"TEACHING PEOPLE TO DOCTOR - Simple Strategies for Success" - Rachel Osborn, MD, M.A.T.

September 18, 2023

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00:00An educator series called Yes
00:03and that is I believe Fridays.
00:07So there is there is basically about
00:11every week or every other week a session
00:15that is geared towards enhancing
00:18your skills as educators and so very
00:21excited about this upcoming year.
00:24So wanted to introduce our first
00:27speaker of the year and it's really
00:30an honor to introduce Rachel Osborne,
00:34who I personally recruited back to Yale.
00:39I know there were many other voices,
00:41but particularly proud of this achievement.
00:46As you all know, Rachel,
00:47she's presently the residency
00:48director and as of July 1st,
00:51Associate professor of
00:54Pediatrics and hospital Medicine.
00:57And for those of you who might not have
00:59known Rachel for that long or her history,
01:02Rachel did her undergrad at
01:04Stanford and then got her Masters
01:06in Arts and teaching also,
01:10and that was at National
01:12Lewis University. It's a teachers
01:14college when I was a high school teacher.
01:17And so Rachel's kind of
01:21understanding education certainly
01:24far preceded this present position.
01:28She was a residence here,
01:32a chief resident in Med Pete's,
01:35and then was an instructor in
01:39Pediatrics as well as, let's see,
01:41an assistant professor before
01:43leaving us to go to University
01:47of Michigan for two years.
01:49At which point we recruited her back in
01:53order to become our residency director.
01:57Certainly Rachel has a strong history
02:02in Qi and her understanding of how
02:06to first of all problem solve,
02:11her adherence to critical thinking and
02:16her support for critical thinking in
02:19the residency program and her approach
02:22in terms of education as a systems
02:25process to me is just unparalleled.
02:29Rachel has done work in the
02:32X&amp;Y scheduling for clinic.
02:34She's also done work in addressing
02:38bias and discrimination in the
02:41recruitment process and most recently
02:44is really I would say a pioneer
02:47in the ambulatory core rotations
02:50and that's just to name a few.
02:52And of course Rachel has every year the,
02:56regardless of which institution she's
03:00in has received honors in teaching,
03:03whether it's the honor roll here
03:06or University of Michigan.
03:07So I'm extremely,
03:09extremely honored to have Rachel as
03:12one of our educational leaders and
03:14certainly as our first speaker to
03:16kick off is year into the pediatric
03:20education learning community.
03:21So thank you,
03:22Rachel.
03:24Thank you so much, Panina,
03:25and thanks everybody for coming.
03:27It's actually really exciting to see
03:28this many people sort of excited to,
03:31to spend lunch with me today.
03:34This session is going to be interactive.
03:35I'm not going to do the thing
03:37with my residents where I make
03:39everybody turn on their cameras,
03:40but at some point I probably will
03:42ask folks to turn on cameras because
03:43we're going to go into breakout rooms.
03:45And talking to yourself on Zoom
03:47is always a little disconcerting.
03:49So if you're eating lunch or whatever,
03:51just be prepared that we are
03:52going to go into some breakout
03:54rooms a couple of times today.
03:56And this is really meant to be quite
03:59informal and sort of give you a little
04:01bit of an overview of how learning
04:04theory can inform the decisions
04:06we make when teaching residents.
04:09I will add. Medical students, I will.
04:11I will just offer a quick
04:14disclaimer before I begin.
04:15I'm in my office and my Wi-Fi is
04:17sometimes a little challenging here.
04:18So if I freeze for just a moment,
04:20know that I'm going to come back.
04:21But I turned off the blur,
04:23my background to save all my
04:25processor speed that I can.
04:27So to start, I have no disclosures.
04:28As I always say,
04:29if anyone has a lead on any way that I
04:31can get something that someone will pay
04:32me to do that I would have to disclose,
04:34just let me know.
04:35But until such time arises,
04:37I have no disclosures.
04:38And I'm going to start.
04:40I just came off a very busy week of
04:42service on the Blue Orange team.
04:43And I'm going to start by sort
04:45of talking a little bit about an
04:46actual case from this past week to
04:48give you a sense of how complex
04:50the task is that we're actually
04:52asking people to learn how to do
04:54in a really short period of time.
04:56So we have an 11.
04:58I I came into morning bolus my first
04:59day of service and heard from my from
05:02my night senior and my night intern
05:03in a little 30 minute conference in
05:05the morning that we had an 11 year old,
05:08previously healthy boy admitted with four
05:10days of progressive neck and back pain.
05:13And they went through and sort of told
05:15me different different facts about
05:17him including that he'd had a fever,
05:19had been in the emergency department
05:21and had had an unsuccessful LP
05:24attempted times two while he was in
05:27the while he was in the emergency
05:29room and was sort of admitted for
05:31this idea that he was going to be re
05:34LPD with interventional radiology.
05:38And so that was the,
05:39the handoff that I received and then
05:41asking some questions in conference,
05:44I learned a number of things.
05:46So I was very specific to ask,
05:47did they do a dedicated neurologic exam?
05:50And in fact they did do a dedicated
05:52neurologic exam and found that
05:54he had left upper extremity,
05:55numbness and weakness only in
05:57the Palmer aspect of his hand and
05:59sort of this part of his forearm.
06:02And I asked some other questions,
06:03including did he have any history of trauma?
06:05He did not. And I asked importantly
06:07if he'd had any altered mental status,
06:09been tired or cranky at all.
06:11And the answer was no.
06:13And it was, it was interesting because this
06:16patient was sort of presented to us as a,
06:18this is a kid who might have bacterial
06:21meningitis and we need to tell P him again.
06:23And the ultimate answer of what he
06:25had was cervical osteomyelitis with
06:26an Abscess that was compressing
06:28part of his upper spinal cord.
06:29We were able to sort of come to
06:32that decision that he needed an
06:33urgent MRI within about 6 minutes
06:36of discussion in the morning.
06:37But when you actually think about this case,
06:40it's incredibly complicated, right?
06:43It is an incredibly complex process by
06:46which we're asking brand new doctors to
06:49ascertain a differential diagnosis for
06:51things that don't always fit into a nice box.
06:55And So what I have here on the slide is,
06:59is Bloom's Taxonomy.
07:00Mine is the very top.
07:01I always leave Create off.
07:03I was a creative writing major.
07:04I'm allowed to be to be
07:06dismissive of the create,
07:07although that's that's an
07:08important thing at the end,
07:09but I like to end it evaluate when
07:11I'm talking about clinical reasoning.
07:14And so you can imagine that any
07:16resident or medical student who's
07:18going to ultimately arrive at
07:20this correct diagnosis first has
07:21to remember a number of facts.
07:23They have to remember how the
07:25dermatones work.
07:26They have to remember where
07:27people can get infections.
07:28They have to remember the types
07:30of of bugs and presentation
07:31that that might present with.
07:33They have to understand a little bit of
07:36how those facts apply to this current kid,
07:39right.
07:39They have to understand that not every
07:42single patient will will ultimately
07:44have a perfect presentation of spinal,
07:46of spinal root compression and
07:48they have to apply that knowledge
07:50to the kid in front of us.
07:52They have to think about what
07:53questions they're going to ask,
07:54how are they going to do a hypothesis
07:57driven history and physical.
07:58Then they have to analyze the
08:00data that they receive.
08:02So for example,
08:03this patient had a CRP of 180, right?
08:05They need to analyze that particular
08:08piece of information in order to
08:11create and evaluate a diagnostic
08:13plan or therapeutic plan.
08:15And so much of how we teach people
08:17in medical school and in residency
08:19in didactic sessions really focuses
08:21on these bottom parts.
08:23We're really trying to get people
08:25to remember facts and sort of have a
08:27have a surface understanding of how
08:29of how those facts impact patient care.
08:31So I'm guilty of this.
08:33You know, it's like the,
08:33the leading question,
08:34you know,
08:35what bacteria are you most worried about
08:37in a patient who has a bone infection?
08:39That's a fact, right?
08:40That's a fact that we want them to
08:43remember and they need to remember that
08:46fact in order to apply an antibiotic
08:48regimen for for a given patient.
08:50But we often end up stopping right
08:53here at those remember and those
08:55understand and sort of spoon feeding
08:57our residents or our students.
08:59The rest of this we say you're right,
09:01it's staff or strep.
09:02And so we're going to give
09:03Oxicillin and there's there's some
09:05opportunities here to think about
09:07these higher order objectives.
09:08When we go through our process
09:11today and think about how we're
09:13actually teaching people to do the
09:15complex task of being a doctor.
09:17Because it's not just knowing the facts.
09:19It's also things like how am I going to
09:21elicit this history from a child who's
09:23pretty afraid and in a lot of pain?
09:25This particular family spoke Spanish.
09:27How am I going to utilize an interpreter
09:30to adequately ascertain this history?
09:32There are so many pieces that go into
09:35teaching someone how to actually be an
09:38effective clinician in in an environment,
09:41whatever that environment is,
09:42be it an acute care environment,
09:44a hospital, a clinic and outpatient setting.
09:47We really need to be thinking about
09:49how are we using our learners at
09:52all stages of Bloom's Taxonomy.
09:55And I'd like to take just a moment
09:57to think about how we can engage
09:58our learners in this.
09:59I hear the phrase,
10:01quote UN quote adult learners a lot.
10:03When I talk about residents and
10:05medical students, I hear the phrase,
10:06well, they're adult learners,
10:07so they'll read on their own, right?
10:09Or they're adult learners,
10:10so they're going to choose if they
10:11want to come to noon conference or not.
10:13And I think we use this phrase to imply
10:17something that it doesn't necessarily.
10:19That's not actually what adult learners are.
10:22So adult learners refers to a
10:24very specific learning theory,
10:25sort of within the humanistic
10:27lens of learning theory that talks
10:29about how adults approach learning
10:31slightly differently, right,
10:32than a first or a second grader.
10:33So they tend to be problem oriented.
10:35They like to apply their previous
10:37life experience to that problem.
10:39They're theoretically internally
10:40motivated to learn certain things
10:42and are more ready to learn,
10:43and they're they therefore they
10:45can be more self-directed.
10:47But that doesn't simply mean
10:48that we say to an adult learner,
10:50hey, you want to be a doctor,
10:51go read up to date and pub bed
10:53and come back to me in a week.
10:54There's still an argument to be made
10:57for really significant scaffolding,
10:59and I think it's also a misunderstanding
11:01to assume that everyone who is an adult
11:04who is also learning is by definition
11:07an adult learner in that setting.
11:09So I was joking before I began
11:11that I was trying to figure out
11:13how to rewire the the lights in my
11:15house this past weekend.
11:17The lights in my children's rooms
11:18have been wonky for some time,
11:20right? So yes, that's been
11:22true for two years, right?
11:24You can make an argument that
11:25I should have been an adult
11:27learner for two years, right?
11:28I had a problem,
11:29Don't have a lot of experience,
11:30but theoretically I'm internally motivated.
11:32I should be self-directed, right?
11:34And ultimately one day decided that
11:36I was going to be an adult learner
11:38in this setting and I was going
11:39to figure out how to fix this.
11:41But it took a little while and
11:43there were a lot of things that
11:44sort of entered into my decision to
11:47eventually decide to rewire my house.
11:48And that's true for everyone who's
11:51learning these very complex clinical
11:52structures that we're asking them
11:54to learn in residency as well.
11:56So self motivated does not
11:59necessarily mean fully independent.
12:01And I bring up Maslow's hierarchy
12:02within this as well because I think
12:04it's important to remember that
12:06residents are human beings and adult
12:08learners and that certain things
12:09need to be met in order for them to
12:12actually do the hard work of being a learner.
12:15So self,
12:16self motivated learners are often within
12:18this sort of top tier on Maslow's hierarchy,
12:21right?
12:21They're realizing their potential.
12:23They have self actualization.
12:24But in order to achieve that,
12:26we have to make sure that they have
12:27at least some baseline functioning
12:28of these things below them, right?
12:30So food, shelter, warmth.
12:32I don't know if you guys have
12:34noticed if any of you are ever
12:35in the inpatient setting,
12:36but our residents have a how much
12:39water did I drink board on their
12:41walls in all of these rooms?
12:42So they're actually calculating how
12:44many times they drink water in a day.
12:46And I have yet to see a single
12:48team actually meet their goal.
12:50Right. So did they get to pee?
12:51If they're a nursing mom,
12:52do they have time to go express breast milk?
12:54Right.
12:54Like,
12:55what are we actually needing
12:56their physiologic needs?
12:57The answer is often no, right?
13:00And then there's this question
13:01I'm so happy Panina brought up,
13:03you know,
13:03our upcoming session on sort of safety,
13:05right.
13:05And the idea of safety that
13:07do people feel protected?
13:09So we had an incident last year
13:11in which a resident was sort of
13:14verbally and nearly physically
13:15threatened by a parent who was
13:18secretly filming the entire encounter.
13:20And that resident really wanted
13:22there to be some support from from
13:24faculty and from hospital leadership
13:26to make sure that she knew she was
13:28still safe in this environment.
13:30And until we were able to sort
13:32of demonstrate that in fact
13:34that learner is protected here,
13:35they aren't going to be able
13:38to be self actualized and it's
13:40foolish to think they can.
13:42I think it's also important to realize
13:43that people want to feel connected.
13:45One of the reasons why we as a
13:47residency program spend so much time
13:49and energy forming peer-to-peer
13:50connections is because that's
13:52crucial for people to becoming
13:53self actualized as
13:54doctors do. People care who they are, right?
13:58So one of the examples that I sometimes give,
14:00and this isn't meant to throw shade
14:02at the University of Michigan,
14:03I was very happy there.
14:04But when I won their teaching award,
14:07the quote that was read out loud about
14:08me at the banquet that started the
14:10the session in which they gave me this
14:12award was from a thirdyear resident
14:14who said Doctor Osborne is unique and
14:16that she treats us like actual human
14:19beings with names that she remembers.
14:21And I think we all have to sort of let
14:24that sink in for a second because I I
14:26think I have personally encountered many,
14:28many times in which someone has
14:29wanted to give me constructive
14:31feedback about a learner.
14:32And I say, well, who was the learner?
14:34And the faculty doesn't
14:36know that learner's name.
14:37And so this is they they aren't going
14:39to be able to achieve what we want
14:41them to achieve if we don't take the
14:43time to sort of know who they are,
14:45at least on a very surface level.
14:49And then residents and students want
14:50to feel like their value added.
14:52They want to feel like the process and
14:54the work that they're doing is important
14:56to the ultimate care of the patient.
14:58They want to feel respected.
15:00Now that doesn't mean that we just tell
15:02them that their ideas are always right,
15:04but listening to their ideas and asking
15:06probing questions about those ideas,
15:08those are things that help
15:09residents and students become
15:11sort of self actualized learners.
15:13And then we get to this question right.
15:14I I love when my third years are
15:17starting to panic because they
15:18realize that in fact they're going to
15:20be in charge next year or at least
15:22partially in charge in many settings.
15:24And that's when you're starting to to
15:26develop that self actualization, right?
15:27Am I ready to know what I know?
15:29What I don't know?
15:30Am I ready to access the resources
15:32that I need to access?
15:34But in order to get there,
15:35we really need to be thoughtful about
15:37these things below it or else we're
15:40never going to have a learner who
15:42ultimately becomes self actualized.
15:44So Adult learner Theory is really
15:46based in the same idea of Self
15:48Determination Theory.
15:49I use a lot of Liz and Molly cartoons.
15:51I love Liz and Molly.
15:52If you guys don't follow them on Instagram,
15:54I highly suggest it.
15:55But the idea here is that residents
15:57and students need to feel like
15:59they're always sort of moving and
16:01that they can reach the top.
16:03And this is based in in
16:06psychological learning theory,
16:07that this doesn't just happen
16:08because you turn 20 and all of
16:10a sudden you're adult learner.
16:12And it doesn't just happen because
16:13you become to medical do you go
16:15to medical school?
16:16There are three components of helping
16:18people be effective adult learners
16:21with effective self determination.
16:23And those 3 components are connection,
16:26competence and autonomy.
16:27So people have to feel
16:29like they've got a buddy,
16:31that they have someone who cares
16:32about them and that they're part of a
16:34system that cares about who they are.
16:36They have to feel like they're
16:37learning what they're doing.
16:38Like they kind of know what they're doing
16:40and have the opportunity to continue to
16:42grow because they have baseline competence.
16:44And then they have to have
16:46some degree of autonomy.
16:47And we're going to talk a little bit about
16:49that autonomy at the end of the session.
16:53So I'm going to ask us all to be
16:55a little bit vulnerable here,
16:57and we're going to go into
16:58some breakout rooms.
16:59But I will role model this first.
17:02I think one of the things that's very
17:05challenging for residents in training,
17:07and one of the reasons why medical
17:09trainees have probably the highest
17:11rates of burnout and depression of any
17:14profession in in the United States is
17:16because they can feel incredibly isolated,
17:19right?
17:19We we have an unwritten curriculum
17:22that you repress and ignore,
17:24repress and ignore,
17:25repress and ignore and that actually
17:27having any kind of emotional
17:29response to something that happens
17:30at work is a sign of weakness.
17:33And I can tell you one of the
17:35things that's been sort of most
17:36powerful for me in creating a little
17:37bit of a learning and creating a
17:39positive learning climate is being
17:41willing to admit when I have an
17:43emotional response to something or
17:45when I regret a decision that was
17:48made or a mistake that I made.
17:50So I've led a noon conference in which I
17:52talk about as a as a second year resident,
17:54a patient was admitted with
17:56increased work of breathing who I was
17:58pretty sure had a cardiomyopathy,
18:00but I thought it could wait until
18:01the morning and that patient
18:03coded at 5:30 in the morning.
18:05And I still think about that case
18:08and being able to share that with
18:10with residents and talk about
18:11how difficult it was for me to
18:13go through that as a learner.
18:14But also what I learned from and how
18:17I moved forward is it it allows our
18:20residents to feel connected and to feel seen.
18:24I also talk a lot about my and I'm I'm,
18:26I'm like this bonus.
18:27I'm not asking anyone to be quite
18:29this vulnerable today guys.
18:30I'm leading the session.
18:31So don't worry.
18:32You don't have to bury your your
18:34deepest most personal secrets.
18:35But many of you have probably
18:37heard me talk about this,
18:39that I had a very difficult time
18:40with nursing, with my first child.
18:42And really it was, it was sort of in in.
18:45It was all wrapped up in what is,
18:47in hindsight,
18:48very obviously recognized as
18:49severe postpartum depression.
18:50And I wrote about this and
18:52it was published in a jam,
18:53a piece that residents have read and
18:55have approached me and talked to me about it.
18:57And I think being willing to
18:59admit that I am
19:00a person who is also a physician has
19:02been really, really helpful for our
19:05residents and for learners overall.
19:07I have never had a learner
19:08come to me and say, man,
19:09I wish I didn't know that about you.
19:12They've always come to me and said
19:13that they really appreciate that.
19:15I make it a little more normal for
19:17them to be going through some of these
19:19feelings that they might be going through.
19:21So we're I'm not going to make
19:22anyone do it in a big group.
19:24But Karina,
19:24we're going to put people in breakout
19:27rooms and I want everybody for
19:295 minutes to think about a case.
19:32Everyone's going to take two or
19:34three minutes each.
19:34You're going to think about a day that
19:37you had an actual emotional response
19:39to something at work and you're
19:41going to authentically validate it
19:43to one another in your small group.
19:46It's Vegas rules.
19:47What happens in the breakout rooms
19:49stays in the breakout rooms.
19:50People are only allowed to share
19:52their own story, Okay.
19:53So Karina,
19:53can we put people in in the
19:55rooms and we'll come back here in
19:57about 5 or 6 minutes guys?
20:11And I sent you instructions,
20:12Rachel, for how to share in the
20:14breakout rooms if you want to. OK,
20:16perfect. I need it for the last
20:17one, but not for this one.
20:24All right. Looks like
20:26everybody's in. OK. Perfect.
20:32Gives me a little break.
20:44There's one room ended up
20:45with only two people. I think
20:47a few people. As long as they're
20:48both active in it, it'll be fine.
21:02I'm going to try to do this real
21:03quick and see if it lets me.
21:04I'm going to stop, share, and reshare
21:06while they're in the breakout rooms.
21:11There we go. Perfect.
21:15It does work. I've never done it before,
21:17but I just googled how to do it
21:27for the next breakout. Do we want
21:28to keep the same people together?
21:31It's a completely different vibe.
21:33Then I'll probably change it up just
21:36to for the sake of changing it up.
21:46You
21:50need to speak more often. This is
21:52the best attended health yet. Well,
21:55we'll see how it goes.
21:56I don't know that I've got
21:58anything that amazing to say.
22:00I'm just like, let's all talk
22:01about our feelings, guys.
22:02We and I had a couple of robots
22:05and I had a couple people ask music
22:08recorded. So people are interested.
22:18I'm going to send a broadcast.
22:25Do
22:36you know if we have a timer
22:38on these breakout rooms?
22:38We probably can't tell, can we?
22:40We usually do like a 62nd timer.
22:44I'm going to assume we do.
22:50I'm sorry, I have myself on mute.
22:52When you hit closed rooms,
22:54it starts a sticky 62nd timer.
22:58So just let me know when you're ready
23:00for me or if you want. You said you
23:02sent a message already out, right?
23:03I sent a broadcast to people that said
23:05two minutes, so I'll tell you when
23:06we should actually try to close them.
23:23It's Betty. I'm not sure
23:24when you say close all rooms,
23:26you may have to recreate them
23:27again. I'm not sure. Yeah,
23:29I'll recreate them again.
23:31Thank you. Sorry guys.
23:44Okay, we can hit close all rooms.
23:59Hi, Jim. Hi Rachel.
24:01Sorry, accidentally clicked
24:02leave the room a little early.
24:04That's Okay. I do that all the time.
24:07Thanks for joining today.
24:08This is great.
24:17I
24:51Hi, boss.
25:00Right, So it looks like
25:02people have made it back.
25:03I I don't see anyone in hives
25:05or tears so I'm assuming that
25:08that that process was okay.
25:10But I I just really want to
25:12tell you it it takes it.
25:13The first time I ever did this
25:15right really talked about something
25:17that really was hard for me.
25:18I was so nervous.
25:19I thought I was going to
25:21make the residents afraid.
25:22I thought they were going
25:24to lose respect for me.
25:25I was a relatively junior attending
25:27when I did this the first time and
25:29and I just have to tell you that
25:31it it pays dividends and their
25:33willingness to engage with you in the future.
25:36So you don't have to do that every day.
25:38Other strategies that are really
25:40important for sort of connection,
25:42what I call connection light, right,
25:44is ask their names and then use them.
25:47So I'm not good with names.
25:49I'm really not.
25:49I've learned a lot of skills over
25:51the years to get better at it,
25:53partially from when I was a teacher
25:55and partially from just having
25:56sort of this job that I have.
25:58But I write their names down on
25:59the back of my patient list.
26:01And at the end of the day,
26:02when I'm done writing my notes,
26:03I refresh and I remind myself
26:05I've put them in my phone before,
26:07right, so you can cheat.
26:08No one is saying you can't have
26:10a cheat cheat,
26:11but ask their names and use
26:12them on a consistent basis.
26:14Small gestures of appreciation go a long way,
26:17right?
26:18Saying thank you can be really,
26:21really important.
26:21I remember when I was a trainee one
26:25day I spent two hours organizing
26:27A sedated lymph node biopsy and
26:30MRI for a patient only to have the
26:33attending tell me it was going to be
26:35cancelled 3 minutes after I did it.
26:37And I was like,
26:39and then the fellow looked at me and said,
26:41thank you so much for your hard work.
26:42I know that that was really unfortunate
26:44that you did all that for nothing.
26:45And I remember it now as a positive
26:47thing instead of as a negative thing.
26:49And so small gestures of appreciation
26:52really can help those connections form.
26:55And I just like to make a little,
26:56a little reminder that we can all
26:58be part of ending generational
27:00trauma and medical training.
27:02Yes, we all have horror stories,
27:04and the vast majority of us will
27:06have trained in a time that was
27:08empirically more challenging than
27:09the residents who are training today.
27:11But that doesn't mean that that's
27:12the right way to have done it.
27:14So the picture here is my daughter
27:16wrote this book about feelings
27:18that she published and like,
27:19sold a bunch of copies of.
27:21And this is her.
27:22This is like her, her,
27:23her essential representation of
27:25what it is to sort of heal,
27:28right.
27:28And so really thinking a
27:29little bit about how
27:30we can be part of that,
27:31acknowledging things that
27:32happened to us that were hard,
27:34but not necessarily leveraging that
27:36misery on someone else because we think
27:38that's the only way to teach them.
27:42All right, let's move on
27:43to the next one. I promise.
27:45All the feelings are done now, guys.
27:46So the next one really has to do with,
27:49with competence, right?
27:51So we talked that residents need connection.
27:53Residents also need to feel like they
27:56are becoming increasingly competent,
27:58and one of the ways in which
27:59residents can feel that the most is
28:01in helping them develop their skill
28:03set and clinical reasoning, right?
28:05So this takes a whole different
28:06learning theory.
28:07This really is moving away from the
28:09humanistic learning theory and moving
28:10much more into into some sort of
28:12social cognitive learning theories.
28:14But the idea behind this is teaching
28:17people to recognize how they are
28:20thinking and that can be an incredibly
28:22useful tool in helping residents and
28:24medical students learn a little bit
28:26more of how to be sort of effective
28:28clinicians in different in different arenas.
28:31So who just I know, Not everyone.
28:33I wouldn't even ask.
28:34Show of hands Zoom is the worst.
28:36Anyhow,
28:36I'm assuming many people have
28:38heard of type one thinking,
28:39which is sort of heuristic thinking.
28:41So it's like that knee jerk reaction.
28:43This is the kid who has a history of eczema
28:47and a strong family history of asthma,
28:49who's presenting at age 3 with
28:52whee's right and and it's natural for
28:54physicians to use a little bit of knee
28:56jerk thinking when we hear that right,
28:57like okay, let's give that's asthma,
28:59right?
28:59Let's give that kid treatment for asthma.
29:02Whereas type 2 thinking is really forcing
29:04yourself to slow down and be like,
29:06are there components of this
29:08particular history and physical that
29:10don't fit with what I think, right.
29:12And so or what is the differential
29:14that I could actually generate that
29:16might be relevant for this patient.
29:18So a few weeks ago,
29:20I had a patient admitted on service
29:22who had had recurrent wheeze for his
29:24whole life but had no personal family
29:27history of A to P and no no personal
29:29or family history of A to P including
29:31like an IGE of nothing and EO's of nothing.
29:34And my team just had a conversation
29:36that that's interesting,
29:37right.
29:38That's puzzling.
29:38That makes us wonder,
29:39is it possible that this kid could
29:42have ciliary dyskinesia or another
29:44reason for his ongoing we use that
29:46isn't necessarily traditional asthma.
29:48And so helping people recognize
29:50when they're using sort of quick
29:52thinking and when it's important
29:54to slow down is really crucial.
29:56This is something most advanced physicians,
29:58right,
29:59which I'm calling us all advanced physicians.
30:02A medical student the other day
30:03called me an expired millennial.
30:04So I'm going to call us all
30:07advanced physicians.
30:07And so thinking a little bit about
30:10those that that idea of like when we
30:13recognize that something doesn't fit,
30:15but saying that out loud and role
30:17modeling that for learners is
30:19incredibly important rather than
30:20just saying this is an asthma,
30:22this is ciliary dyskinesia.
30:23Saying the reason why I think
30:25this is an asthma is because XYZ and being
30:28really explicit and role modeling that
30:31the other really important thing that
30:34can be helpful is creating a skill set
30:37and developing an illness script, right.
30:39And so one of the things,
30:41one of the concrete takeaways
30:42I really want you guys to,
30:44to learn from today's talk is how easy
30:46it is to teach residents and students
30:48to create an illness script for a given
30:51presentation and how useful that is for
30:53them in widening their diagnostic library.
30:57So I have a whole bunch
30:59of illness scripts here.
31:00I tried to sort of spread out Outside
31:02of just the hospitalist world though
31:05you'll notice that I I'm bad,
31:07I don't know,
31:07a lot of clinical medicine outside
31:09my own purview, but that's okay.
31:11So you know, you,
31:12you might say that we have a four
31:14day old X30 X 36 week infant
31:17with hypoglycemia to 40, right.
31:18That is an illness script.
31:20That's a pretty straightforward
31:21illness script, right,
31:23a 17 month old admitted with
31:25recurrent wheeze.
31:26So things we might add to that.
31:28So you can say things like is this acute,
31:31subacute or chronic,
31:32making sure every presentation the
31:34residents are recognizing acute,
31:36subacute or chronic recognizing
31:37criteria that might come along with
31:40that particular patient, right.
31:42So a 17 month old with no past medical
31:44history of any kind is different than
31:46a 17 month old who has a history of peanut,
31:49an egg allergy as well as
31:51severe refractory eczema,
31:52right.
31:52And so adding those small details
31:55can be incredibly helpful.
31:57I'll say,
31:57like a 10 year old who presents with
31:59unilateral pain and swell knees,
32:01pain and swelling and mild anemia.
32:03So that would be one we're really knowing,
32:04like is this acute?
32:05Did the kid wake up that way or
32:07was this subacute,
32:08did this happen over a period of weeks?
32:10Is it recurrent?
32:11Is it the only time it's ever happened?
32:13So adding those qualifiers is really,
32:16really crucial because I find
32:18that many residents and students
32:20present a summary statement when
32:22they tell me their assessment.
32:23So they say things like,
32:25oh, well,
32:25this is an 8 year old with refusal to
32:28to take solid PO for a week, right.
32:30I'm like, OK, well,
32:30I remember that from when you
32:32actually presented the kid, right.
32:33So let's add a few more qualifiers.
32:35Right.
32:36So it's an 8 year old with subacute
32:39decrease in oral intake and an acute
32:41refusal to take PO to solids with
32:44maintained hydration status, right.
32:45So really forcing them to add as
32:48many qualifiers as they can that
32:51we think are relevant.
32:52So I tell people this is the,
32:55this is the, the rhythm to follow, right.
32:57So age and comorbidities, who is the kid?
33:00Is this a kid who has chronic?
33:02Is this a kid who's technology
33:04dependent or not?
33:05Is this, you know,
33:06to use a neonatology example,
33:08right?
33:08Is this a kid who was born at term
33:09or is this a kid who was born at 26 weeks?
33:11Those are very different posts, right.
33:14So those those types of things, you know,
33:16all three month olds are not created,
33:17the equal and so age and comorbidities
33:20is important, Acute, subacute,
33:22chronic, recurrent or or non
33:24recurrent are important things.
33:26And then I force learners to pick
33:283 words to describe what they have
33:30because otherwise you'll find that they
33:32just want to pick everything, right.
33:34They'll say, well,
33:34this is a 10 year old,
33:36previously healthy child with
33:38acute right sided knee pain who's
33:40presenting with a normal CRP and a
33:43normal white count and a little bit
33:45of anemia and a rash on their belly
33:47and had a headache three days ago.
33:49And they find themselves just
33:51repeating everything that they
33:52originally said in their presentation.
33:54So forcing them to sort of nickel
33:56down to three will help them to
33:59develop this illness script.
34:01This is a habit that I've taken to for
34:02all of our when we do morning boluses,
34:04which is when we have the night
34:07team present their day admissions.
34:08I force the night team when they get
34:11to their assessment to say stop,
34:13give me this kind of assessment
34:15every single time.
34:16And in doing that,
34:18you will find that they're better
34:19able to elucidate why they might want
34:21to do the next step that they want
34:23to do or if the next step that they
34:25presented is in fact not the right next step.
34:28So with that case that I presented, I said,
34:30I said so now we've got a 10 year old,
34:31previously healthy kid with acute fever,
34:35neck pain and upper extremity symptoms
34:39and unilateral upper extremity symptoms.
34:40Do you really think an LP is the next step?
34:43And the first thing out of their
34:44mouth was no,
34:45we need an urgent MRI of the neck.
34:47And I said great,
34:48let's do an urgent MRI of the neck.
34:49And so really pushing them to
34:51think about that illness script
34:53can be incredibly useful.
34:56So I was going to pick.
34:59I was going to pick on some people,
35:00but I feel like there's a lot of people here,
35:02and that will be mean.
35:03Unless anyone wants to.
35:05I'll just do it. Sorry.
35:06Well, I'll just listen to my own
35:08sound of my voice a little more.
35:10So really thinking about how to flush out
35:12these illness scripts a little more, right?
35:14So another case from last week,
35:16a four month old who
35:17presented with a diaper rash.
35:19So this is a better illness
35:20script for it right?
35:22A four month old,
35:23otherwise healthy child who presented with
35:25an acute on chronic non blanching violations,
35:27papular diaper rash.
35:28The actual diagnosis there?
35:30Langerhans cell histeocytosis.
35:32Thank you Adam Burke for picking
35:34that up from just Googling it.
35:36But you can really see that forcing
35:38people to be thoughtful about that
35:41very specific illness script is,
35:43is crucial.
35:47And so, you know, another example here,
35:50right, is that this is a 7.
35:52You know, instead of just saying
35:53a 17 month old who was wheezing,
35:54a 17 month old with significant
35:56atopic history, who presented with
35:58subacute wheezing times 3 weeks
36:00without fever or rhinorrhea, right.
36:02And so that starts to be like,
36:04OK, so maybe this kid actually
36:05has a foreign body, right?
36:07Or maybe this kid has some kind of
36:09airway anomaly and not asthma because
36:11the illness script no longer fits
36:13with necessarily a presentation of
36:16asthma or recurrent preschool weeks.
36:19All right,
36:19so we're going to move on to the last,
36:21the last criteria.
36:23So we talked about methods to
36:25create connection.
36:26We talked about methods to increase their
36:29subjective feeling of competence and
36:31making diagnosis and developing plans.
36:33So now I want to talk about the one that's,
36:34you know,
36:35traditionally thought of as the most floated,
36:37which is autonomy.
36:38I have learned over the years that pediatric
36:41attendings hate when I talk about autonomy,
36:44right.
36:44And that our brains all start to move
36:46towards this thing that's like, yeah,
36:48but they don't know what they're doing.
36:49Or.
36:49Yeah, but not in my clinical arena, right.
36:52Or. Yeah, but but not yet.
36:54And I want us to just turn off those,
36:56yeah,
36:56butts for a second and hear me
36:59out about ways in which we can
37:01actually promote autonomy and
37:03really help you understand how
37:05crucial it is to promote some
37:07autonomy if we want our learners to
37:10become self actualized physicians.
37:13So I defined, I Googled this,
37:15I defined autonomy.
37:15Me and Google were like this lately.
37:18So having the authority to make one's own
37:21decisions and the freedom to act right.
37:23So in the clinical arena,
37:24right.
37:25It's the idea that like our
37:26residents able to make a decision
37:28and implement that decision without
37:30betting every single component of
37:32that decision with someone else.
37:34Because if they have to vet every
37:35component of the decision over time
37:37they're going to stop making those decisions.
37:39In their mind they're going to
37:41just wait to be told what to do.
37:43And and this is a crucial piece of them
37:46becoming self actualized physicians.
37:48So we want to think about how can we,
37:49how can we promote autonomy safely
37:52in a variety of clinical spheres.
37:55So I also will just tie this back
37:58to to Maslow's hierarchy, right.
38:01And the idea of respect.
38:03So I'll be honest,
38:05I have had learners catch things
38:07that I haven't caught.
38:09I suspect that's true for nearly
38:11everyone on this call, right.
38:13I've said something and a
38:14resident has been like, yeah,
38:16but they actually had a fever to 103.
38:18So don't you want to do this?
38:19I'm like, oh, yes, I do, right.
38:22And so if I haven't made an
38:25environment in which it's clear
38:26that I care what they have to say,
38:29I'm actually way more dangerous
38:31as a physician than I would be
38:33if I just told them everything.
38:35You know, like if I just tell them
38:37everything and they never bring up a thought,
38:39I'm way more dangerous than I am if
38:41I'm making some space for them to
38:43offer their perspectives and ideas.
38:45Because eventually you will
38:46create this this world, right,
38:48in which people feel like their
38:50voice doesn't have a space,
38:51so why would they share anything?
38:53And that's bad for patients
38:55and it's bad for education.
38:58So we're going to use a strategy
39:00called the One minute Preceptor.
39:03And I talk about this strategy as a way
39:06to it's it's autonomy light, right.
39:08It's it's,
39:09it's a way to make residents feel
39:11that they're growing into an
39:13autonomous physician without having
39:14to give them so much autonomy that
39:16we're all wringing our hands and
39:18developing ulcers about the decisions
39:19that are being made overnight.
39:21So this is the these are the components
39:24of the one minute preceptor.
39:26A resident presents something to you.
39:27It can be a full HMP, it can be a blood gas,
39:30it can be anything, right?
39:32It can be a new lab.
39:33This, this CRP went from 180 to 80
39:36and I asked the learner for a commitment.
39:39It can be any commitment.
39:41I'm going to pick on Lubena because
39:42she's a hospital medicine fellow.
39:43I'm not actually going to make
39:44you say anything,
39:45Lubena, don't worry.
39:45But I would say to Lubena,
39:47so when do you want to check another CRP?
39:50And Lubena is going to answer me
39:52and then I'm going to say why.
39:54So if Lubina says I want to check
39:56another CRP because I think we
39:57might be able to transition off
39:59IV antibiotics tomorrow,
40:00I'm like this is not going to happen.
40:01You're not going to go from 80
40:03to 3:00 tomorrow, right?
40:03So I can give her some feedback
40:06about her thought process.
40:08But if Lubina says I want to check
40:10another CRP in four days because
40:11I think she's is down trending,
40:13we don't need to check it as long
40:15as he's staying clinically well.
40:17And I think that might be a time
40:18in which we can push infectious
40:20disease to come up with a final
40:22duration of treatment.
40:23Well, all of a sudden,
40:24two things have happened.
40:25One, Lubina's been able to demonstrate that,
40:27in fact, she does know what she's doing,
40:30right?
40:31And two,
40:32I now trust Lubina more because I now
40:35know that in fact she has thought
40:37this through and has made a great decision,
40:40right?
40:40And so either the resident learned
40:42something that they didn't know
40:44before or we learned something
40:46about that resident that allows
40:48us to give them more autonomy and
40:51similar situations in the future.
40:52And so the the criteria of of the
40:54of the one minute researchers,
40:56you ask for a learner,
40:57you ask them why you provide feedback.
40:58And then if there's a general learning point,
41:00particularly if you're in a room, right.
41:02If you're in a group of people,
41:03you can say, yeah, that sounds great.
41:05This is why this is the right answer here.
41:07Right. You know,
41:08we generally can transition to oral
41:11antibiotics when the CRP is nothing
41:13for uncomplicated osteomyelitis,
41:14whatever that general rule might be.
41:16So everyone has learned,
41:18but Lubene has been able to utilize
41:20some autonomy and I have demonstrated
41:22that I respect her opinion by asking
41:25it and listening to it before I just
41:27tell everybody what we're going to do.
41:30So I don't know I I've messed up my
41:34my animations they're clearly anyhow,
41:36moving on someone can do a how
41:38to do PowerPoint for me at some
41:39point in the future.
41:40So I'm going to do can I
41:43actually a bridge party.
41:45Will you come off mute
41:46and be my learner For me?
41:48Once, once my chief resident.
41:50Always my chief resident.
41:52I'm ready. All right.
41:54So I'm going to you're going to be
41:56my learner here, Okay. And I'm.
41:57I'm the. I'm the preceptor.
41:59So I have a three.
42:00You've presented this to me.
42:02You want to read it out loud for us,
42:04Lavina.
42:05So this is a three-year old boy who
42:07presents with a cute Shigala gastroenteritis
42:10complicated by severe dehydration.
42:12He is not yet taking oral intake.
42:16And then they go so, right.
42:18And they're often waiting for us to jump in,
42:20right. There's this like pause that
42:22many of you have probably noticed
42:23in which the learners like, are they
42:25just going to tell me what to do here?
42:27Am I expected to come up with a plan?
42:29And so when you come to that pause,
42:31you can ask any question you want, right?
42:33Maybe I ask Lubena, So what do you want?
42:36What did I say? What do you want
42:38to do with this fluids today?
42:39Or maybe I ask,
42:40do you want to give him antibiotics, right.
42:43Or maybe I ask,
42:45when do you want to check labs again?
42:47So we'll be going to pick one
42:48of those two to answer.
42:50What do you want to do today?
42:51Or do you want to start antibiotics?
42:54I would like to resuscitate him first
42:57with simple horses and then start him
43:00on continued continuous fluids as well.
43:02OK. So why do you want,
43:03why do you want to do that?
43:06I think that he's already very behind.
43:08So I think that we have to catch him
43:10up first before we can support him
43:12with what his maintenance needs are.
43:15Yeah. And you know what?
43:15If I'm really in the clinical environment,
43:17I can push her further
43:18using these same things.
43:18I won't make her do this because she
43:20doesn't actually have the kids labs, right.
43:21But saying like,
43:22what fluid do you want to use?
43:24How much of it do you want to use, right.
43:25And providing feedback about that.
43:27You guys saw that took 30 seconds
43:30for me to ask Lubina those
43:31questions instead of just saying.
43:33So we're still way behind and we need
43:35to give them some boluses today, right?
43:36Or if I said what do you
43:38want in his case 2.7,
43:39what do you want to do about that, right.
43:40And have Lubina say,
43:41I want to give oral K I'm like good luck,
43:43he'll puke that up in a second, right.
43:45And so those are opportunities
43:46to really engage.
43:47But you're you're you have
43:49to ask them a question.
43:50Do you actually want to hear the answer
43:52to And it's A-frame shift from from that,
43:54like guess what I'm thinking question, right.
43:56So often on rounds I might be tempted to say,
43:59So what are the criteria for starting
44:01antibiotics in a patient with Shigella?
44:03And I'm waiting for people
44:05to spit out those criteria.
44:06That's a knowledge level.
44:07That's the bottom of the pyramid, right?
44:10By saying what do you want to do?
44:11You want to start antibiotics, right?
44:13Or what do you want to do
44:14with this fluids today?
44:14That's an application that's a higher level.
44:16So I'm,
44:17I'm both encouraging higher level thinking.
44:20I'm teaching myself how much
44:21autonomy I can give my learner.
44:23And I'm giving my learner
44:25the illusion at least,
44:26of autonomy by asking those questions.
44:29So let's practice again.
44:30Who else can I pick on?
44:35Doctor Loyal. Do you want
44:37to be a learner for me?
44:41Once my boss. Always
44:42my boss. Okay, you're going to be my learner.
44:45Can you read the the, the, the case there?
44:48Yes. This is an 18 month old here for
44:51a well child check who presents with
44:53poor weight gain and decreased oral
44:55intake for the past seven months.
44:58So I could ask any of these questions.
44:59You don't have to ask all of them, right?
45:01Maybe I say to Jespree, what workup
45:03do you want to start for him today?
45:04Or I'm going to ask you the second question.
45:06So Jespree, when do you think is the
45:08threshold to admit him to the hospital?
45:10Do you think we need to admit
45:11him or what's the threshold?
45:17Okay, I'm overthinking this. If you want,
45:19I was going to say, do
45:20we have to admit, right.
45:22So you could say we might not have to.
45:24So that might be your answer, Right.
45:25And like, what would be your reasoning
45:27for why you might not admit?
45:29Because we're hospitalists and we try
45:31to avoid these admissions at all costs.
45:33well-being, I think being in a
45:35hospital is a stressful environment.
45:36So I don't know, you know,
45:39sometimes like that can be
45:41worse for the family dynamic,
45:43right. And so I hear that from Jess Free,
45:45right. And I say to her,
45:46like, absolutely right.
45:46And I think we want to avoid that
45:49hospitalization at all costs, right.
45:51And so for me, I would only want
45:52to admit this kid to the hospital
45:54if I think we really, truly cannot.
45:55We've tried a lot of things to get
45:57him to gain weight in the outpatient
45:59setting or I think he's at risk of
46:01acute refeeding syndrome, right.
46:02And those are kind of the two reasons why
46:04I might admit a kid to the hospital, right.
46:06And so I've asked Jaspreet her opinion.
46:08I've heard where she's at and
46:10thinking about this patient,
46:11and I'm able to sort of continue
46:13the conversation moving forward.
46:14But
46:15what if I tell you the PCP
46:16wants him admitted? Then what?
46:19Well, then I would say, but do you agree?
46:20Right. So if I'm using this method,
46:22I would say, but do you agree?
46:24Right. And. And maybe maybe the
46:25resident says I don't agree, right.
46:27And I and that's an opportunity
46:28for us to connect. Right.
46:29I I share that opinion, right.
46:31Then I can share,
46:32go back to that connection piece,
46:33right where I can say, you know,
46:35as a hospitalist who sees the stressfulness
46:37of this for families, I agree.
46:38It's lousy to admit a kid for failure
46:40to thrive to the hospital when I feel
46:42like I can't do very much for them.
46:44Sometimes we exist in this reality, right.
46:46And so you're able to sort of
46:48offer that connection, right.
46:49So there's don't be afraid of
46:51asking them this question.
46:53Nothing bad can happen from it.
46:55Either they learn or we learn that
46:57they didn't need to learn that
46:59particular piece of information
47:00and both are incredibly useful.
47:03So we're going to go and break out rooms
47:04one more time for five more minutes.
47:06I'm going to stop my share for
47:07a second because I'm going to
47:08reshare with my breakout rooms,
47:09being allowed to share,
47:13share the breakout rooms.
47:15And you guys are going to go into a
47:18breakout room and pick one of these
47:20cases that you want to practice.
47:23So be a learner, Be an educator.
47:25Ractice the the oneminute preceptor.
50:17I'm going to close the rooms.
50:18OK, Karina, but I have it here, so,
51:28OK oh, look, we've got a baby guest.
51:33So I think so I hope you guys got
51:35a chance to sort of practice that.
51:37I find a lot of people want to jump into,
51:39like asking more questions and
51:40doing more didactic learning.
51:42And when you use the strategy,
51:43it's important that you stick to what
51:45do you want to do and why and then teach
51:48from that moment, very limited, right.
51:49And it's meant to be something you can do
51:52in all sorts of busy and busy environments.
51:55So I will, I will wrap up today with
51:58just a few important takeaways, right.
52:01So, one, I think we know this,
52:03but I think sometimes we forget this.
52:05Learning to be a doctor is an
52:09incredibly complex task that
52:11requires tremendous scaffolding,
52:13and the idea that we're going to teach
52:16people to do it by just harping on
52:19knowledge is really fundamentally unsound.
52:22I also want to to really impress
52:24upon you guys that adults are not
52:27inherently selfmotivated learners.
52:29They're not inherently selfdetermined.
52:31We build selfdetermined learners by
52:34creating environments that allow for
52:37that connection for like recognized
52:39improved competence and for autonomy
52:41in in certain settings that are safe,
52:44right.
52:45And those are all crucial towards the clip,
52:47towards developing a healthy and
52:50happy clinical learning environment.
52:52And when you do this right and you
52:54do this well,
52:54I assure you that you can give residents
52:57and students a lot of feedback.
52:59You can tell them all sorts of things
53:02that you want them to do better
53:04because they believe you that you
53:06are in fact invested in helping
53:08them be self actualized learners.
53:10When you've done these things to sort
53:12of lay the groundwork to demonstrate
53:14that you were in fact invested in them
53:17becoming self actualized learners.
53:18This is my daughter becoming a self
53:21actualized learner in Harry Potter
53:23world where these little magic
53:25wands are actually way harder to
53:27to to work than you think.
53:28Right.
53:29And she's up there like trying to make
53:31this stupid umbrella rain and you know,
53:33but she she wanted to do this.
53:35She was surrounded by other kids,
53:37you know, she felt that connection.
53:38She got better at as time went on.
53:41Right.
53:41And I let her pick which one
53:42she wanted to do next.
53:43It was a great three hour activity
53:45that only cost me $55 per wand.
53:47We'll talk about that another day.
53:49But it was it, you know,
53:51I think that that mentality that can exist
53:53in the clinical learning environment,
53:56it can kid residents can be like
53:58kids at Harry Potter World,
54:00but you have to build the
54:01right setting for them.
54:02And so I know we're running low on time,
54:05but I will end by asking
54:07if anybody has questions,
54:08thoughts they'd like to share.
54:10I'm open to be taken in the jaws.
54:13And if anyone has something
54:14negative but wants to pretend to
54:16radiate positive energy,
54:18my six year old's here for it.
54:20So any questions or comments that people
54:22want to share in our last minute or two,
54:29Rachel, how do you pick just one thing
54:31to focus on for one minute preceptor like
54:34you're going to learn something new
54:36the next time, right? And so remember,
54:38if you do it for every patient,
54:40then you'd pick something different, right?
54:41So in bronchiolitis, I try to vary, right?
54:43What do you want to do
54:44with their high flow today?
54:45You want to give that one albuterol, right?
54:47And so you can sort of pick
54:49different questions or if it's a
54:51really interesting and complex kid,
54:52you can ask different learners
54:53different questions.
54:54So you can say what do you want
54:55to do next diagnostically what
54:57antibiotics you want to give.
54:58And so you can sort of walk around the
55:00room that way and that can be a way to do it.
55:02But just realize this isn't the
55:04last time they're going to learn
55:05about whatever topic it is.
55:07So why pick whatever I want to talk about,
55:08which is you guys can tell is quite a lot.
55:10So
55:19okay. Thank you, Rachel,
55:21so much. Really, this was a great
55:24kickoff and so appreciate you sharing
55:27your experience as well as you know,
55:30certainly the expertise that you have.
55:34All right, thanks guys. Take care, everyone.
55:38Great. Thank you.