim or IRL (as Sarah Janssens discussed).

    • Ben Symon Post author

      Hi Jenny,
      Thanks for commenting, I found your extension of the safe container for learning analogy into this space very helpful. I agree that much like debriefing with good judgment, avoiding implying shame around mistakes can maintain that it is safe for everyone to make some errors.

      Interestingly in the clinical environment, I have found this to sometimes to be a double edged sword, and I think part of that can be that learners/junior staff bring their own internal expectations of their seniors. Sometimes these expectations can be on the verge of magical. “The consultant never makes mistakes”, for example. “If the consultant says it’s this diagnosis, then that diagnosis must be correct.”.

      There have been times when I have simply admitted I don’t know something, or that something (like orthopaedics or something), isn’t my strong suit, and some learners find that really empowering, while other times I can see this flash of disillusionment and fear go across their eyes. In that moment I feel this sense that they’re like “You’re supposed to protect me, and you don’t know what’s going on? Fuck! What now?”.

      Sometimes I’ll console myself that the long term learning objective of understanding that all of us are fallible is worth it, sometimes I’ll just feel like I let them down.

      But I think my take home from that, is that the integrity of the ‘holding environment’ you describe includes scaffolding from both the educator’s comfort with the material, but also from the (sometimes unrealistic) expectations of the learners.