Leadership and Professional Development

“No one cares how much you know, until they know how much you care.”

—Theodore Roosevelt (attributed)

Like many early career clinician-educators, you are likely embarking on your teaching role with excitement and trepidation. Excitement accompanies the opportunity to develop the next generation of physicians. Trepidation arises from a fear of insufficient knowledge. This concern is understandable but misplaced: great teachers are great because of their emotional intelligence, not their medical intelligence. These five principles will help you establish an optimal learning environment.

Small-Talk before Med-Talk. “What do you like to do outside of the hospital?” “Where is your favorite place to eat?” These questions indicate that your interest in learners transcends clinical work. Leaders who are more relationship- than task-oriented achieve greater group cohesion and more team learning. Exemplary inpatient attending physicians use learners’ first names and get to know them on a personal level to signal that they care as much about the person as they do about the performance.¹

Be Available. Medical educators balance supervision and autonomy while trainees engage in high-stakes decisions. The best teachers get this right by signaling “I have faith in you” and “I’m always available.” Clinician-educator Kimberly Manning, MD portrayed this balance in a recent Twitter thread. The resident called: “I am sorry to bother you.” Dr. Manning responded, “Never be sorry.” The resident was concerned about a patient with new abdominal pain but reassured Dr. Manning that she did not need to return to the hospital. She returned anyway. She assessed the patient and had nothing to add to the resident’s outstanding management. As the patient recovered from his operation for a perforated ulcer, Dr. Manning reflected, “On a perfect Saturday afternoon, I chose to return to the hospital. To make not one decision or write one single order. But instead to stand beside my resident and intentionally affirm her.”

Build from the Ground Up. Asking questions is the teacher’s core procedure. Strive to master the true Socratic method of starting with an elemental inquiry and then leading a conversation that poses questions of increasing difficulty until you reach the limits of the learner’s understanding. This method reinforces their hard-earned knowledge and sets the stage for growth. “What would be your first test to evaluate tachycardia?” Once the correct answer is firmly in hand, explore the margin of their knowledge. “Which regular, narrow complex tachycardias stop with adenosine?”

Never Judge. Never endorse an incorrect response—but do not disparage it either. A trainee must learn that their answer was wrong but should not feel defeated or embarrassed. Use judgment regarding whether constructive feedback should be delivered in public or in private.

I recall answering a question incorrectly in medical school. The attending responded, “How many years did you take off before starting third year?” I had not taken any time off. The attending was a phenomenal clinician but a lousy teacher. A master teacher would have accessed a foothold and built my knowledge without judgment.

Remain Humble. One of the most liberating phrases you will deploy as a teacher is “I don’t know.” Its utterance demonstrates the honesty and humility you hope to instill in learners. Be on the lookout for the many times your trainees will know more than you.

Recently my team evaluated a patient with blunted facial expression, bradykinesia, and a resting hand tremor. I disclosed to my team: “I don’t know the key maneuvers to distinguish the Parkinson plus syndromes from Parkinson disease.” The medical student had spent one year studying patients with neurodegenerative diseases (I learned this during the “small-talk before med-talk” phase). I invited him to demonstrate the neurologic exam, which he did admirably. That day I did not know the subject well, and we all learned because I freely admitted it.

Being a physician is the greatest job in the world. If you leverage your EQ (emotional quotient) as much as your IQ (intelligence quotient), your learners will conclude the same.

“No one cares how much you know, until they know how much you care.”

—Theodore Roosevelt (attributed)

Like many early career clinician-educators, you are likely embarking on your teaching role with excitement and trepidation. Excitement accompanies the opportunity to develop the next generation of physicians. Trepidation arises from a fear of insufficient knowledge. This concern is understandable but misplaced: great teachers are great because of their emotional intelligence, not their medical intelligence. These five principles will help you establish an optimal learning environment.

Small-Talk before Med-Talk. “What do you like to do outside of the hospital?” “Where is your favorite place to eat?” These questions indicate that your interest in learners transcends clinical work. Leaders who are more relationship- than task-oriented achieve greater group cohesion and more team learning. Exemplary inpatient attending physicians use learners’ first names and get to know them on a personal level to signal that they care as much about the person as they do about the performance.¹

Be Available. Medical educators balance supervision and autonomy while trainees engage in high-stakes decisions. The best teachers get this right by signaling “I have faith in you” and “I’m always available.” Clinician-educator Kimberly Manning, MD portrayed this balance in a recent Twitter thread. The resident called: “I am sorry to bother you.” Dr. Manning responded, “Never be sorry.” The resident was concerned about a patient with new abdominal pain but reassured Dr. Manning that she did not need to return to the hospital. She returned anyway. She assessed the patient and had nothing to add to the resident’s outstanding management. As the patient recovered from his operation for a perforated ulcer, Dr. Manning reflected, “On a perfect Saturday afternoon, I chose to return to the hospital. To make not one decision or write one single order. But instead to stand beside my resident and intentionally affirm her.”

Build from the Ground Up. Asking questions is the teacher’s core procedure. Strive to master the true Socratic method of starting with an elemental inquiry and then leading a conversation that poses questions of increasing difficulty until you reach the limits of the learner’s understanding. This method reinforces their hard-earned knowledge and sets the stage for growth. “What would be your first test to evaluate tachycardia?” Once the correct answer is firmly in hand, explore the margin of their knowledge. “Which regular, narrow complex tachycardias stop with adenosine?”

Never Judge. Never endorse an incorrect response—but do not disparage it either. A trainee must learn that their answer was wrong but should not feel defeated or embarrassed. Use judgment regarding whether constructive feedback should be delivered in public or in private.

I recall answering a question incorrectly in medical school. The attending responded, “How many years did you take off before starting third year?” I had not taken any time off. The attending was a phenomenal clinician but a lousy teacher. A master teacher would have accessed a foothold and built my knowledge without judgment.

Remain Humble. One of the most liberating phrases you will deploy as a teacher is “I don’t know.” Its utterance demonstrates the honesty and humility you hope to instill in learners. Be on the lookout for the many times your trainees will know more than you.

Recently my team evaluated a patient with blunted facial expression, bradykinesia, and a resting hand tremor. I disclosed to my team: “I don’t know the key maneuvers to distinguish the Parkinson plus syndromes from Parkinson disease.” The medical student had spent one year studying patients with neurodegenerative diseases (I learned this during the “small-talk before med-talk” phase). I invited him to demonstrate the neurologic exam, which he did admirably. That day I did not know the subject well, and we all learned because I freely admitted it.

Being a physician is the greatest job in the world. If you leverage your EQ (emotional quotient) as much as your IQ (intelligence quotient), your learners will conclude the same.

“No one cares how much you know, until they know how much you care.”

—Theodore Roosevelt (attributed)

Like many early career clinician-educators, you are likely embarking on your teaching role with excitement and trepidation. Excitement accompanies the opportunity to develop the next generation of physicians. Trepidation arises from a fear of insufficient knowledge. This concern is understandable but misplaced: great teachers are great because of their emotional intelligence, not their medical intelligence. These five principles will help you establish an optimal learning environment.

Small-Talk before Med-Talk. “What do you like to do outside of the hospital?” “Where is your favorite place to eat?” These questions indicate that your interest in learners transcends clinical work. Leaders who are more relationship- than task-oriented achieve greater group cohesion and more team learning. Exemplary inpatient attending physicians use learners’ first names and get to know them on a personal level to signal that they care as much about the person as they do about the performance.¹

Be Available. Medical educators balance supervision and autonomy while trainees engage in high-stakes decisions. The best teachers get this right by signaling “I have faith in you” and “I’m always available.” Clinician-educator Kimberly Manning, MD portrayed this balance in a recent Twitter thread. The resident called: “I am sorry to bother you.” Dr. Manning responded, “Never be sorry.” The resident was concerned about a patient with new abdominal pain but reassured Dr. Manning that she did not need to return to the hospital. She returned anyway. She assessed the patient and had nothing to add to the resident’s outstanding management. As the patient recovered from his operation for a perforated ulcer, Dr. Manning reflected, “On a perfect Saturday afternoon, I chose to return to the hospital. To make not one decision or write one single order. But instead to stand beside my resident and intentionally affirm her.”

Build from the Ground Up. Asking questions is the teacher’s core procedure. Strive to master the true Socratic method of starting with an elemental inquiry and then leading a conversation that poses questions of increasing difficulty until you reach the limits of the learner’s understanding. This method reinforces their hard-earned knowledge and sets the stage for growth. “What would be your first test to evaluate tachycardia?” Once the correct answer is firmly in hand, explore the margin of their knowledge. “Which regular, narrow complex tachycardias stop with adenosine?”

Never Judge. Never endorse an incorrect response—but do not disparage it either. A trainee must learn that their answer was wrong but should not feel defeated or embarrassed. Use judgment regarding whether constructive feedback should be delivered in public or in private.

I recall answering a question incorrectly in medical school. The attending responded, “How many years did you take off before starting third year?” I had not taken any time off. The attending was a phenomenal clinician but a lousy teacher. A master teacher would have accessed a foothold and built my knowledge without judgment.

Remain Humble. One of the most liberating phrases you will deploy as a teacher is “I don’t know.” Its utterance demonstrates the honesty and humility you hope to instill in learners. Be on the lookout for the many times your trainees will know more than you.

Recently my team evaluated a patient with blunted facial expression, bradykinesia, and a resting hand tremor. I disclosed to my team: “I don’t know the key maneuvers to distinguish the Parkinson plus syndromes from Parkinson disease.” The medical student had spent one year studying patients with neurodegenerative diseases (I learned this during the “small-talk before med-talk” phase). I invited him to demonstrate the neurologic exam, which he did admirably. That day I did not know the subject well, and we all learned because I freely admitted it.

Being a physician is the greatest job in the world. If you leverage your EQ (emotional quotient) as much as your IQ (intelligence quotient), your learners will conclude the same.

“If you define the problem correctly, you almost have the solution.”
—Steve Jobs

In the classic tale of a chaotic kitchen before an important dinner, two feuding chefs urgently need the only remaining orange in the pantry for their respective dishes. The first chef asserts its necessity for his prized sauce. The second chef retorts that her dessert will be ruined without it. After an emotion-laden battle, they finally agree to compromise, cutting the orange in half. The first chef squeezes the juice out of his half of the orange for his sauce, while the second grates half the zest she needs for her cake. Each chef had less of the orange than their recipe needed, but figured this was the best they could do given the dispute.¹

Conflict frequently occurs for hospitalists leading change efforts, managing service lines, and caring for patients. Often conflict can help clarify a decision or course of action. However, when navigated poorly, disputes can also consume precious energy and sap the goodwill and cooperation needed to effectively lead change and ensure excellent clinical care. Worse yet, ineffective conversations can result in begrudging and ultimately value-destroying agreements, as the chefs above demonstrate.

Instead of focusing on someone’s position (the need for the orange), successful leaders first seek to understand all discernible underlying interests (zest, juice) and motivations (creating a signature dish) of each party.¹ Essential to this process is swift recognition of the conflict and self-regulation. Rather than succumbing to strong fight-or-flight reactions, the wise hospitalist first takes inventory of their own interests and calmly applies a known schema, similar to their approach to common clinical scenarios.

So how can you get to the underlying interests effectively? We use a three-step process reminding us of the benefits of the orange’s ACID.²

Ask open-ended questions and closely listen to their responses. Listening more than talking is critical to this process. When facing conflict, it is common to listen only to refute the other’s position. Instead, actively suppress your instinct to “reload” and seek to genuinely understand the other’s perspective. Continue to ask clarifying questions until you feel you understand their interests.

A new hire requests a higher salary than offered. Ask with curiosity: “Can you tell me more about some of your financial priorities? Even if I can’t do much about the dollar figure, there may be benefits and other helpful tips I can suggest.”

Restate your understanding of their interests from listening. This critical step serves to confirm your good-faith effort to address a common problem and to demonstrate that you have heard their perspective accurately. Even if you ultimately cannot agree on a solution to the dispute at hand, demonstrating an understanding of their perspective helps to preserve the relationship, which can be useful for future conflicts.

“I am hearing that you are hoping to save money for the future, to pay down outstanding loans, and to expand your family. Is that right?”

Accurately defining interests and demonstrating your understanding will maximize the possibility of mutually acceptable solutions. Share your own perspective, being careful to describe your underlying interests, not positions. What mutual goals do you share? What potential solutions were not immediately evident based on positions alone? During this process, remain open to arriving at a solution that you had not anticipated.

“While I unfortunately have little wiggle room on annual salary, there are some options for loan repayment, housing down payment assistance, and low-cost childcare at the health system, which is where my kids went.”

Whether you are a chef or a hospitalist and whether you are dividing oranges or clinical shifts, understanding the interests buried within the conflict will help define and potentially solve the problem. When you encounter an orange, remember the value of its ACID.

Acknowledgement

The authors wish to thank Charlie Wray, DO, Division of Hospital Medicine, San Francisco VA, for assistance with revisions of early drafts.

“If you define the problem correctly, you almost have the solution.”
—Steve Jobs

In the classic tale of a chaotic kitchen before an important dinner, two feuding chefs urgently need the only remaining orange in the pantry for their respective dishes. The first chef asserts its necessity for his prized sauce. The second chef retorts that her dessert will be ruined without it. After an emotion-laden battle, they finally agree to compromise, cutting the orange in half. The first chef squeezes the juice out of his half of the orange for his sauce, while the second grates half the zest she needs for her cake. Each chef had less of the orange than their recipe needed, but figured this was the best they could do given the dispute.¹

Conflict frequently occurs for hospitalists leading change efforts, managing service lines, and caring for patients. Often conflict can help clarify a decision or course of action. However, when navigated poorly, disputes can also consume precious energy and sap the goodwill and cooperation needed to effectively lead change and ensure excellent clinical care. Worse yet, ineffective conversations can result in begrudging and ultimately value-destroying agreements, as the chefs above demonstrate.

Instead of focusing on someone’s position (the need for the orange), successful leaders first seek to understand all discernible underlying interests (zest, juice) and motivations (creating a signature dish) of each party.¹ Essential to this process is swift recognition of the conflict and self-regulation. Rather than succumbing to strong fight-or-flight reactions, the wise hospitalist first takes inventory of their own interests and calmly applies a known schema, similar to their approach to common clinical scenarios.

So how can you get to the underlying interests effectively? We use a three-step process reminding us of the benefits of the orange’s ACID.²

Ask open-ended questions and closely listen to their responses. Listening more than talking is critical to this process. When facing conflict, it is common to listen only to refute the other’s position. Instead, actively suppress your instinct to “reload” and seek to genuinely understand the other’s perspective. Continue to ask clarifying questions until you feel you understand their interests.

A new hire requests a higher salary than offered. Ask with curiosity: “Can you tell me more about some of your financial priorities? Even if I can’t do much about the dollar figure, there may be benefits and other helpful tips I can suggest.”

Restate your understanding of their interests from listening. This critical step serves to confirm your good-faith effort to address a common problem and to demonstrate that you have heard their perspective accurately. Even if you ultimately cannot agree on a solution to the dispute at hand, demonstrating an understanding of their perspective helps to preserve the relationship, which can be useful for future conflicts.

“I am hearing that you are hoping to save money for the future, to pay down outstanding loans, and to expand your family. Is that right?”

Accurately defining interests and demonstrating your understanding will maximize the possibility of mutually acceptable solutions. Share your own perspective, being careful to describe your underlying interests, not positions. What mutual goals do you share? What potential solutions were not immediately evident based on positions alone? During this process, remain open to arriving at a solution that you had not anticipated.

“While I unfortunately have little wiggle room on annual salary, there are some options for loan repayment, housing down payment assistance, and low-cost childcare at the health system, which is where my kids went.”

Whether you are a chef or a hospitalist and whether you are dividing oranges or clinical shifts, understanding the interests buried within the conflict will help define and potentially solve the problem. When you encounter an orange, remember the value of its ACID.

Acknowledgement

The authors wish to thank Charlie Wray, DO, Division of Hospital Medicine, San Francisco VA, for assistance with revisions of early drafts.

“If you define the problem correctly, you almost have the solution.”
—Steve Jobs

In the classic tale of a chaotic kitchen before an important dinner, two feuding chefs urgently need the only remaining orange in the pantry for their respective dishes. The first chef asserts its necessity for his prized sauce. The second chef retorts that her dessert will be ruined without it. After an emotion-laden battle, they finally agree to compromise, cutting the orange in half. The first chef squeezes the juice out of his half of the orange for his sauce, while the second grates half the zest she needs for her cake. Each chef had less of the orange than their recipe needed, but figured this was the best they could do given the dispute.¹

Conflict frequently occurs for hospitalists leading change efforts, managing service lines, and caring for patients. Often conflict can help clarify a decision or course of action. However, when navigated poorly, disputes can also consume precious energy and sap the goodwill and cooperation needed to effectively lead change and ensure excellent clinical care. Worse yet, ineffective conversations can result in begrudging and ultimately value-destroying agreements, as the chefs above demonstrate.

Instead of focusing on someone’s position (the need for the orange), successful leaders first seek to understand all discernible underlying interests (zest, juice) and motivations (creating a signature dish) of each party.¹ Essential to this process is swift recognition of the conflict and self-regulation. Rather than succumbing to strong fight-or-flight reactions, the wise hospitalist first takes inventory of their own interests and calmly applies a known schema, similar to their approach to common clinical scenarios.

So how can you get to the underlying interests effectively? We use a three-step process reminding us of the benefits of the orange’s ACID.²

Ask open-ended questions and closely listen to their responses. Listening more than talking is critical to this process. When facing conflict, it is common to listen only to refute the other’s position. Instead, actively suppress your instinct to “reload” and seek to genuinely understand the other’s perspective. Continue to ask clarifying questions until you feel you understand their interests.

A new hire requests a higher salary than offered. Ask with curiosity: “Can you tell me more about some of your financial priorities? Even if I can’t do much about the dollar figure, there may be benefits and other helpful tips I can suggest.”

Restate your understanding of their interests from listening. This critical step serves to confirm your good-faith effort to address a common problem and to demonstrate that you have heard their perspective accurately. Even if you ultimately cannot agree on a solution to the dispute at hand, demonstrating an understanding of their perspective helps to preserve the relationship, which can be useful for future conflicts.

“I am hearing that you are hoping to save money for the future, to pay down outstanding loans, and to expand your family. Is that right?”

Accurately defining interests and demonstrating your understanding will maximize the possibility of mutually acceptable solutions. Share your own perspective, being careful to describe your underlying interests, not positions. What mutual goals do you share? What potential solutions were not immediately evident based on positions alone? During this process, remain open to arriving at a solution that you had not anticipated.

“While I unfortunately have little wiggle room on annual salary, there are some options for loan repayment, housing down payment assistance, and low-cost childcare at the health system, which is where my kids went.”

Whether you are a chef or a hospitalist and whether you are dividing oranges or clinical shifts, understanding the interests buried within the conflict will help define and potentially solve the problem. When you encounter an orange, remember the value of its ACID.

Acknowledgement

The authors wish to thank Charlie Wray, DO, Division of Hospital Medicine, San Francisco VA, for assistance with revisions of early drafts.

“For every complex problem there is a simple solution. And it’s wrong.”
—Anonymous as quoted in Barry Johnson’s Polarity Management¹

Hospital medicine leaders often face what seem like unsolvable problems involving two opposing sides or viewpoints. Examples include individual versus team, margin versus mission, learner autonomy versus supervision, and customization versus standardization. Dr. Barry Johnson describes these dyads as polarities, which are two different values or points of view that are interdependent.^1,2 Leaders who fail to realize this concept create a problem by artificially inserting the word ‘versus’ between the poles.

Polarities are not problems to be solved. How does one solve individual? Or team? How can a hospital have one without the other? When leaders treat polarities like problems to be solved, they typically crusade for one side over the other, until the losing side rises up for its own cause, causing a perpetual back and forth cycle described as an infinity loop where nobody is happy for long.¹

How then can leaders avoid getting caught in this fruitless cycle?

Instead of trying to solve the unsolvable, learn to manage polarities. Polarity management seeks to maximize the best of both poles while minimizing the worst. Both sides of a polarity carry upsides and downsides. When leaders want change, or want to resist change, it is the fear of being caught in the downsides of the opposite pole that motivates behavior, and dominates conversation. The first step to changing this conversation is to introduce the concept to your team so they recognize polarities when they arise and model approaching issues in this manner.

Some issues truly are problems to be solved (for example, the ultrasound machine is broken and needs to be repaired), but many conflicts are polarities masquerading as problems. To identify polarities, ask two questions. (1) Is the situation ongoing? (2) Are there two interdependent poles? If yes, then the issue is a polarity. Ideal polarity management involves maximizing the upside values of both poles before potential conflict even begins. People often force themselves into unnecessary “either/or” mindsets rather than striving for “both/and”.

Here is a classic example in Hospital Medicine: Pole 1: customization Pole 2: standardization -- The Chief Medical Information Officer (CMIO) wants everyone to use the same electronic health record (EHR) template, while the hospitalist group wants to innovate templates using rapid cycles of change. Typical patterns of conflict: the CMIO releases a template and the hospitalists resent it, or the hospitalists each create their own notes but the CMIO bemoans the variability.

Once polarities are recognized, teams can draw a ‘polarity map’ to see the whole picture, identifying the upside values and downside fears of each pole.^1,2 For example, standardization reduces unnecessary variation, but stifles innovation, while customization does the opposite. In fact, the upside values of one pole are usually the opposite of the downside fears of the other.

Leaders can actively engage people in both poles to make opposing views productive rather than destructive. The CMIO in our standardization/customization example could insist that everyone begins with the same template, but allow hospitalists to innovate to find a better way. Now the most resistant hospitalists become improvement agents. If a better way is found, then this becomes the new template that all hospitalists use, until the next better way is found. If an innovation is not an improvement, then hospitalists agree to return to the most recent successful template until a better way is found. This method of action and compromise produces both standardization and customization.

Using polarity management strategies does not guarantee success, but it can help engage all stakeholders, and break the frustrating cycle of repeatedly trying to solve the unsolvable.

Disclosures

The authors report no conflicts of interest or sources of funding.

“For every complex problem there is a simple solution. And it’s wrong.”
—Anonymous as quoted in Barry Johnson’s Polarity Management¹

Hospital medicine leaders often face what seem like unsolvable problems involving two opposing sides or viewpoints. Examples include individual versus team, margin versus mission, learner autonomy versus supervision, and customization versus standardization. Dr. Barry Johnson describes these dyads as polarities, which are two different values or points of view that are interdependent.^1,2 Leaders who fail to realize this concept create a problem by artificially inserting the word ‘versus’ between the poles.

Polarities are not problems to be solved. How does one solve individual? Or team? How can a hospital have one without the other? When leaders treat polarities like problems to be solved, they typically crusade for one side over the other, until the losing side rises up for its own cause, causing a perpetual back and forth cycle described as an infinity loop where nobody is happy for long.¹

How then can leaders avoid getting caught in this fruitless cycle?

Instead of trying to solve the unsolvable, learn to manage polarities. Polarity management seeks to maximize the best of both poles while minimizing the worst. Both sides of a polarity carry upsides and downsides. When leaders want change, or want to resist change, it is the fear of being caught in the downsides of the opposite pole that motivates behavior, and dominates conversation. The first step to changing this conversation is to introduce the concept to your team so they recognize polarities when they arise and model approaching issues in this manner.

Some issues truly are problems to be solved (for example, the ultrasound machine is broken and needs to be repaired), but many conflicts are polarities masquerading as problems. To identify polarities, ask two questions. (1) Is the situation ongoing? (2) Are there two interdependent poles? If yes, then the issue is a polarity. Ideal polarity management involves maximizing the upside values of both poles before potential conflict even begins. People often force themselves into unnecessary “either/or” mindsets rather than striving for “both/and”.

Here is a classic example in Hospital Medicine: Pole 1: customization Pole 2: standardization -- The Chief Medical Information Officer (CMIO) wants everyone to use the same electronic health record (EHR) template, while the hospitalist group wants to innovate templates using rapid cycles of change. Typical patterns of conflict: the CMIO releases a template and the hospitalists resent it, or the hospitalists each create their own notes but the CMIO bemoans the variability.

Once polarities are recognized, teams can draw a ‘polarity map’ to see the whole picture, identifying the upside values and downside fears of each pole.^1,2 For example, standardization reduces unnecessary variation, but stifles innovation, while customization does the opposite. In fact, the upside values of one pole are usually the opposite of the downside fears of the other.

Leaders can actively engage people in both poles to make opposing views productive rather than destructive. The CMIO in our standardization/customization example could insist that everyone begins with the same template, but allow hospitalists to innovate to find a better way. Now the most resistant hospitalists become improvement agents. If a better way is found, then this becomes the new template that all hospitalists use, until the next better way is found. If an innovation is not an improvement, then hospitalists agree to return to the most recent successful template until a better way is found. This method of action and compromise produces both standardization and customization.

Using polarity management strategies does not guarantee success, but it can help engage all stakeholders, and break the frustrating cycle of repeatedly trying to solve the unsolvable.

Disclosures

The authors report no conflicts of interest or sources of funding.

“For every complex problem there is a simple solution. And it’s wrong.”
—Anonymous as quoted in Barry Johnson’s Polarity Management¹

Hospital medicine leaders often face what seem like unsolvable problems involving two opposing sides or viewpoints. Examples include individual versus team, margin versus mission, learner autonomy versus supervision, and customization versus standardization. Dr. Barry Johnson describes these dyads as polarities, which are two different values or points of view that are interdependent.^1,2 Leaders who fail to realize this concept create a problem by artificially inserting the word ‘versus’ between the poles.

Polarities are not problems to be solved. How does one solve individual? Or team? How can a hospital have one without the other? When leaders treat polarities like problems to be solved, they typically crusade for one side over the other, until the losing side rises up for its own cause, causing a perpetual back and forth cycle described as an infinity loop where nobody is happy for long.¹

How then can leaders avoid getting caught in this fruitless cycle?

Instead of trying to solve the unsolvable, learn to manage polarities. Polarity management seeks to maximize the best of both poles while minimizing the worst. Both sides of a polarity carry upsides and downsides. When leaders want change, or want to resist change, it is the fear of being caught in the downsides of the opposite pole that motivates behavior, and dominates conversation. The first step to changing this conversation is to introduce the concept to your team so they recognize polarities when they arise and model approaching issues in this manner.

Some issues truly are problems to be solved (for example, the ultrasound machine is broken and needs to be repaired), but many conflicts are polarities masquerading as problems. To identify polarities, ask two questions. (1) Is the situation ongoing? (2) Are there two interdependent poles? If yes, then the issue is a polarity. Ideal polarity management involves maximizing the upside values of both poles before potential conflict even begins. People often force themselves into unnecessary “either/or” mindsets rather than striving for “both/and”.

Here is a classic example in Hospital Medicine: Pole 1: customization Pole 2: standardization -- The Chief Medical Information Officer (CMIO) wants everyone to use the same electronic health record (EHR) template, while the hospitalist group wants to innovate templates using rapid cycles of change. Typical patterns of conflict: the CMIO releases a template and the hospitalists resent it, or the hospitalists each create their own notes but the CMIO bemoans the variability.

Once polarities are recognized, teams can draw a ‘polarity map’ to see the whole picture, identifying the upside values and downside fears of each pole.^1,2 For example, standardization reduces unnecessary variation, but stifles innovation, while customization does the opposite. In fact, the upside values of one pole are usually the opposite of the downside fears of the other.

Leaders can actively engage people in both poles to make opposing views productive rather than destructive. The CMIO in our standardization/customization example could insist that everyone begins with the same template, but allow hospitalists to innovate to find a better way. Now the most resistant hospitalists become improvement agents. If a better way is found, then this becomes the new template that all hospitalists use, until the next better way is found. If an innovation is not an improvement, then hospitalists agree to return to the most recent successful template until a better way is found. This method of action and compromise produces both standardization and customization.

Using polarity management strategies does not guarantee success, but it can help engage all stakeholders, and break the frustrating cycle of repeatedly trying to solve the unsolvable.

Disclosures

The authors report no conflicts of interest or sources of funding.

“The most valuable of all talents is that of never using two words when one will do.“
—Thomas Jefferson

Attendings, residents, and medical students identify education as a top purpose of team rounds.¹ Learners report being dissatisfied with teaching on rounds most of the time.² Time with learners is a finite resource that has become even more precious with increasing clinical demands and work hour restrictions.³ Attendings report insufficient time to teach on rounds, and often neglect teaching because of time constraints.⁴ What can we do to in the face of this conflict between time and teaching?

One approach to this problem is what we call “ultra-brief, deliberate teaching sessions.” These sessions, or UBDTs, led by clinicians, create dedicated time for teaching on service. UBDTs ideally occur before team rounds because, in our experience, this is when the team is most unified and focused. Our sessions are time-limited (5 minutes or less) and designed so they are applicable to clinical scenarios the team is actively facing. Other learners can also lead these sessions with faculty coaching. Sessions of germane size and scope include: (1) Focus on a single clinical question from the previous day; (2) Discuss Choosing Wisely^® recommendations from a single specialty; (3) Provide a concise cognitive framework for a diagnostic or treatment dilemma (eg, draw a simple algorithm to evaluate causes of hyponatremia); (4) Review one image or electrocardiogram; (5) Present one case-based multiple-choice question; (6) Prime the team with a structured approach to a difficult conversation (eg, opioid discussions, goals of care).

As an example, if our team orders intravenous antihypertensives overnight, a UBDT session on asymptomatic hypertension would occur. The first minute may involve a discussion on the definition of hypertensive emergency versus asymptomatic hypertension. Next, we spend one minute asking learners the common causes of inpatient hypertension (eg, missed medications, pain, anxiety, withdrawal), highlighting that this warrants a bedside assessment. For two minutes, we next discuss the management options for asymptomatic hypertension with an emphasis on the avoidance of intravenous antihypertensives, tying this back to our current patient. Questions are welcomed, and a one-page summary of the major points and references is distributed during or after the talk. A repository of common topics and summaries may be a useful faculty development resource to be shared.

We have found UBDTs to be easy to implement for a variety of clinician educators. Because they are so brief and focused, they are also fun to create and share among teaching faculty. Importantly, these sessions should not delay clinical work. To ensure the avoidance of this trap, don’t select a topic that is too large or involves complex clinical reasoning, exceeds 5 minutes, or lead a UBDT session in a distracting environment or without preparation.

While we have not found a way to slow down time, UBDT sessions prior to the start of rounds can prioritize teaching, ensure the delivery of important content, and engage learners without significantly delaying clinical work. We invite you to try one!

Acknowledgments

The authors thank John Ragsdale, MD, MS for his leadership and support for UBDTs.

Disclosures

We have no relevant conflicts of interest to report. No payment or services from a third party were received for any aspect of this submitted work. We have no financial relationships with entities in the bio-medical arena that could be perceived to influence, or that give the appearance of potentially influencing, what was written in this submitted work.

“The most valuable of all talents is that of never using two words when one will do.“
—Thomas Jefferson

Attendings, residents, and medical students identify education as a top purpose of team rounds.¹ Learners report being dissatisfied with teaching on rounds most of the time.² Time with learners is a finite resource that has become even more precious with increasing clinical demands and work hour restrictions.³ Attendings report insufficient time to teach on rounds, and often neglect teaching because of time constraints.⁴ What can we do to in the face of this conflict between time and teaching?

One approach to this problem is what we call “ultra-brief, deliberate teaching sessions.” These sessions, or UBDTs, led by clinicians, create dedicated time for teaching on service. UBDTs ideally occur before team rounds because, in our experience, this is when the team is most unified and focused. Our sessions are time-limited (5 minutes or less) and designed so they are applicable to clinical scenarios the team is actively facing. Other learners can also lead these sessions with faculty coaching. Sessions of germane size and scope include: (1) Focus on a single clinical question from the previous day; (2) Discuss Choosing Wisely^® recommendations from a single specialty; (3) Provide a concise cognitive framework for a diagnostic or treatment dilemma (eg, draw a simple algorithm to evaluate causes of hyponatremia); (4) Review one image or electrocardiogram; (5) Present one case-based multiple-choice question; (6) Prime the team with a structured approach to a difficult conversation (eg, opioid discussions, goals of care).

As an example, if our team orders intravenous antihypertensives overnight, a UBDT session on asymptomatic hypertension would occur. The first minute may involve a discussion on the definition of hypertensive emergency versus asymptomatic hypertension. Next, we spend one minute asking learners the common causes of inpatient hypertension (eg, missed medications, pain, anxiety, withdrawal), highlighting that this warrants a bedside assessment. For two minutes, we next discuss the management options for asymptomatic hypertension with an emphasis on the avoidance of intravenous antihypertensives, tying this back to our current patient. Questions are welcomed, and a one-page summary of the major points and references is distributed during or after the talk. A repository of common topics and summaries may be a useful faculty development resource to be shared.

We have found UBDTs to be easy to implement for a variety of clinician educators. Because they are so brief and focused, they are also fun to create and share among teaching faculty. Importantly, these sessions should not delay clinical work. To ensure the avoidance of this trap, don’t select a topic that is too large or involves complex clinical reasoning, exceeds 5 minutes, or lead a UBDT session in a distracting environment or without preparation.

While we have not found a way to slow down time, UBDT sessions prior to the start of rounds can prioritize teaching, ensure the delivery of important content, and engage learners without significantly delaying clinical work. We invite you to try one!

Acknowledgments

The authors thank John Ragsdale, MD, MS for his leadership and support for UBDTs.

Disclosures

We have no relevant conflicts of interest to report. No payment or services from a third party were received for any aspect of this submitted work. We have no financial relationships with entities in the bio-medical arena that could be perceived to influence, or that give the appearance of potentially influencing, what was written in this submitted work.

“The most valuable of all talents is that of never using two words when one will do.“
—Thomas Jefferson

Attendings, residents, and medical students identify education as a top purpose of team rounds.¹ Learners report being dissatisfied with teaching on rounds most of the time.² Time with learners is a finite resource that has become even more precious with increasing clinical demands and work hour restrictions.³ Attendings report insufficient time to teach on rounds, and often neglect teaching because of time constraints.⁴ What can we do to in the face of this conflict between time and teaching?

One approach to this problem is what we call “ultra-brief, deliberate teaching sessions.” These sessions, or UBDTs, led by clinicians, create dedicated time for teaching on service. UBDTs ideally occur before team rounds because, in our experience, this is when the team is most unified and focused. Our sessions are time-limited (5 minutes or less) and designed so they are applicable to clinical scenarios the team is actively facing. Other learners can also lead these sessions with faculty coaching. Sessions of germane size and scope include: (1) Focus on a single clinical question from the previous day; (2) Discuss Choosing Wisely^® recommendations from a single specialty; (3) Provide a concise cognitive framework for a diagnostic or treatment dilemma (eg, draw a simple algorithm to evaluate causes of hyponatremia); (4) Review one image or electrocardiogram; (5) Present one case-based multiple-choice question; (6) Prime the team with a structured approach to a difficult conversation (eg, opioid discussions, goals of care).

As an example, if our team orders intravenous antihypertensives overnight, a UBDT session on asymptomatic hypertension would occur. The first minute may involve a discussion on the definition of hypertensive emergency versus asymptomatic hypertension. Next, we spend one minute asking learners the common causes of inpatient hypertension (eg, missed medications, pain, anxiety, withdrawal), highlighting that this warrants a bedside assessment. For two minutes, we next discuss the management options for asymptomatic hypertension with an emphasis on the avoidance of intravenous antihypertensives, tying this back to our current patient. Questions are welcomed, and a one-page summary of the major points and references is distributed during or after the talk. A repository of common topics and summaries may be a useful faculty development resource to be shared.

We have found UBDTs to be easy to implement for a variety of clinician educators. Because they are so brief and focused, they are also fun to create and share among teaching faculty. Importantly, these sessions should not delay clinical work. To ensure the avoidance of this trap, don’t select a topic that is too large or involves complex clinical reasoning, exceeds 5 minutes, or lead a UBDT session in a distracting environment or without preparation.

While we have not found a way to slow down time, UBDT sessions prior to the start of rounds can prioritize teaching, ensure the delivery of important content, and engage learners without significantly delaying clinical work. We invite you to try one!

Acknowledgments

The authors thank John Ragsdale, MD, MS for his leadership and support for UBDTs.

Disclosures

We have no relevant conflicts of interest to report. No payment or services from a third party were received for any aspect of this submitted work. We have no financial relationships with entities in the bio-medical arena that could be perceived to influence, or that give the appearance of potentially influencing, what was written in this submitted work.

“Better than a thousand days of diligent study is one day with a great teacher.”
—Japanese proverb

My chairman of medicine in medical school was a looming, intimidating, diagnostic genius—and one of the best teachers I have ever had. As a sub-intern it seemed I learned more in one month with him than in my prior six months of medical school.  After the rotation, I asked him how he became such an effective teacher. “Simple,” he said, “I invest significant time and effort.”

But time is limited and you have to be smart with how you invest it. Here are three pearls that are a wise investment—they will make you a better teacher.

Those who seem to teach effortlessly do so after substantial behind-the-scenes effort. Read on your patients before rounds. Identify key teaching points and useful literature. Get some questions ready to define knowledge gaps and create “Teaching Scripts.”

Teaching Scripts are preplanned summaries of specific topics that can be used on rounds or longer talks and are “triggered” by common scenarios (eg, hypoxia). Great teaching scripts use a “hook” to engage the learner (commonly a thought-provoking question or story), two to five teaching points, and purposeful questions, mnemonics, and visual representations.

You should aim to develop at least five teaching scripts on commonly encountered topics. Eventually, you should have twenty scripts you can easily reference.

Technology significantly enhances the efficiency and impact of your teaching. For example, on rounds use your cell phone to display and teach anatomy, radiographic images, and EKGs. Use an iPad as a mobile whiteboard. Use email to collate and disseminate teaching points or send links to valuable learning resources like procedural videos. At its best, you can develop new programs and recruit team members to create resources, like I did with an online series focused on teaching to teach using graphically-enhanced TED-style talks¹ and animated whiteboard videos.²

Do you easily remember the content from your medical school lectures?  Likely not. But you likely remember moments from your favorite comedian or TED talk. Unlike the many PowerPoint lectures you’ve sat through, I’ll bet you stay engaged in films and documentaries. Why the difference? In short—medical educators often don’t make content engaging, readily understood, or memorable. To be most effective in teaching, learn from experts in other fields. Think how storytelling, film, theater, and graphic design contribute to learning. Don’t be afraid to be different.

All of these disciplines recognize the power of storytelling to make their points more impactful and memorable. Leverage this by mixing lessons with stories to create teaching points that stick. Lessons of character and morals can be highlighted through stories of personal struggles, prior patients, or people you admire. Clinical tips can be reinforced through sharing a “clinical story”—concise retellings of high-yield patient cases with diagnosis or management tips.

These disciplines also recognize the importance of “setting the stage” to create an optimal experience. We too can learn from this by setting the stage for our learners. Build a learning environment that is positive, collaborative, and fun by being open, curious, and enthusiastic. Treat your team to coffee rounds or lunch and get to know each learner as you walk between patients. As Teddy Roosevelt said, “people don’t care how much you know, until they know how much you care.”

My chairman taught me that exceptional teaching is not a talent of the gifted, it is a skill of the diligent. If you invest in your teaching, you can make a tremendous impact in the lives of your learners. Are you ready to be empowered?

Acknowledgments

The author wishes to thank Rana Kabeer and Sally Salari for their assistance in storyboarding, graphic design, and video editing of the MENTOR Video Series.

Disclosures

Dr. Cronin has nothing to disclose.

 

“Better than a thousand days of diligent study is one day with a great teacher.”
—Japanese proverb

My chairman of medicine in medical school was a looming, intimidating, diagnostic genius—and one of the best teachers I have ever had. As a sub-intern it seemed I learned more in one month with him than in my prior six months of medical school.  After the rotation, I asked him how he became such an effective teacher. “Simple,” he said, “I invest significant time and effort.”

But time is limited and you have to be smart with how you invest it. Here are three pearls that are a wise investment—they will make you a better teacher.

Those who seem to teach effortlessly do so after substantial behind-the-scenes effort. Read on your patients before rounds. Identify key teaching points and useful literature. Get some questions ready to define knowledge gaps and create “Teaching Scripts.”

Teaching Scripts are preplanned summaries of specific topics that can be used on rounds or longer talks and are “triggered” by common scenarios (eg, hypoxia). Great teaching scripts use a “hook” to engage the learner (commonly a thought-provoking question or story), two to five teaching points, and purposeful questions, mnemonics, and visual representations.

You should aim to develop at least five teaching scripts on commonly encountered topics. Eventually, you should have twenty scripts you can easily reference.

Technology significantly enhances the efficiency and impact of your teaching. For example, on rounds use your cell phone to display and teach anatomy, radiographic images, and EKGs. Use an iPad as a mobile whiteboard. Use email to collate and disseminate teaching points or send links to valuable learning resources like procedural videos. At its best, you can develop new programs and recruit team members to create resources, like I did with an online series focused on teaching to teach using graphically-enhanced TED-style talks¹ and animated whiteboard videos.²

Do you easily remember the content from your medical school lectures?  Likely not. But you likely remember moments from your favorite comedian or TED talk. Unlike the many PowerPoint lectures you’ve sat through, I’ll bet you stay engaged in films and documentaries. Why the difference? In short—medical educators often don’t make content engaging, readily understood, or memorable. To be most effective in teaching, learn from experts in other fields. Think how storytelling, film, theater, and graphic design contribute to learning. Don’t be afraid to be different.

All of these disciplines recognize the power of storytelling to make their points more impactful and memorable. Leverage this by mixing lessons with stories to create teaching points that stick. Lessons of character and morals can be highlighted through stories of personal struggles, prior patients, or people you admire. Clinical tips can be reinforced through sharing a “clinical story”—concise retellings of high-yield patient cases with diagnosis or management tips.

These disciplines also recognize the importance of “setting the stage” to create an optimal experience. We too can learn from this by setting the stage for our learners. Build a learning environment that is positive, collaborative, and fun by being open, curious, and enthusiastic. Treat your team to coffee rounds or lunch and get to know each learner as you walk between patients. As Teddy Roosevelt said, “people don’t care how much you know, until they know how much you care.”

My chairman taught me that exceptional teaching is not a talent of the gifted, it is a skill of the diligent. If you invest in your teaching, you can make a tremendous impact in the lives of your learners. Are you ready to be empowered?

Acknowledgments

The author wishes to thank Rana Kabeer and Sally Salari for their assistance in storyboarding, graphic design, and video editing of the MENTOR Video Series.

Disclosures

Dr. Cronin has nothing to disclose.

 

“Better than a thousand days of diligent study is one day with a great teacher.”
—Japanese proverb

My chairman of medicine in medical school was a looming, intimidating, diagnostic genius—and one of the best teachers I have ever had. As a sub-intern it seemed I learned more in one month with him than in my prior six months of medical school.  After the rotation, I asked him how he became such an effective teacher. “Simple,” he said, “I invest significant time and effort.”

But time is limited and you have to be smart with how you invest it. Here are three pearls that are a wise investment—they will make you a better teacher.

Those who seem to teach effortlessly do so after substantial behind-the-scenes effort. Read on your patients before rounds. Identify key teaching points and useful literature. Get some questions ready to define knowledge gaps and create “Teaching Scripts.”

Teaching Scripts are preplanned summaries of specific topics that can be used on rounds or longer talks and are “triggered” by common scenarios (eg, hypoxia). Great teaching scripts use a “hook” to engage the learner (commonly a thought-provoking question or story), two to five teaching points, and purposeful questions, mnemonics, and visual representations.

You should aim to develop at least five teaching scripts on commonly encountered topics. Eventually, you should have twenty scripts you can easily reference.

Technology significantly enhances the efficiency and impact of your teaching. For example, on rounds use your cell phone to display and teach anatomy, radiographic images, and EKGs. Use an iPad as a mobile whiteboard. Use email to collate and disseminate teaching points or send links to valuable learning resources like procedural videos. At its best, you can develop new programs and recruit team members to create resources, like I did with an online series focused on teaching to teach using graphically-enhanced TED-style talks¹ and animated whiteboard videos.²

Do you easily remember the content from your medical school lectures?  Likely not. But you likely remember moments from your favorite comedian or TED talk. Unlike the many PowerPoint lectures you’ve sat through, I’ll bet you stay engaged in films and documentaries. Why the difference? In short—medical educators often don’t make content engaging, readily understood, or memorable. To be most effective in teaching, learn from experts in other fields. Think how storytelling, film, theater, and graphic design contribute to learning. Don’t be afraid to be different.

All of these disciplines recognize the power of storytelling to make their points more impactful and memorable. Leverage this by mixing lessons with stories to create teaching points that stick. Lessons of character and morals can be highlighted through stories of personal struggles, prior patients, or people you admire. Clinical tips can be reinforced through sharing a “clinical story”—concise retellings of high-yield patient cases with diagnosis or management tips.

These disciplines also recognize the importance of “setting the stage” to create an optimal experience. We too can learn from this by setting the stage for our learners. Build a learning environment that is positive, collaborative, and fun by being open, curious, and enthusiastic. Treat your team to coffee rounds or lunch and get to know each learner as you walk between patients. As Teddy Roosevelt said, “people don’t care how much you know, until they know how much you care.”

My chairman taught me that exceptional teaching is not a talent of the gifted, it is a skill of the diligent. If you invest in your teaching, you can make a tremendous impact in the lives of your learners. Are you ready to be empowered?

Acknowledgments

The author wishes to thank Rana Kabeer and Sally Salari for their assistance in storyboarding, graphic design, and video editing of the MENTOR Video Series.

Disclosures

Dr. Cronin has nothing to disclose.