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MEdIC Series: The Case of the Difficult Debrief

2017-10-28T10:55:25+00:00

Welcome to season 5, episode 2 of the ALiEM Medical Education in Cases (MEdIC) series! Our team (Drs. Tamara McColl, Teresa Chan, John Eicken, Sarah Luckett-Gatopoulos, Eve Purdy, Alkarim Velji, and Brent Thoma) is pleased to welcome you to our online community of practice where we discuss the practice of academic medicine!

This month’s case was developed collaboratively with the team at Simulcast. For the unacquainted, Simulcast is an excellent simulation website operated by our Australian colleagues that even includes a Journal Club set-up based loosely on the MEdIC discussion concept. Check it out following the completion of the case for a podcast that will delve into some of the issues that arose from this month’s MEdIC case which presents a simulation educator who is having difficulty connecting with her learners during debriefing sessions.

MEdIC: The Case of the Difficult Debrief

By Brent Thoma, MD, Victoria Brazil, MBBS, FACEM, MBA, and Ben Symon, MBBS

Eliza slumped down at her desk and without a word began to tap quietly at her keyboard. It had only been a few weeks since she’d started at the Simulation Center, but her director, Susan, could already recognize the telltale signs of frustration.

“Tough debrief?” Susan asked.

“Just a rough session,” Eliza replied. “We did an airway scenario and I wanted to discuss some communication points, but less than a minute after I got into the room I found myself arguing with the senior residents about the merits of apneic oxygenation… That wasn’t even something that I wanted to talk about!”

She clapped shut her laptop and turned her chair towards Susan.

“I remember how much fun simulation was in residency. I learned so much from those sessions and thought that I’d be able to give our residents the same experience. But it’s just not happening! Our residents and nurses don’t seem to “buy in” to the scenarios, you know? They’re always complaining about the manikins rather than owning their performance, and when I ask them questions in the debrief, they just stare at me!”

Susan listened closely. “Tell me more.”

“I just…” She paused warily in front of her new boss, but then allowed herself to be honest. “When I ask them how the sim went, they say it went well. When I hint about issues that came up, they don’t take the bait. And when I clearly outline their mistakes, the seniors get defensive! Even when I finally get them talking, they’re talking about the wrong things!”

She gestured at the Masters of Education degree hanging on her wall. “I thought that thing would prepare me to teach in any environment,” she said, “but my debriefs aren’t working, and I don’t even know where to start.”

Susan paused for a second before responding. How could she help Eliza?

Discussion Questions

  1. How is teaching with simulation different than teaching on shift? Does debriefing effectively require a skillset beyond that of a medical educator?
  2. What are the qualities of a “good” debrief?
  3. Eliza mentioned that she both had difficulty getting her learners to talk and with them talking about the “wrong things.” How can simulation debriefers start the conversation effectively while ensuring that they address both their priorities and the needs of the participants?

Weekly Wrap Up

As always, we will post the expert responses and a curated commentary derived from the community responses 2 weeks after the case is published.

Our 2 experts for this month’s case will be:

  • Dr. Glen Posner
  • Dr. Andrew Hall

On November 10,  2017 we will post the curated commentary and expert responses to this case! After that date, you may continue to comment below, but your commentary will no longer be integrated into the curated commentary. That said, we’d love to hear from you, so please comment!

All characters in this case are fictitious. Any resemblance to real persons, living or dead, is purely coincidental. Also, as always, we will generate a curated community commentary based on your participation below and on Twitter. We will try to attribute names, but if you choose to comment anonymously, you will be referred to as your pseudonym in our writing.

MEdIC Series: The Concept
Tamara McColl, MD FRCPC MEd(c)

Tamara McColl, MD FRCPC MEd(c)

Associate Editor, ALiEM MEdIC Series
Emergency Physician, St. Boniface Hospital, WRHA
Academic Lead, Educational Scholarship
Department of Emergency Medicine
University of Manitoba
  • Victoria Brazil

    Hi there
    Great topic and Eliza’s dilemma is common and heartfelt for those of us doing simulation debriefing, or arguably any kind of feedback in medical education.

    The first point i’d make is that this story is told from the point of view of Eliza – who clearly has a fairly negative view of her debrief. Of course her insight might also be flawed and perhaps her learners found it much more beneficial than she thought. One of the challenges in debriefing is knowing how to judge our ‘performance’, and recognising that we might be just as insightless as some of our learners
    Related to this is the perception that the debrief quality depends on the debriefer. Walter Eppich and Adam Cheng have written a lot about learner centred debriefing, and one point they make is that the learners do need to take responsibility for the debrief too. I wonder whether we shouldn’t spend more time training folks to learn in sim, in addition to the already significant emphasis on how to teach in sim.

    The suggested question – does debriefing require a separate skill set beyond a ‘general’ medical educator? – is dependent on what we think those respective skill sets are. Facilitating learning from experience is the goal of this skill set, but we risk getting tied up in formats.
    Personally i believe we’ve made a larger distinction than there needs to be. Skills in structuring a conversation, active listening, coaching and facilitating reflection are ‘generic skills’. The tipping point seems to be when a specific structure or approach is desired – for eg to have a consistent approach for a simulation program across debriefers – and then this needs to be adhered to. Its tricky – consistency is good but treating and debrief as a recipe is unlikely to have sufficient flexibility.

    What is a ‘good debrief’? Simply the one that achieves what you intended. And that is rarely a yes/no outcome. I worry Eliza is very influenced by the need for learners to ‘self discover’ as she ‘hints at their issues’….. Although hard, i have found that it more efficient and more comfortable when i speak plainly about my perceptions of performance in a way that’s direct and nice 🙂
    At worst the ‘hints’ eat away at psychological safety as the learners try and guess what the facilitator is trying to get at and feel manipulated.
    Both generic feedback literature and simulation specific papers describe advocacy inquiry approaches that are useful for direct conversations about performance gaps, with the aim of deep dives into the way we approach problems, as opposed to merely norming to desired behaviour

    Perhaps the most interesting part of this case is where does the conversation between Susan and Eliza go from here?
    Susan has been very patient in listening to Eliza’s perceptions of the debrief. Now the difference between merely empathising with a ‘vent’ from her colleague versus truly ‘debriefing the debrief’ depends on what Susan says next. Susan may have to use many of the same techniques for exploring perceived performance gaps as she does with the scenario participants – having a structure, exploring performance in terms of perceptions, consequences and match to desired outcomes, and offering alternatives from her experience.

    So I’m especially interested in seeing what others would say if they were Susan ?

    Thanks again for the great case and looking forward to the discussion

    vb

    • @bronespen

      Question 1 How is simulation different…
      I wonder how Eliza introduced the simulation to the learners? Were clear goals of learning set beforehand? Were the manikin shortcomings explained? These two elements are important in developing a framework on which the debriefing is structured. The limitations of the manikin must be acknowledged to ensure learner buy-in.
      Only then can can the true debrief begin…

      Hinting, as you mentioned, can lead to confusion, direct questions that allow engagement and reflection from the learner will lessen the chance of the learner going off on a different limb.

      And finally, in my experience, the debriefer must be open to the unexpected pearl that is dropped and which allows a brilliant learning opportunity for all. This means that there must be an element of flexibility in the debriefing.

      In the summation, the original key objectives can be brought out again and highlighted but never ignore the unexpected pearl.

      As an entusiastic novice to simulation, I find these discussions invaluable.
      From sunny SA, a big thanks.

      Bronwen

    • Eve Purdy

      Hi Vic,

      Thanks for your thoughts!

      I’m interested in how you and others are training learners to learn in simulation? Do you have an processes in place to do so at your site? Perhaps some of our virtual community members have suggestions. At our institution simulation is so deeply embedded in our emerg educational program that it would seem natural to train us to optimize this educational experience!

      In this case it seems to me that Eliza is losing confidence in her abilities. If I was Susan, I don’t know exactly where I would take the conversation from here but I do know that I would offer to observe her next session and debrief it with her after.

      Eve

    • George Mastoras, MD

      Really great point from Vic – what is Eliza’s objective with the rant? Does she just want to vent or to Debrief the debriefer? It would be an important question for Susan to ask, for sure. I think she is identifying her own performance gaps and this would be a perfect moment to D the D, but an invitation would be important to establish psychological safety. From a structured perspective, this rant would probably serve as the “reactions phase” – so a good time to empathize and then see if she wants to proceed and dissect the situation.

    • Hey vic… do you mind sharing the citations of the great work by Walter and Adam?
      The first thing that pops up in my mind is their PEARLS stuff?

      https://www.ncbi.nlm.nih.gov/pubmed/25710312

      Their KT stuff is great, though they are still seeking feedback so, I am unsure if it’s ready for primetime yet?

      https://debrief2learn.org/pearls-debriefing-tool/
      http://journals.lww.com/academicmedicine/Citation/publishahead/The_PEARLS_Healthcare_Debriefing_Tool.98069.aspx

  • Ben Symon

    Hi all,

    I think that when I listen to Eliza’s concerns, at their heart is one recurrent theme : Trust.
    Eliza notes that her learners aren’t identifying the same discussion points as the ones she has decided are important, but maybe what she needs to learn is to trust them enough to allow them to find their own learning objectives.
    She expresses frustration that the residents aren’t buying into her scenarios, but maybe she hasn’t provided a prebrief that generates trust within the simulation environment.
    Instead of hinting at their errors, Eliza might need to trust her learners enough to speak to them honestly, believing in their determination to improve their practice.
    Thankfully, Eliza at least allows herself to trust her new mentor, and to ask for feedback and guidance.

    I think if I was Susan, I’d be so excited to work with Eliza because not only is she clearly passionate, she’s opening herself up to change. I would let Eliza know that she has really only just begun a very long journey towards mastering learning conversations, and that it is a journey that can be filled with revelation.

    The Simulation Community has a load of resources at its disposal to help us get better at debriefing, whether it be podcasts from the likes of debrief2learn.com, CMS DJ Simulationistas or Simulcast, or from attending courses, or by finding an ally in the workplace who will commit to giving constructive feedback. But above all, if I could give only one piece of advice though, it would be this :

    Read.

    As Tyrion says in Game of Thrones, “A mind without books is like a sword without a wetstone”, and there is a vast ocean of knowledge in Sim waiting out there in the pages of journals like Simulation in Healthcare, Advances in Simulation and Clinical simulation in Nursing (and more). I can’t believe how much reading has transformed my debriefs, whether it be learning how to work better with a co-debriefer, being more open to ‘mitigated speech’ patterns in non western cultures, creating a safe container for learning, or finding pathways to seek honest peer feedback. Not only have these papers proved transformative, but the authors of those papers are passionate, caring educators who are constantly pushing themselves to improve and to help others on that journey.

    So good luck Eliza, and I hope that today’s reflection is that start of a really awesome journey towards helping others learn, and learning more about yourself.

    • Tamara McColl

      Love the GoT reference! Thanks for joining the conversation!

  • Rowan Duys

    Thanks everyone for the case and the discussion.

    When we ran up against a group of learners that were struggling to engage with the sim format, and kept suggesting that they would’ve behaved differently if it hadn’t been ‘a mannikin’ we felt like we had some success running a very quick mini-sim using faculty as confederates in leadership roles in the scenario as a sort of demonstration of how the whole thing works. I’m afraid I don’t have data to support if it worked or not….but if felt better 🙂

    Of course, Eliza’s group of learners are probably far more accustomed to sim, but despite being comfortable with the format, have played the ‘its the plastic’ card. Something is preventing them from owning their performance and I would think psychological safety is the likely problem. (which I think speaks to Ben’s trust narrative) If Eliza is a new faculty member for them, or perhaps even someone that has just graduated from their ranks, she will need to work hard at creating an environment where feedback is acceptable. I agree with Vic, hinting at faults, rather than voicing ‘good judgement’, is going to be a barrier.

    As to her problem with learners talking about things she doesn’t want to; I have been struck, time and again, at how tightly constructed the scenario needs to be to address specific learning needs. And, I’m not sure I really know where a sim will take learners until we’ve run it a few times. Perhaps more experienced sim-peeps have pointers on this? We reiterate hard until we have the sim we want. And, in the discussion phase, we try to preview where we’re taking the discussion….making the unpredictable predictable.

    I agree with Vic about the division between the skills required to facilitate learning from clinical vs simulation experience. Its all experience, right? But again, as Bronwen describes, psychological safety is hard; perhaps its harder to create in sim than for real cases? The phenomenon of being observed by your peers while you perform in sim is such a threat. But the conversation tools I’ve learned in debriefing absolutely help me engage colleagues around clinical events.

    I know when a debrief is going well when the learners are doing all the talking, about how they are going to do things differently tomorrow. (ref: Walter Eppich on simulcast)

    To Eliza: examine your own stance. Are you curious about why your learners do what they do or are you fighting a largely internal battle to demonstrate your competence as an educator? That you’ve chosen this job suggests you care deeply about helping people grow. Let them see this. Learn with them and from them. They will buy into that happily.

    (And I’m with Ben on what great resources there are out there to use)

  • Adam Cheng

    Hi Folks
    Great case – thanks for getting the discussion going on a challenge that many of us have struggled with! I don’t have any quotes to share from Game of Thrones … but here are some random thoughts in answer to the questions put forth at the end of the case.

    1. While there are skills common to teaching on shift and facilitating a debriefing, I believe there are several core differences too. (a) Debriefing requires FACILITATION skills, which are quite different than traditional didactic teaching skills. Facilitation requires careful listening, taking interest in your learners’ point of view, and asking the right questions, at the right time, to the right people. Most importantly, being an effective facilitator may require a mindset shift for some educators; from being present for the purposes of TEACHING, to being present for the purposes of FACILITATING LEARNING. (b) Debriefing typically involves interaction with and amongst multiple learners, whereas clinical teaching is mostly 1:1 (at least in the ER!; or 1:2 in some cases). Engaging multiple learners in meaningful learning conversations (ie. debriefing) is a unique skill that requires specific training and practice!

    2. Lots of great work out there describing characteristics of effective debriefs – I typically look to the DASH tool published by Brett-Fleegler et al / CMS group, and the OSAD tool published by Arora et al – two examples of debriefing assessment tools that highlight many of the desirable features of effective debriefings.

    3. Getting learners to talk isn’t always that easy! One of the key tasks of the facilitator is effectively managing the balance between his/her own agenda (ie. things the facilitator wants to talk about; often these are pre-defined learning objectives) and the learner agenda (ie. things the learners want to discuss). Easiest thing to do is to tackle the common agenda (ie. things that are common to both the facilitator and learner agendas) FIRST – that is the lowest hanging fruit! Next, you have a decision … do I introduce a topic on the learner agenda, or do I chat about something on my agenda? No right answer here … although your answer will be one factor influencing how learner vs instructor-centered you are as a debriefer. My own personal formula for prioritizing topics of discussion in a debriefing goes a little like this:
    a. Common agenda items first (note: I can usually identify these by listening carefully during the reactions phase)
    b. Items that are related to critical / life threatening errors, or severe patient safety concerns
    c. Learner agenda items of high priority – ie. many learners have brought it up; or one or two learners have brought it up multiple times; and lastly
    d. Instructor agenda items
    The above approach provides a fairly learner-centric approach without sacrificing patient safety …. although it does sometimes require the facilitator/educator to hold onto his/her learning objectives loosely.

    Keen to hear others’ thoughts on these issues.
    Thanks for sharing the interesting case.
    Adam

    • Tamara McColl

      Insightful comments! Thanks for posting, Adam!

  • Rob Bryant

    1. Debriefing / Facilitating is different that on shift teaching. Attending a dedicated facilitator course and learning how to teach by listening (‘tell me more about that…’) rather than teaching by telling is an acquired skill for even accomplished bedside / on shift teachers.

    2. A good debrief is one where the debrief meets the pre-specified objectives. High performance learners (ED residents) seem happier when we tell them the objectives at the start of the debrief and then teach to those objectives.
    A good debrief requires a good pre brief. We spend 30 minutes at the start of each of our 5 hour resident simulation sessions re-stating the basic assumption, ensuring psychological safety, and acknowledging the need to suspend disbelief in our scenarios. We have a new (<2 years) sim program for our residents and they are demonstrating a progressive improvement with their level of comfort in the simulations, and their engagement in the debriefs, with fewer critiques of the process (manikin issues, equipment issues) and better acknowledgement of the need to focus on the learning objectives for each case.

    3. Define the objectives. Acknowledge the content the residents also want to discuss. 'You raise a great point about apneic oxygenation, today we really want to focus on the human factors issue of communication. Lets loop back to talk about apneic oxygenation at the end of the debrief.' This approach validates the residents' desire to talk about Ap ox, and tries to refocus them to debrief to the objectives.

    • Tamara McColl

      Thanks for posting Rob!

  • Damon Dagnone

    Hey sim colleagues.

    This is a great case to discuss for so many reasons. After almost 15yrs since my first training in sim debriefing, I can honestly say there are a lot of components to a successful sim session and I’m definitely still learning as I go. Many others have already commented on a number of important factors to consider in this scenario, which include: a well designed scenario, appropriate objectives, learner acceptance/buy-in with sim, fidelity concerns, creating a safe environment, advocacy-inquiry questioning, debriefer rigidity in style, and perhaps overly critical self-appraisal.

    Perhaps my favourite part of simulation debriefing is that it’s different every time …and I like that. I like to see where the residents “take me” when leading a debrief. “So how did it go” I’ll say to the team leader and really leave it open-ended at first. Based on their initial response (self-confident vs too confident vs just enough confidence etc) to the scenario, I then reframe my objectives as we collectively explore their viewpoints. I’ll admit I’m a big advocacy-inquiry fan and I often use expressions like “I heard you say …” or “what affected your decision making at point X …” or “I like how you did Y”… then I try to dive in to their reactions. It’s fun and spontaneous, but not unstructured. Although I always try to weave my objectives back in to the discussion, when I’m unable, sometimes I just admit to the group that we pursued a different thread – and I’d like to highlight a few points before we close the loop on the case.

    Finally, I am fortunate enough to work in a small enough academic centre where we do lots of weekly sim and it is not uncommon to follow up with our residents in the ER in the days following with actual patient cases. Defensiveness often reveals itself in real patient encounters as well …so I look at the sim debrief and ER shift debrief as quite complimentary. Patience is a virtue and can be capitalized on with a 5yr FRCPC training program. There’s lots of time for me to work on my relationship with each individual trainee, and time for each trainee to be mentored, mature, and grow.

    So my advice for Eliza moving forward is keep working at it, cut yourself some slack, and reframe your approach to debriefing. Let a little more spontaneity and advocacy-inquiry into your debriefings and build that trust & safety over time both in the sim lab and the clinical environment. I think you’ll find in no time that things will start coming together.

    Cheers.
    🙂 D

    • Tamara McColl

      Thanks for adding to the rich conversation, Damon! You’ve provided some great pearls and insights!

    • Thanks for your contributions Damon! It is always great to have folks with such amazing Sim expertise tell us to cut ourselves some Slack. 😀

  • George Mastoras, MD

    Great case. I think Eliza needs to come back to a couple important philosophies in sim ed: The Basic Assumption, Good Judgement, and the concept of Genuine Curiosity.

    1. The Basic Assumption that all learners are skilled, caring, and trying to do their best: this needs to color how she approaches the debrief. She seems to be viewing the debrief as a standoff when in fact the problem may simply be that the learners care about certain other aspects of the case. Perhaps she could let her guard down and negotiate a bit of a debriefing agenda that is *mutually* desireable to meet their needs as adult learners and caring providers while still ensuring her concerns get conveyed.

    2. Good Judgement: Perhaps she needs to reframe her concerns with performance more explicitly rather than “hoping they’ll take the bait” – they may not have the insight and really feel it went well. At the same time, judgement is an important aspect of learning in sim and learners need to hear objectively about their performance. Advocacy-inquiry provides an optimal means for offering the assessment with a view to identifying gaps, and promoting self reflection, that is more direct than “dangling bait” or asking “guess what I’m thinking questions”.

    3. Genuine Curiosity: one of the most important skills a debriefer can bring into the debrief room is an open mind. I’m curious to know why these learners get so hung up on fidelity issues. Is it that the moulage needs to be improved? Does there need to be a better pre-briefing? Or is it an effort to avoid having hard conversations or deflect blame from a case that went the wrong way? Eliza could do well to ask some Genuinely Curious questions here to probe the depths of this hangup, and perhaps help to identify and close knowledge gaps in a different way: eg. asking about the hangup on fidelity as a springboard into discussing patients with “occult” presentations, and what other clinical signs and symptoms might need attention.

    • Tamara McColl

      Excellent insights! Thanks for posting, George!

  • Glenn David Posner

    In advance of my published response, I just want to take a moment to highlight and praise Susan’s behavior as a mentor, which is not the point of this case, but is so beautifully written. Susan role-models patience and active listening skills. She closes her laptop, and pauses thoughtfully before answering. The authors are to be commended for including this powerful message between the lines.

  • Shannon McNamara

    Great case, great comments! I’m going to share thoughts on question one – how is simulation debriefing different than bedside teaching?

    I think both settings are an opportunity to talk about error. In simulation, if learners make a mistake, no bad outcome will happen to a simulated patient. There’s inherently more psychological safety to discuss error. Others have commented on some excellent strategies like prebriefing, debriefing with good judgement, advocacy inquiry, and PEARLS above. Those are all great tools to help us discuss gaps and errors in a psychologically safe and learner centered way.

    But what about bedside teaching? I find myself doing much more clinical debriefing these days – reflecting on our team performance and individual learner decisions in the clinical setting. The tools are the same. Advocacy inquiry works great in the ED. The stakes are much higher – real harm may come to patients from error. So how do we reflect on our performance in a psychologically safe way that is patient centered?

    I find the just culture model to be essential, paired with the basic assumption we use in simulation. I believe my staff and learners are well trained, doing their best, and want to improve. I also acknowledge that we are all humans, prone to error, working in imperfect systems. While we must all avoid risky or reckless behavior, we also have to remove the blame centered approach to error in order to improve our care.

    In conclusion, I would argue that what makes a good simulation debriefing – productive, respectful, constructive reflection on performance – makes good bedside teaching. In medical education, we often have a culture of “pimping,” and sometimes blame and shame around teaching and error. Whether in the sim lab, the lecture hall, or at the bedside, we are all challenged to make our teaching, learning, and debriefing more patient centered to provide the best possible care we can.

  • Rowan Duys

    I know I don’t need to preach to people posting comments on this forum about the virtues of a digital community of practice. But for people like @bronespen and I, who are about a continent away from our nearest sim-mentors (although our growing team is working hard at peer-to-peer coaching and feedback), the online sim community provide equal parts inspiration and challenge. Thank you again for the case, discussion and learning.

    1. The debriefing training and experience i have received through sim has opened up a series of conversations around clinical events that I would not have had the skill to pursue before. No, it is not didactic bedside teaching, but wowzers it has been a powerful journey learning to create a safe-space for someone to share, recognising their burning issues, discussing the events that led to this, and then exploring their frames and learning.

    2. I agree with many others, the debrief that achieves the objectives is a good debrief. But I have found Walter Eppich’s comment from an earlier simulcast podcast to be an accessible yardstick: “I know a debrief is going well when the learners are doing all the talking, and they’re planning how they will do things differently tomorrow”. (Apologies for paraphrasing and probably not nailing it)

    3. Commenters have suggested several useful strategies. I would just add that one of the toughest lessons we’ve learned in our programme is just how tightly constructed a sim needs to be if you have very narrow learning objectives. Usually, it is only through iteration that we narrow a sim down to the point where we gain a semblance of control over the issues that rise for discussion.

    As for Eliza, as new faculty, she’s struggling for legitimacy isn’t she? Both in the eyes of the residents whose ranks she has just left, and in her own. This struggle will leak into her debriefs. That she has taken this job implies she is keen to learn to facilitate learning, and to invest in her colleagues. I think I’d remind her of that. If she lets this stance shine through, that she desperately wishes to learn to help others learn, she may find the trainees ‘buying in’ a bit more.

    • Victoria Brazil

      Hi Rowan

      I think you’ve nailed that insight about Eliza’s struggle for legitimacy. Our personal identity and emotions are a critical aspect of the debrief dynamic.
      We can be really hard on ourselves about being good at an externally described ‘good debrief’.
      At worst this leads us to try and conform to an overly prescriptive structure and can come across as artificial.
      Of course at best it means we are learning from good principles developed by those more experienced.

      Viva the grey zones……

      • Holy moley Rowan, I hadn’t even thought of that.

  • Gregory Podolej

    Joining this great discussion a little late, lots of great comments so far! Not too much else to add but do have some good reads at the bottom

    As a simulation fellow and current MHPE student I can speak to the fact that a degree in education does not make you a good debriefer. Debriefing is an art and arguably the most important part of a simulation. The simulation environment provides you with the time and a space to “unpack” a lot more than the clinical setting because of time constraints, patient safety, etc. (which is why simulation based education is such a valuable tool).

    A lot of these points have been already covered, but I wanted to echo the importance of advocacy inquiry and cite 3 very important articles. Another great resource is the Harvard CMS course which is excellent for debriefing instruction. I had the pleasure of learning from Jenny Rudolph and Walter Eppich who both have done foundational work in the field of debriefing.
    Advocacy inquiry is a technique that lends itself well to difficult debriefing (see references below) and would have been a great tool for Eliza to use. I think it is particularly effective because you “call it how you see it” which leaves learners with little room for interpretation or extrapolation. Its difficult and awkward to do at first, but I’ve noticed that learners appreciate the straightforwardness and honesty.

    Some of the articles I like…

    Eppich W, Cheng A. Promoting Excellence and Reflective Learning in Simulation (PEARLS): development and rationale for a blended approach to health care simulation debriefing. Simul Healthc. 2015 Apr;10(2):106–15.

    Rudolph JW, Simon R, Rivard P, Dufresne RL, Raemer DB. Debriefing with Good Judgment: Combining Rigorous Feedback with Genuine Inquiry. Anesthesiology Clinics. Elsevier; 2007 Jun 1;25(2):361–76.

    Rudolph JW, Simon R, Dufresne RL, Raemer DB. Thereʼs No Such Thing as “Nonjudgmental” Debriefing: A Theory and Method for Debriefing with Good Judgment. Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare. 2006;1(1):49–55.