So Vesna, tell me about your practice. >> So I'm a pediatric neurologist, which means that many days out of the week I get to be in the operating room doing surgery on little kiddos and their kidneys and bladders and testicles that didn't drop. And the mother days of the week I'm in clinic. >> Mm-hm. And so when you think about using this model, how do you think about briefing? And I'd like you to focus on being in the clinic, and approaching children in the clinic with a learner. So how do you brief this? >> Yes, that is actually a challenge for a lot of our residents, who are used to dealing in adult world with neurology patients. And in that situation their main focus is talking to the patient themselves. And here they have a different situation where they're walking in, maybe talking to someone who doesn't talk, who doesn't yet have words to express themselves. And they have a parent or a guardian in the room, and that is a person that they also need to build a connection with and trust with. So before we even walk into the room, we sometimes talk about ideas and kind of tips and tricks on how to gain comfort with a child. Maybe distracting them, maybe talking about things that they might be interested in, which is sometimes hard if you're a 20 old who doesn't have kids, but I can give them some ideas of video games that are currently popular or TV shows. So then when they walk in, they can talk to the kid a little bit and talk to the parents a lot and establish a trust with those people before they start to do an exam. >> I understand. So I would think that when they come to clinic with you, they think their goal is to be able to do a testicular exam. >> Sure. >> On these children, but in fact you can't actually do that skill unless you master this other skill of how do you deal with the child and the parent. >> Right, right and that takes time, and I'm not expecting the residents to do it perfectly right away. It took me years to figure it out, and I can still be much better at it. But I feel like when the resident comes in they think, the pediatrician has said they can't feel this testicle so my job is to feel it. And, gosh darn it, I'm going to do everything I can to feel this testicle and find it. But, really their job is to be able to gain the trust of that little child to even let them do a good exam. And, sometimes a good exam alone will prevent the need for surgery, but you have to have a kid who trusts you and lets you do it. And, before you can have a kid that trusts you, you have to have a parent who trusts you. >> Interesting, and so, do you explicitly say that to the learner? Do you say, I know your goal is to be able to examine the testicle, but in fact, the way that you do that is through this other goal? >> Sometimes, I find some residents are more intuitive than others and get that right away, especially those who have children, but for most, you do have to explicitly say that. That this is something you're going to have to, it's almost like a password, like a secret you have to get to be able to have access to do what you need to do to make your surgical decision-making. >> Right, interesting. And so now let's say you're in the clinic and you're in a room with a patient, so you've got a child, a parent, the learner who's supposed to do the exam, and you. And let's say it's not going really well. The kid is like freaking out. >> Yes. >> How do you manage that? >> That's tricky. So there are many relationships there, and everyone is anxious. [LAUGH] So the first way is to get the parent on your side. So they are the ones who are going to best be able to calm down that child. And maybe Stopping whatever made the child freak out, and going back to just talking, can help. And maybe the child is just sitting up on a table and would feel much more comfortable on mom's lap. And if you just let mom hold the little toddler, and settle them down, and give them a little goldfish, or whatever snack is going to make them more comfortable, then you can kind of start talking again to the parent about what have you noticed at home? What do you think the problem is? What's going on? And once the parent has had an ability to express themselves and the child has calmed down a little, maybe you can try again. But there are sometimes when just have to say okay, this is not the day. And maybe we can come back on another day and try, maybe we can do this in the operating room if we know we have to go to the operating room anyway. But you can only do so much, and the parents will be the best judge of whether that child can tolerate more. >> And so for an example would be that the learner will come in, or the resident will come in, and just kind of really directly approach the child. >> Right. >> And you can sense that that child is not comfortable with it. And so, instead, you might change the conversation by saying to the resident, why don't you talk to the parents about how this presented and what did they see? >> Yeah, and maybe even just in a broad way say, no, you're right to ask the child that, but wait, let's just first ask Mom. Mom, what have you noticed at home? Tell us, and include myself, tell us what you have noticed at home and what you think the problem is. Or, what does she say to you when she comes home from school, and then involve Mom in the process more. And sometimes just changing the physical environment and having the child be closer to Mom will allow for better trust. >> And when in the debriefing piece of that, do you say that explicitly? Do you say, did you notice how this child got really anxious when you approached them directly? >> Yes >> And did you notice how I kind of brought it around? >> You do have to often say those things very explicitly, and there are times when, God forbid, I've even seen a resident try to push the child's legs down, because the child starts closing, because the child is scared. And I know that all they're trying to do is to see better, to do something better, but then we have to very explicitly have the conversation of, never,never can we do that! And you can use your words to try to help calm them down, to say, don't worry, if you say stop, I will stop. I will do nothing that hurts. If anything hurts you or bothers you, you have control, you say stop and we'll go away, but if you could just let your legs fall out to the sides. And saying things that sound very sort of gentle and reassuring and allow them to have the control. So, I say those kinds of phrases, specifically to the residents because sometimes, the resident doesn't have bad intentions, they just don't know. They've never thought about it, how to say that differently. >> And so, let's say you come out of the room and it was a not a great exam. >> Yeah. >> And so how do you debrief that case with the learner? How do you start? >> So, it is good to let them express themselves first. I think it's helpful just from the standpoint of venting and I think they often do understand that something went wrong and they feel guilty. And it's almost that they want to apologize or try to explain why their strategy didn't work. And then I tried to give them some ideas, and tips, and tricks. But then I also kind of encourage them and say look, this is really challenging. This is difficult. And when you have small children at home it's hard to get them to do what you want them to do as a parent too. Much less strangers they've never met asking them to do things that are uncomfortable. So there are times when we've said, we'll try this again another day, and then there's other times when we've taken kids to the operating room to do a good exam. And that sometimes is necessary but kind of encouraging the learner to understand that this was a very difficult thing, that they did some things well. And then here's next time, how we can try in this age group what might work. >> Well, that seems pretty effective. Sounds great, I think you're a great teacher. [LAUGH] >> Aw, thanks, I try, I could be a lot better, I could, yeah.
