The last segment is debriefing and the rationale for this is this allows you to solidify the learning that your learner did in the operation. And it also gives you a chance to assess whether or not you actually got your teaching accomplished. So this is a step that's easily skipped and I'm going to urge you not to skip it. I want you to think about doing it, maybe you can do it during the close or after the salient part of the operation, when you've achieved the learning objective It should be close to the time of the operation, though. So in other words I think that it's not good practice to wait a couple of days and then go through the debriefing. I think it's very important that this happen sometime close to the operation. And the debriefing consists of four segments, reflection, rules, reinforcement and correction. So now I'm going to talk to you about what each of those things are. So the first part of debriefing is reflection. And this stimulating reflection on the part of the learner, asking them how do you think you did and why do you think so? We think this is important because having the learner self-assess gives you an opportunity to focus their assessment and gives you an opportunity to correct their assessment. And this is how expertise develops. So, you want ask yourself Is your learner's perception accurate? By guiding them with their understanding of their performance, you are helping them create expertise and then you can ask yourself the question were the learning objectives addressed to you satisfaction? And if the answer is no you can tell the learner that and that's something to focus on the next time you do an operation with this learner. The second segment of debriefing is rules. And we think it's important for learners to state a rule that they've learned in this operation to guide their future practice. So you can ask them, what are you going to remember from this operation? What are you going to take out of this room? What's going to help you in the future? We think that leaners are more likely to remember rules that they generate themselves, and saying them out loud helps them to reinforce those rules. And again, I'm not telling you that you as the expert have to give up your expertise and allow them to make rules that don't make sense. So if a learner comes out of an operation and creates a rule for him or herself that you don't think is good practice, then absolutely modify it. Reinforcement is the next part of debriefing and we think it's important to tell somebody if they've done something properly. Because sometimes people do things properly by accident and there's absolutely nothing wrong with encouraging your learners. So it's helpful if you're very explicit. If you say, when you did X, you did Y, which made it effective. So what is it that they did, and why did it make it effective? That's a true reinforcement. The last part of debriefing is correction. So we know that inappropriate performance has to be corrected and the correction should be focused on learning objections. Although you may find that there are other things that need to be addressed in the learner's performance. The correction should be short, and it should be explicit. So it needs to be focused on an actual element of performance. When you do X, you need to be sure that Y is prepared. Now let's think about how to do that in other settings. All right, let's talk about debriefing. It's really important, and you're right. I love that you made the point that you must not forget it because we do tend to do it and if you don't do it, the learner's not going to consolidate the learning. >> Right, yeah. They may do it on their own but it's really, this is part of your role as the expert is to really help them shape what was the lesson for today? What should I take away from this? Asking them to reflect on you had a learning objective, we did some work in between the tie you set the objective and now. What do you think about what you learned based on that objective? What are you going to carry out of the room about that objective? I think that that's really important, and I'm not giving you permission to skip steps, but if you're going to skip steps don't skip this one. >> Yeah. >> This is really essential. It's essential for the learner to say to the expert, here's what I think I learned, here's what I want to carry out of the room. So that's the reflection piece. I think it's really, really helpful to ask the learner what rule for practice are you going to take out of here that gives you two pieces of information? First of all it solidifies their learning again. So it gives them something explicit that they leave the room with. And second of all, gives you, as the experts, a piece of information about how are they consolidating this information. >> Yeah, do they get it? >> Did they get it? Exactly. And if the answer is no, that gives you another opportunity to intervene. So, you can say, that's not really what I want you to take out of here. I don't want you to do that thing that you just said was your rule for future practice. Here's what I want you to do instead. Most of the time if you've been doing the teaching all along they're going to walk out of there with a proper rule. >> Do you think, so in some settings? Do you think it's okay to substitute a rule with a piece of knowledge, like I need to, I've learned about this process the center criteria for sore throat or some piece of knowledge other than a rule, per say? >> What I think is good practice is to have something that's going to guide you in the future. >> Okay. >> So, it could be a rule, it could be a piece of knowledge, something solid that you can go back to the next time you're in a similar situation. >> Okay. >> Okay. And then the reinforcement piece, I struggle with that because do you think it's easier to do the correction first and then the reinforcement? Do you think it needs to be in that order, or do you think it's okay? >> Honestly, the reason it's in that order is because our seat. >> There we go. >> So, I'm ambivalent as to what order you do it in. >> Okay >> But I think that it is important if you can find something that's reinforceable. Because I think that we tend to focus on error and we have to focus on error, there's nothing wrong with that, but I think learners can get can get a little uneasy, and if they know that they've done something properly that helps. And it also, like I've said before, it could be that they did this thing properly and they didn't know it, and so telling them yes that was the way to do it gives them that reinforcement so they know oh, good that thing I will keep as part of my standard practice. >> Yeah, yeah. It's funny this actually models, the model of effective feedback, so when we've talked about effective feedback, the first step is for the instructor to plan. Which you've kind of done all the way through. And then the next step is to ask for the learner assessment, which is kind of the reflection piece. >> Mm-hm. And then we talk about kind of having a conversation and in that conversation is the things to both reinforce and the things to correct. And then in the end they need to have an action plan, which in some ways is the rules, it's just a little bit of a different order for it. >> Yeah. >> So that they leave with this is what I did well and want to keep doing this is what I need to do better and this is my way that I'm going to think about doing it or the way I'm going to get to get to doing something better. >> Mm-hm yeah. And I think a lot of times the correction piece when I've seen it in action the correction piece isn't necessarily you did this thing wrong and you need to do it better but it might be a tweak on practice so for instance at least in the operating room I'll see surgeons say you know you need to make your incision just a little bit longer and a little bit tilted >> Mm-hm. >> This way or something like that. In a procedure it might just be just a little tweak on how you're holding something or how you're positioning your needle. It doesn't necessarily have to be a big oh you made a big error, it's just here's here's something that I know as an expert that you could do. >> Mm-hm, I think that's really helpful. Thank you. >> Yeah. >> Thank you very much for you help today. After the endoscopy or just want to kind of get a sense of what you thought, how you thought it went. >> Well, now at the beginning I thought the getting the scope into the bladder it went pretty well but towards the end, trying to get that stent up, I really had some difficulty there. >> And as we've talked about it beforehand we had some goals. Getting access into the bladder with a cystostomy and the male patient being cognizant of the prostatic urethra. And knowing you need to drop off your hands is very important. You did that beautifully. Once we got inside into the bladder, be able to get the wires up into the ureter, and get our ureteroscope up. Focus in on the wire, focus in on the stone, break it up. You did beautifully managing the wires kind of throughout that process. All right, as we got towards the end of the case, getting the stent up was a little more challenging. And you noticed as soon as we straighten that wire, made it rigid we're able to get that stint out much more easily. >> Yeah. >> Well-done. It really was well done. >> Yeah, thanks. You have another ureteroscopy case later today. Do you mind if I come in and help pull the wires that way I can work on keeping the tension and on the wire? >> Absolutely. I'd love to have you on the case. So as you move forward with each of these cases try to take one or two things away each time. You did great with dropping your hands, managing the wires in the case. This time as we move forward make certain that wire's rigid anytime you're passing anything up the ureter and it will go much more smoothly. >> Okay. Thank you. >> Well done David. >> Great.