ASRA Pain Medicine Update

Communicating with my fellows is akin to interacting with my children. The passion to see them succeed in our field and the expectation for their clinical and academic progress are no less vigorous. In addition, the methods that I use to engage our fellows are eerily similar to how I engage my kids.

Like with the five languages of love, people have multiple learning styles. The best strategy is to present the information multiple times using different modalities, substantiating the topic repetitively and differently each time, until they successfully receive it.

 What follows is what I’ve learned on this journey through chartered, but mainly undisclosed, territory.

1. Preemptive discussions are, like all things in life, better than reactionary responses. Preemptive discussions represent mental preparation for things to come, an exchange of each party’s objectives and a written or spoken timeline of events. I usually disclose to the fellows that, as postgraduate learners, they get out of the fellowship what they put in to it. They need to be the ones seeking the opportunities. (Alternatively, they also need to know when their plates are full.) A little bit of coaching before game day can smooth out the path ahead. Therefore, expectations from both sides are clearly laid out.

2. Faculty have a multitude of ways to distribute information to the learner, and diffusion or osmosis is definitely not one of them. Think of it more as active transport. One of my truly engaging and exuberant faculty members, bless his heart, would at frequent intervals during the fellowship, corner a fellow for multiple hours in an effort to inundate him or her with information. Later, when I queried the fellow on some details of that topic, the fellow would not be able to recall. Meanwhile, the faculty could have sworn that he had touched on every single point.

Like with the five languages of love, people have multiple learning styles. Some fellows need the topics to be in the form of a question and to be sent on the hunt (with lots of hints dropped along the way) for a response. Some fellows are visual learners, audio learners, or both. Some fellows are hands-on learners, cognitive learners, or both. Some fellows take your word for it, and some argue (hopefully tactfully) at each step of the way and need proof.

The best strategy is to present the information multiple times using different modalities, substantiating the topic repetitively and differently each time, until they successfully receive it. Learning trajectories are different for all. Embrace and build on their strengths. Be patient with their weaknesses.

3. They can’t read your mind.

You need to be concrete! And if they do not understand what you are saying, you need to be well versed in describing the topic in a different way. Leaving things vague and open ended will only result in miscommunication and the potential for clinical or technical errors down the road.

4. Selective hearing is a universal trait.

It does not matter whether I put things in writing, discuss them orally during our monthly discussions, or send more than one email about topics. Please refer back to point #2: repetition using multiple different modalities to express the same concept or thought. If group emails do not work, I make sure that I email directly to the individual. Persistence is key.

5. They need to have skin in the game. “Everyone gets a sip of the honey from the honey pot.”

Their success stories and mistakes must be meaningful, not just to patients or faculty, but to the fellows as well.

 For example, in clinical practice, they should be asked to routinely check up on patients whom they have cared for. Getting feedback from patients and learning the results of their management are critical for their own professional growth. Therefore, rounding on patients is extremely important.

Another example from administration is to invite them to division meetings to contribute to decision-making conversations. In the least, they will better understand the concerns and issues that arise with each change in protocol.

6. See one, do one, teach one.

They need to realize that they’ve transitioned from trainee to trainer. They are no longer just there to receive information, but they also have the dual role of distributing that information. This is actually a hard transition to make because most fellows feel that because they are taking the extra year to learn more about their subspecialty, they want to be the ones performing procedures and receiving instruction directly from the faculty, not teaching it to the resident. I think it is extremely important for fellows to teach topics and procedures to residents. This encourages them to delve deeper into the subject, find ways to express the information clearly, and recognize their own knowledge deficits.

 I used to have faculty solely present at our monthly meetings, feeling that the fellows had so little experience to draw on to give meaningful talks. Sadly, unless we had a very motivated group of fellows, their attendance was dismal. Currently, for our monthly educational rounds, I preserve some time for fellows to present current literature. This gives them opportunity to take on roles as educators and distribute knowledge to their faculty and fellow colleagues.

7. You don’t need to be a micromanager, but you should probably scrub in. Be a role model, not just a coach.

It helps that as a faculty, you work beside them instead of delegating and simply providing guidance. Letting them observe your technical skills or hear your thought processes can be enlightening for them (hopefully in a good way).

 For example, it could be something clinical, like improving in-plane needle visualization, acquiring optimal ultrasound images, or demonstrating the best way to advance a needle for a neuraxial block. They may have a somewhat reasonably precise way to guide the needle or hold a probe, but a step-by-step breakdown of the needle or probe manipulation with demonstration can give them more alternative maneuvers. Let’s face it: sometimes, particular motions cannot be explained by words but are easier to demonstrate by action.

 Or it could be something academic, like writing a manuscript. Having them participate in the literature review, outline the goals and objectives, or write part of the passage with you may be much more beneficial to fellows’ education than merely delegating the work to them while giving some words of guidance. Preparing a manuscript with a fellow certainly may require significantly more time than would be required to simply do it yourself. However, going through this exercise with the fellow will likely result in a much more positive and beneficial experience for that individual.

 Finally, it may be something professional, like being available on call or in person to handle challenging scenarios as they arise. Seeing experienced faculty run through their decision tree and act on those decisions provides fellows with not just insight into how to proceed but also a peace of mind that the course of action taken was drawn from a greater breadth of experience.

8. Positive feedback is a more powerful motivator than negative feedback.

Positive feedback ensures your fellow’s mental well-being. It breaks the barriers to communication by allowing fellows to be freer with their ideas and musings, minimizing those unspoken thoughts or erroneous assumptions. It gives them more incentive to come back each day with joy and a desire to learn. It helps fellows focus on the important issues: ensuring their patients’ comfort and furthering their education instead of diverting their mental energy to the emotional stress that comes with negative feedback.

 However, receiving only positive feedback can lose its efficacy. Negative feedback should be delivered when the situation arises, but its delivery can be done tactfully and offer examples for improvement. Failed blocks or analgesic modalities should be discussed, and a debriefing period allows for self-reflection and personal growth.

9. When faculty-fellow interactions become destructive instead of constructive, focus on goals instead of relationships.

Perhaps the most challenging topic is the occasional negative interaction between particular fellows and faculty that usually snowballs as the year progresses. Of this, I am still searching for an answer. Sometimes, different styles of interaction just do not fit well with each other and asking faculty or fellows to modify their character traits to be receptive to the other party is like putting a Band-Aid on a gaping wound. My response, because I am not known to be a very confrontational person by nature, is to re-emphasize fellows’ goals for their year to redouble their efforts toward patient care and their education and to remind them that one negative relationship should not dictate the entire year. However, I am amenable to suggestions on this topic. (Email me at lle@anest.ufl.edu.)

Final Words

Every fellow class has a certain character, a particular footprint they leave behind, and just as each fellow class is shaped by our teachings, so are we as faculty molded by their personality and quirks. This unique feel from each fellow class is what keeps my job as fellowship director so fresh each year.