I was asked the other day what I did to switch off from my work every day, given the intense interactions that might be part of a normal day at hospice. I do perform a ritual at the end of the day. I take off my ID badge and place it in my drawer. I also put away any equipment I might be carrying, in particular my stethoscope. Back when I used to wear ties I would take my tie off, and undo the collar buttons of my shirt. I’d pack my bag and then prepare for the drive home.
I’d play easy-listening radio on the way home. I used to listen to a news channel, but I found that to be too frustrating given the usual news headlines. Having a mixture of music from lots of different decades is good. There is still something about 80s music that continues to appeal to many in the world, myself included. The commute home is usually through rush hour traffic, thus a drive that takes 20 minutes in the morning, takes at least double that in the afternoon.
Once I arrive home I change my clothing, taking away the last vestiges of the doctor. Again this is ritualistic and marks my return to the rest of my life, and the other roles I hold. Each transition is marked by a slight change of costume. This is to maintain boundaries between my work and the rest of my life.
Most days I can switch off from work by going through the above rituals. Some days might be tougher than others and then extra effort is required, e.g. mindfulness meditation or walking in nature. Choose a ritual for yourself and practise it regularly until it becomes part of your daily life routine.
I found myself having to really question myself as to what I was doing. Professionally I was promoting self-care to everyone at work, and to the audiences at the lectures I was presenting. I felt like a fraud at times as I wasn’t practising what I was preaching myself. I had to do what it said on my packet I had to stop and have a break for myself. That meant a stop to the blogging and the daily writing. It was supposed to only be for a few weeks but it ended up being three months, and it was okay. I’ve restarted things again but at a smaller scale. I started timing myself for ten minutes a day. I would write for a minimum of ten minutes a day and what would appear would appear and we would see how it all went.
I was back again, writing daily, posting to the blog daily and it felt good. I hadn’t realised how much I had missed the therapeutic aspects of the writing. Also the writing community engagement had been missing over the three month period. I was back in the swing of things again and it was good to feel more like myself again. Some of the pieces of writing ended up being work pieces or parts of assignments I was doing for online courses. Things started feeling too stretched last week and I had to release the pressure again. People all around me in the different parts of my life were struck down by non-Covid viral illnesses and I wasn’t keen to join them. Instead of writing I went to bed. Instead of doing 15 minutes of Duolingo Spanish I only did the bare minimum to maintain my run streak. No-one was going to reward me with a badge for least amount of sleep had in a week. Gamification of my own health wasn’t worth it, in the real world it’s not so easy to spawn yourself back.
I’ve had another short break from the writing and I haven’t beaten myself up too badly over it. I am back again today and will be back again tomorrow. It’s the accumulated efforts over time that add up. What am I writing? My dailies which will become blog posts, which will become who knows? And that is okay. I just need to use the writing muscles again. To reactivate the nerve pathways. To gather up my energy again and make something with it. Daylight savings, travelling between time zones in the past week, and general life stuff have affected how I lived my life in the past fortnight. Other things out of my control have happened and have had to be dealt with. It will all be okay. All we can do is keep on going. One foot in front of the other. One word in front of another. We’ll see where we end up. We’ll see what comes of it all. Take it easy on yourself. There’s a lot going on. Be gentle and kind to yourself.
In the past seven weeks, I have been studying academyEX’s Digital and Collaborative Teaching and Learning micro-credential. In this blog post, I will critically analyse contemporary thinking in education. I will then critically analyse the role of digital and collaborative learning in contemporary education. In the second half, I will evaluate my practice against digital and collaborative learning and teaching. Finally, I will evaluate my practice against relevant aspects of sustainability.
Contemporary Thinking in Education
Behaviourism was the main learning theory utilised in my medical training and is reflected in the way I provide teaching as a doctor. Extrinsic motivation was provided by medical school through the set curriculum. I felt like a passive recipient of knowledge and I was tested on my ability to repeat the vast content provided over many years. This continued in the setting of medical specialist training where even more information was memorised and regurgitated during exams. A lot of knowledge is acquired but is not otherwise utilised, thus retention is poor. Learning was shallow and given the time spent it remains unclear if the return on investment is of high enough value. Other theories of learning need to be considered.
Constructivism takes a learner-centred approach. People are not completely blank slates when they arrive in medical school and may have come from various backgrounds. Some of us may bring skills and knowledge from our previous work and life experiences. The role of the mentor is to assess our prior knowledge and guide the extension of our development.
Constructionism theory involves the students creating new knowledge structures. Social products are created, and learning is by making and can be aided by technological tools such as the Google Suite and many other apps. Students are encouraged to own their learning and to make it more engaging for themselves.
The medical school shifted to experiential learning in the clinical years when we started seeing patients. I learned by dealing directly with patients and their families. Learning was by doing we were provided with hands-on opportunities. It was more engaging when I was given a chance to assess patients and come up with my own management plans. I practised doing interventions with the use of patient simulators and actors. Time for reflection was provided when I presented my findings to tutors and this also involved review of video footage of assessments. This allowed for the practice of clinical skills in simulated situations.
The role of digital and collaborative learning in contemporary education
Older education approaches may have taken a cooperative approach in which group members would be assigned various parts of a learning task to do themselves. They would all come back together to present their information to each other. This is similar to a potluck dinner in which the meal that you eat together may be a random collection of dishes which may or may not work together well.
Contemporary education requires a collaborative approach in which students come together and discuss how they will learn together, utilising a horizontal division of labour. An analogy is when people gather to cook a meal with each other. New skills and knowledge can be learned together. Everyone has a role in putting together the meal and there is a more cohesive outcome. This also helps to model how doctors could work together in collaboration with others. Garnering opinions and information from team members rather than all working completely independently. Complex wicked problems demand input from all team members who each have their individual roles to play. Everyone has a role to play in the learning situation and it models good future behaviour. Collaborating with other doctors or other services is considered good healthcare practice.
How can digital tools be incorporated into this learning? The potential audience of any digital artifacts could be vast, we don’t need to limit ourselves to face-to-face teaching any more. In 2013, when I engaged with online learning companies I was quoted $ 100,000 for the production of four 15-minute modules. In 2023 I can create my own using readily accessible apps, at low or no cost apart from my own labour.
Evaluation of my educational practice against digital and collaborative learning and teaching
The Covid-19 pandemic forced medical education to try new ways of engaging. The traditional face-to-face tuition could not be done during the many Aotearoa/New Zealand lockdowns we experienced from 2020 onwards. We learned how to do virtual assessments including home visits, clinic sessions and joint visits via the use of video-calling technologies. Joint visits allow different members of the multidisciplinary team to assess a patient together, with each member assessing the situation from their own point of view. One or more members of the team could be present either in person or virtually in a more collaborative approach.
In medical training, experiential learning is via doing with real cases being worked on together. Standard medical assessments involve assessing patients face-to-face. This assessment formulates a problem list and differential diagnoses are considered. A management plan is then drafted to treat the problems identified. Online resources could be checked to assist with any of the prior steps. The case is then presented to the clinical supervisor(s) and together a joint management plan is finalised. As the trainee becomes more experienced their level of supervision decreases until they can work independently. In the future sophisticated patient simulations could be created and could involve various team members assessing the simulated patient at the same time. As artificial intelligence improves, these scenarios could become more and more realistic. Virtual reality technology could allow virtual face-to-face interactions between clinicians and patients regardless of distance. Wearable devices could allow remote physical examination of patients. Communication between clinicians, patients and families could be improved with technology.
Evaluation of my educational practice against relevant aspects of sustainability
My educational practice involves teaching various clinicians, patients and their families about palliative care. Western medicine including palliative care has historically been a white person’s medicine and one size has never fit all. Extra effort has been required to take into account people’s cultural origins and particular emphasis has been placed on becoming culturally competent practitioners, to make our environment feel safer for all. Bilingual signage and the use of Te Reo Maori in daily conversations are now part of my workplace. We want our staff/volunteers/students to learn by immersion.
I work in a healthcare training institution but we are also citizens of the world and must play our part when it comes to climate change. Our organisation has focused on place-based learning. We have removed individual rubbish bins, have centralised waste collection and only have bins available at certain sites on our campus. We want people to actively think about where their waste will end up. What can be composted is put in the appropriate bin as is recyclable material, with an overall effort to reduce what goes to landfill. Upgrading of equipment to more energy-efficient versions continues to be done. Shifting our fleet from a fossil fuel one to an electric vehicle fleet has begun. Simple things such as providing our staff members with reusable cups and water bottles are part of the subtle encouragement of environmental sustainability.
In terms of educational sustainability, we have switched from paper-based materials to the use of digital artifacts. Short video tutorials are available on our intranet and internet sites where educational material has been curated. There is a lot of great content out there already and we encourage our staff and students to create content. We foster a culture of ongoing life-long learning. Our students are encouraged to learn how to find information rather than commit it to memory. They are encouraged to think for themselves on important issues especially how we can prepare for the future. Open questions are asked to stimulate the exploration of topics in a deeper fashion.
Conclusion
I have worked as a medical doctor for almost 24 years. When I graduated it was the start of my life-long learning. Over time, without any training, I have also become a teacher. My teaching style has been behaviourism-based as that was how I was taught. AcademyEX’s digital and collaborative teaching and learning micro-credential has exposed me to contemporary learning theories including online tools to aid teaching. It has made me ponder much about sustainability in all of its forms. It has further opened my mind to new possibilities for student engagement and to consider that my teaching needs a wider audience than people who work in the hospice. People have all sorts of preconceptions about things especially if they don’t know about them. Many people are still afraid of hospice. How can I use the skills and knowledge I have learned to make hospice/palliative care more widely known? Maybe I’ll write some more blog posts…
References
Olsen, M. & Hergenhahn, B. (2013). An Introduction to Theories of Learning (9th ed.) Pearson.
Cashman et al. (2005). Teachers Discovering Computers: Integrating Technology and Digital Media in the Classroom (4th Ed.) Course Technology.
Kolb, D.A. (1984). Experiential learning: experience as the source of learning and development. Prentice Hall.
Liu, C. H. & Matthews, R. (2005). Vygotsky’s Philosophy: Constructivism and Its Criticisms Examined. International Education Journal, 6(3), 386-399.
Papert, S. & Harel, I. (1991). Constructionism. Ablex Publishing
I’ve attended regular professional supervision sessions, at least once a month, for over 13 years. I’ve worked full-time in palliative care for almost 16 years and it was recommended that I attend these sessions early in my training. The rest of the team attended sessions and it was expected that I attend them myself. I was recommended a psychologist/psychotherapist who supervised a number of my specialist colleagues at the time.
I wasn’t sure what to expect for the first session. For New Zealand men talking about your feelings is still a foreign concept even in this day let alone 16 years ago. I gave it a go and the first session was spent with my supervisor and I getting to know each other. The sessions were limited to one hour and I was encouraged to talk about any situations that had invoked feelings in me. At the time I talked about clinical situations I was dealing with. Helping patients and their families deal with their death and dying on a full-time, daily basis did take a toll on me. I found myself taking some of the cases part of the way home with me. I was witnessing tragic events a number of times a day and the raw emotions needed to be discussed. Professional supervision was an outlet for this necessary release to happen. Trust in the process developed over the next months and more feelings were shared.
This first supervision relationship lasted for six months. It was initially helpful and thus I continued. Following the penultimate session, things had changed and I found myself feeling upset for the following month. This was not how it was supposed to work. I was supposed to feel better after these sessions, not worse. First, do no harm was the principle that had been taught to us early in medical school. This was not right. I brought it up with my supervisor at the next session. He said he would address it, but I left that session feeling even worse. I decided to fire him. I became disillusioned and did not attend any further sessions for the next 18 months.
In my final year of specialist training, I was encouraged to give supervision another go, with another practitioner. This worked out much better and was much more helpful. It felt safe to discuss some of the situations which had triggered various emotions when dealing with patients and their families. Sometimes people reminded me of my own family members. Other times situations felt a bit too close to my own. An example was when I had to look after someone who had a similar background to me. I didn’t know him but we had gone to the same medical school, and we had become medical registrars at the same time. I was study buddies with some of his classmates. We passed the physician exams at the same time and started our specialist jobs in the same year. The biggest difference between us was he was dying of cancer and I wasn’t.
I’ve had many supervision sessions in the intervening years and they have kept me well. The subject matter changed as my role and responsibility changed over time. With growing experience, the clinical situations did not affect me as much as they did when I started. I have developed resilience and maintain firm boundaries to protect myself and those I care for professionally. When I had to take on managerial and leadership roles this was initially stressful. As specialist doctors, we undergo a long training process lasting at least 13 years. In our curricula, there are no sessions on management, leadership or education. These are all aspects of a specialist’s job and can be a source of stress. My supervision sessions have allowed me to look at things from other points of view and to reflect on my practice. Some months have been particularly tough and I may have needed more than one session in those months.
Overall the sessions have been of great value to me and remain one of the important self-care activities I do regularly to keep myself professionally healthy. I would recommend these sessions to anyone who wants to have a long-term career in palliative care. To anyone considering doing them, I would encourage you to give it a go. The raw emotional work of palliative care can make you feel like you are in a pressure cooker at times. We could all use a release valve to let off some steam and to stop the contents from burning (out). I’ve needed to focus more on self-care this year and professional supervision remains one of the anchors of my self-care practice. I believe that if I take care of myself better, I will be better able to take care of patients and their families.
Four years ago I went on a Wellness Retreat. Some of my colleagues laughed at me once I had returned and discussed some of the activities I had paid a lot of money for. During the retreat, I ate much smaller meals than usual. I woke up earlier than usual to do yoga, followed by a tiny breakfast and then hours of hiking. Another activity was fasting for 36 hours, 24 hours of which were spent in total silence. The activities were interesting to try but I have not continued with most of them. I also learned about thermotherapy, with exposure to heat in the form of a 90-degree Celsius sauna followed by ice baths. The cold water exposure is something I have continued to this day.
I shower as usual using warm-hot water. At the end of each shower, I turn the water temperature to total cold. This feels awful for the first 10 seconds and my mammalian dive reflex is triggered, with much deeper breathing. During the winter months the water is extra cold. The next 10 seconds are less unpleasant. By the time I have reached 30 seconds, I can tolerate it, and my hands and feet have become cold at which point I turn the water off. As soon as the water stops a warm feeling surges through my body and I sure do feel alive.
The cold showers are my daily dose of suffering and I feel they have built up my resilience over the years. I will continue BBRRRRRRR.
Some interactions in palliative care with patients and their families can be hard to handle. e.g. breaking bad news to younger people. Some conversations are intense and emotionally draining. In any hospice inpatient unit (IPU) the staff may need to have a number of such conversations with different patients during any given ward round. Often the team may be about to visit the next patient and may still have remnants of the previous case on their mind. This is when I would lead everyone away for a short break.
It might be heading upstairs for a hot drink and a quick snack. A short walk outside for fresh air and a dose of sunshine or it might be heading out into the rain. A reset /restart button is activated. The team is led away from the site of upset feeling for five minutes of self and team care. A brief respite from the frontline. Good role modelling, leading by example.
We might only have been away for a short period of time but on our return we feel better and more open to tuning into the next patient’s problems with our full attention.
If you are a clinician why don’t you try adding small breaks into your schedule after intense patient encounters? Do they work for you?
I have had to focus on self care this year as it has been challenging at times. I’ve had to shift my focus away from saving up all my self care for a holiday as I need more regular doses of self care. In fact if I had not done self care activities on at least a daily basis I would be in much worse condition than I am at present.
I’ve been working on microdoses of self care. This might be as short and simple as a five minute walk in the hospice garden. This is a combination of leaving my usual seated in front of a computer working position and going outside. Five minutes of fresh air and occasional sunshine in between the recurrent episodes of heavy rain we have experienced in Auckland this year. A small dose of exercise for my body which is at risk of pressure injury from prolonged sitting. A chance for my eyes to focus on objects which are further away than the screens I look at while doing computer based work. To feel the wind through my hair. To smell the flowers and the trees.
There is a slightly more shaded area of the garden path I spend a bit more time in. If you stop at the right spot and close your eyes you feel almost transported into a forest. You hear the wind rustling through the trees. There is birdsong from nectar feeders who have had plenty to eat in recent weeks. I walk around the garden and I might bump into some of the many volunteers who keep the garden looking its best. I try to stop and chat to the volunteers as often as I can. To thank them for what they do for our organisation.
Five minutes, 500 steps. A short workout for my otherwise sedentary body. A couple of times per day on a good day. It all adds up, every little bit counts.
What self care activities have you done for yourself today? What can you do for yourself that will take five minutes?
I needed a break. After five years of mostly being alone I was tired of having to make too many decisions about what felt like everything. It came to the point that deciding what to write had become burdensome. So I stopped. Cold Turkey. The stories kept on accumulating but I did not write them down. This is the first time I have sat down to write something in three months. I have set my red tomato timer for ten minutes and I will not stop until the timer’s alarm goes off.
I had been consistently showing up for the past two and a half years. I had tried my best not to miss a daily but some had been missed and it was okay. My world did not end. The world did not notice my absence. I needed to drop out and take some time out to think. What to do next? What do I want to do? I still haven’t answered those questions. Instead I focused on self-care. I restarted doing my morning pages, combined with stationary bicycle riding for a dose of exercise and to warm myself during the colder mornings of the Southern Hemisphere’s winter.
I had amassed a collection of these pages over the past year. Initially I had wanted to review them to see what insights I could glean from them. What secrets would the scrawling reveal to me? Nothing. My scribblings were not fit for human consumption they looked more like graphed heart beats. I could not read my own writing. Pages and pages. Book after book of ink-stained etchings. I threw them into the recycling bin, one after another, after another. Release. Relief. Relive.
A little bird told me that a great combination if you are wanting to improve your communication skills when it comes to palliative care situations is to check out the resources below.
My fitness tracker died on me a few months ago and since then the wear pattern on my shoes has slowed down. The reminders to do at least 250 steps each hour were a good reminder to stay active during the day. I have the luxury of working in a place with a garden surrounding it. A few times a day I can go out for a quick walk around the garden. One orbit is 500 steps, which would add to my daily step count. 10000 steps a day was more than achievable. The fitness tracker wasn’t mine, but one I had inherited from a family member, but I wore it out.
A few minutes of self-care interspersed within busy days. The simple act of walking in some nature. The sunlight on my face, the breezes through my hair. The sounds of the insects and birds doing their thing in the trees. The wind winds its way through many thousands of leaves. Not quite a forest to bathe in but in certain parts of the garden, you can stop under a tree and imagine that you are in much deeper woods. A momentary escape from the hustle and bustle of the workplace, I am briefly transported thousands of kilometres away. The fresh air is scented with the products of the plants themselves. It’s as if I am a time traveller, going back to the wellness retreat I attended three years ago, but I am not the same person anymore. Three years older and hopefully wiser.
I return to my office and the ward feeling refreshed. These micro-breaks throughout the day help to keep things calm.
palliverse.com 