Walter Eppich Plenary Session
by Angela Blood, Rush University
At this year’s annual meeting, one of ASPE’s invited plenary speakers was Walter J. Eppich, MD, MEd of Northwestern University in Chicago, Illinois. Dr. Eppich is well known in the simulation community for his expertise and scholarship related to debriefing, or facilitating discussion and feedback following a simulation exercise.
“Feedback” is the term most often used in the SP methodology community, although many educators who use it in that context intend for a conversation, a give-and-take of information, rather than a one-way delivery of information. In the broader simulation community, “debriefing” is the term most often used, but is very similar (if not identical) to the intent of “feedback” in the SP methodology community. Our goals are the same: in a learner-centered dialogue, identify and encourage behavior that is appropriate while helping learners identify and find strategies to change behavior that is inappropriate or less than ideal. Dr. Eppich’s experience therefore with debriefing is entirely relevant to SP educators.
In his presentation, Dr. Eppich reached outside health professions education. His views on debriefing are formed from a multidisciplinary perspective. While he presented some of his own research, he also shared useful scholarship in which he was not directly involved. Many of us have probably sat through a talk in which the speaker shoehorned the topic to fit their own program of research; for that reason, I was especially pleased to see Dr. Eppich’s broad and thorough approach to his presentation. As we (and other disciplines) have learned time and again, the answers we seek to problems in our field often exist in other fields. We can benefit from exploring outside our comfort zones for theories, models, and best practices.
Dr. Eppich talked of “learning cues.” This refers to how a learners’ experiences outside simulation will influence his or her ability or intention to incorporate lessons learned in debriefing. Learning cues can come in many forms and from many sources, including patients. This is not necessarily harmful, but it can be if we as educators are not aware of competing learning cues. As educators, we must not only be aware of learning cues that will contradict our debriefing, but also work to resolve those contradictions.
For example, if a learner hears during a debriefing session that he needs to “speak up more,” but he is intimidated by senior clinicians in the real environment, that advice is not going to be enacted. The educator must work to be aware of these competing learning cues through both dialogue in the debriefing sessions, and through awareness of the clinical environment. The point is this: if the educator gives an instruction to the learner in debriefing, but the learner then experiences contradictory learning cues (barriers in the environment, poor role models, etc.), it is far less likely that the debriefing instruction will be effective.
With ineffective debriefing, the learner may infer that the simulation is not relevant to their work, and the educator is out of touch with the real clinical world. The learner makes “credibility judgments,” or decisions about which information learned in debriefing to incorporate and which to dismiss. Learners are bombarded with a great deal of information and have a restricted amount of time, so it is natural to prioritize which educational messages to embrace. If the debriefing is delivered ineffectively, or without competing learning cues in mind, the learners will be more likely to dismiss the feedback. If however a skilled educator explores learning cues in the clinical environment, the feedback is more likely to be incorporated into practice. As Dr. Eppich states, “people don’t feel safe because you tell them to. People feel safe if that’s how you make them feel.” A sincere effort is required on the part of the educator to reach beyond their traditional expertise and understand the context in which the learners work.
Another way to think about learning cues, and specifically those that contradict our simulation education goals, is to consider the “hidden curriculum.” Hidden curriculum can be defined as intended or unintended educational messages that learners receive which are not explicit in the educational program. For example, the stated learning objectives for a course may be A, B, and C, but if the learners hear or see messages about D, they are likely learning something about D too. It is important to explore this issue because at times, learners receive messages that the educator did not intend, or actually compete with the educator’s goals. Let’s use an example to make this clearer. In a course for undergraduate students about interprofessional practice, medical students, nursing students, and pharmacy students hear lectures about the importance of working collaboratively. However, when split into small groups, the members of the groups stay within their profession, never mingling with the students from other professions. Although the stated message was “work collaboratively,” the hidden or implicit message was “work with your peers.” With debriefing, hidden or implicit messages may exist in the clinical environment or even elsewhere in the simulation, which contradict the stated values of the debriefing. It is important to explore whether or not these implicit messages exist, as they may impact the efficacy of the debriefing. The idea of hidden curriculum comes from a field outside health professions, but it easy to see how and why it is useful. This again exemplifies the benefits of a multidisciplinary approach to forming a philosophy around debriefing.
Later in his presentation, Dr. Eppich presented research from Maastrich University. This research contrasted a model for health professions education to a model for music education. Once again, the multidisciplinary perspective was fresh and illuminating. In music, teaching skills are appreciated for their own value – the learner does not necessarily need to be taught by a virtuoso to learn. It is not assumed that all virtuosos are exemplary teachers, and all talented musicians who did not achieve virtuoso skill cannot educate others. In medicine, teaching skills are often not given equal value to other faculty responsibilities such as clinical care, administration and leadership, or research. In music, the goal of education is to become “ever better,” always striving for continued improvement. In health professions and especially in medicine, the recent wave towards competency has been inferred (perhaps wrongly) to mean that there is a benchmark to reach and then the work is done. Currently medicine is trying to bridge a competency model with life-long learning, but that match may not feel intuitive as the underlying concepts of the two approaches seem to compete.
It is clear from Dr. Eppich’s presentation that there are concepts from fields outside health professions education which can inform our debriefing philosophies. The SP educator must then be aware of approaches in other disciplines and the environment to which their work in simulation applies. By exploring other disciplines and having a meaningful awareness of the clinical environment, educators will be better able to provide effective debriefing.