[BLANK_AUDIO]. Hi! Welcome back! Well, we've made it through two domains so far in terms of knowledge and skills, and now we will focus on attitudes. So this first session in the attitudes domain will be on reflection. And what we'll try to do is understand the domain of attitude as it applies to health professions education and describe ways to foster the learners' growth and development within this affective domain. And so it's a little hard to get your hands around what is affect or attitude. So many people have used all of these types of synonyms To describe it. So it could be emotion, or your understanding of something, the beliefs you have around an issue, how you behave professionally, the respect that you show to individuals, how you evaluate information or new material. And so those are all things that students sometimes consider soft, or soft science. Or sometimes people would even talk about being touchy feely. But the truth of the matter is that affect or attitude, and how we relate to our individual patients or clients, is actually sort of in my mind some of the most important things we do as caretakers of other human beings. And so, these sessions, we'll talk about well, how do we help people And you know, focus in on those attributes, and expand their understandings, but obviously you can't really teach someone to be nice, right? You can't teach someone to think one thing or the other, per se. But you can hopefully help people expand their understandings, and also at least make an effort to engage in thoughtful and constructive ways with patients and clients. So like I talked about a little bit you know, sort of, why do we care? Well, each one of us comes to our situation with individual beliefs. Values and understandings. And those are all formed by our circumstances, our world views, how we were brought up, perhaps our religious views, or our political understandings. Or even in some cases our age or maturation level. and so. These, especially when you're a new learner and you're confronted with people who have a different belief or a different understanding, can cause, you know, some difficulties and some misunderstandings. And so those understandings that people have may not be at all similar or familiar. To the ones that our patients in our client's holds for instance I would posit that most of us are not intravenous drug users. however we may care for individuals who are intravenous drug users and while we can't understand their circumstances per se, or perhaps we haven't actually been IV drug users there are things that we need to understand and to engage with them about. that requires this, attitudinal domain and this sort of mutual respect for them as human beings. So how do we help our learners make sense of these differences? How do we sort of help people check their judgments or their misunderstandings of others in order to better take care of them? So, there's this concept in physiology called cognitive dissonance and basically if you start with the understanding that people prefer that their thinking, beliefs and understandings all be consistent and in sync. So, for instance if I believe that the sky is blue generally then when I look at this sky I expect it to be blue and so in. Since, you know instances where there's been a, a storm or some other sort of unique change in the light. Then, you notice that the sky looks different. It's green from a thunderstorm. Or the, a sunset as created unique reds and blues and purples. And, so it's something that you take note of, and look at and try to explain for yourself. or you could you know, have the belief that, well if somebody has cancer, then they would want to be treated for cancer. But, there are some people who actually feel, for whatever reason, or whatever circumstances that acutally treating the cancer is not what they want to have done. So, how do we as providers understand that. And put that together. So, what happens is that people become uncomfortable, or even insensitive sometimes, to this inconsistency, and when these cognitive dissonances are created, people want to do things to fix it, right? So to do something to reestablish your understanding, and to reestablish what feels normal or natural to you. So the reason to develop affective ILOs is to help our learners grow, develop, and possibly even mature, and create these normative behaviors or skills. And many of us are familiar with this idea of sort of compassionate care, in which I sort of alluded to. A few minutes ago. And so, the other purpose of the affective ILOs, then, is to help our learners develop habits of mind or patterns of reasoning to work through sort of some of these cognitive dissonances or sort of difficult or uncomfortable things. Right? So, when we talk about rebouncing the the dissonance I'm actually going to challenge our dissonance a little bit. With some thoughts about, you know, the notion between thinking things, versus the behavior. And so, while I may have thoughts about what is, or isn't appropriate in someone's life, or things that I may, or may not do in my own life, the issue is that I can't necessarily change those thoughts. Or I may. hold very tight to my values, but I should not behave in a way that is different from somebody elses values. Meaning that I should have respect for the fact that someone else may think entirely different then I do but that that the way I behave toward them is respectful. And so, we have to be very careful though, that we're trying to figure out who's truth we're talking about. Because some of them may have some socio-political dimensions, right? We may have some westernized notions of how people should undergo care. We may have, you know, religious beliefs about how people should undergo care. So for instance in the United States, one example that we often use as a teaching example are Jehovah's Witnesses who are Individuals who do not want to use blood products. And so how do we as providers sort of work through that dynamic of, you know, even if you are hemorrhaging and may lose your life because of the hemorrhage, we will not give you blood products to save your life. there may even be economic dimensions that we have. So in terms of how we think about High resource environments and low resource environments. So when we're creating these affective changes or these affective challenges and ILOs, we have to also be aware that, you know, our own biases could in theory come into those in, you know, activities. And so really what I want us to make sure we sort of focus upon is that. When creating affective ILOs that we really are using agreed upon professional standards. So, all of us would agree that kind, compassionate, supportive care is a reasonable thing to do when you're in the health profession. you know, reaching out to somebody who's in need, that kind of thing. So, if we just maintain our professional standards around affects, that I think that we'll be you know, in line with what we're trying to do. Okay, so really what we're trying to do is teach, and guide, and support our learners through these difficult domains. And so they're trying to make sense of dissonant, or difficult things. Most of us, before coming to Health Professions education, have never, dealt with an accident, victim. Or a victim of a gunshot, or perhaps you know, death and dying. And those are all very difficult things that each of us as individuals and as society sort of understand. And what we do in those situations is different than when most of our colleagues, or most of our sort of family and friends engage in. And so helping people through those difficult times can really make sense of things. So one of the pedagogies, which is what we're sort of, talking about in this session is reflection. And being able to sort of, take stock of what's happened. Think about the viewpoint of the patient or the events that occurred or our own feelings when we were confronted with a difficult patient care scenario. And those reflective exercises will help deepen understandings. They'll help engage emotional understanding. And again, you can process Complex events and process through them. And, the other thing that it's actually good for is challenging one's own assumptions, right? So if you've never met or engaged with someone who is an IV drug user, and then, for your first time as a student, you are taking care of them, and you see that they actually have many similarities to yourself, right, they, they actually have a family. They have a mom and dad who love them. There are all of these similarities, so that the stigma around sort of drug user, right, should dissipate and disappear. And the notion of compassionate care and understanding care hopefully will emerge. So, we use reflection in medical education, or health professions education, again, to sort of encourage learning, and to encourage learning around affective domains, but you can also use reflection to stimulate self-regulated learning. And then that gets us back to the idea of metacognitive domain. So what do I need. To learn about, what am I missing? What pieces don't I have? Right, so we can use reflection to help develop good therapy of relationships and to develop either personal or expert practice. So we've talked about creating illness scripts before, around the idea of diagnostic reasons. We've also, way back, at the beginning, talked about Kolb's experiential learning cycle, where you actually engage in some sort of activity, reflect on it, learn what worked well, what didn't work well, what do you need to do better. Engage in change for the next time and repeat the whole cycle. So, Amy has a really good guide which I've put the reference at the bottom of the slide that can help understand why we might want to engage reflection. So here's some more pedagogical strategies that you could employ. You could have people tell stories. So telling stories culturally goes back very, very far To, you know, before written communication. And you can learn a lot from people's stories. Whether it's the patients experiences, of their illness, or wellness, or, or what it meant for them to receive diagnosis. You can actually get stories from exemplars in your environment. So, all of us, I'm sure, can think about, gosh, who was the best teacher I ever had. and you can You know, sort of conjure up the image of that best teacher. Well, what did they do well? You know, whats the story that you can share about their good performance. or, you could even think about, well, gosh, this person's an exemplar. Let me go talk to them, let me interview them and figure out what it is that they think they're doing. And, then of course, you always learn what not to do from people. And, so, you can learn. From sub-standard performers. Or from watching individuals who actually don't, sort of, demonstrate the levels of professionalism that we might expect our students to maintain. So, other pedagogical strategies would include creating learning portfolios, so, we might know them in medicine, or nursing. Or other fields as, you know, sort of, procedure logs, or, you know, how many cases of this did I do, or how many patients like this have I seen? And that's one way to structure a learning portfolio. You could create a list of, you know, to be able to do this, you need 16 of these types of patients that you see. Or, you could say, okay, when I see this type of patient. So, someone with diabetes. What are the things that I need to make sure I learn about or cover? And so, the, the individual can create a portfolio of learning experiences, to make sure that they've sort of reached all of the goals. Journal writing is actually a very powerful way to help people deal with the affective domains, right, so the stress of being on call or, again, the, the challenges of dealing with, patients who don't agree with what we want or who are in very difficult circumstances and And even though they want assistance, and we want to provide assistance, there are systems issues, or other things that are barriers that are keeping us from helping them. And so how do you process through that information? So writing journals can be very powerful for individuals. [INAUDIBLE]. the other thing that works really well, [LAUGH], believe it or not, is for individuals to engage in artistic expression. And we'll have a session on that in a few videos. But, you know, being able to hear somebody's story, reflect on it. Or to express your own feelings in, in art or poetry. Or, again, writing, music. can really, help as well. So I know that that's a sort of a broad picture of the affective domain, and, and, you know, what we can do with reflection. But the key is to get people thinking, not only about their own beliefs and sort of what they bring to the patient encounter, but then. To be able to reflect upon activities, or engagements, or you know things that they did, while they where taking care of patients that seemed uncomfortable, or seemed, you know, just really a struggle and created this dissidence. Now a lot of times, you'll see the literature talk about, sort of affected domains. kind of around all of these difficult topics, right, and I've talked a lot about difficult topics, but I would also encourage us to think about the positive affects, right? So, the first time somebody got to see a baby boy. Or the first time that they went to the operating room and they saw someone you know, have a surgery and then they followed them through and, and saw that they received, you know, good care and went home safely. Or, you know, the. Sort of, interpersonal interaction that nurses have with families in intensive care units, and, and how powerful that can be to be supportive for the family and also to sort of help that individual recover. So there are lot of, of places and spaces where this affective domain works. And, and creating the opportunity for our learners to reflect on what that means for them, what it might mean for our patients. Is a thing that can help us grow in the way that we care for individuals. All right. I'll see you soon. Thanks.