Hilary: Welcome everyone to another episode of the EMS Educator Podcast, Powered by Prodigy. ⁓ I am so thrilled today to be joined by Ginger Lock for the second time in a row as a host. And also today we say hello to Rob in Absentia, who is on other duties as assigned, as well as Maya, who is so busy that I don't even know if she knows where she is. But ⁓ that's okay because whatever she's doing, she's changing the world.

Rob: Hello, this Rob Lawrence in with a quick Rob Review. This is going to be one of those conversations that has the potential to fundamentally change the way you think about educating paramedics. The topic is remediation. Now, if that word makes you think of struggling students, failure, or punitive action, think again. This discussion turns that entire concept onto its head. Our guests are

Hilary: Today we're joined by Ryan Battenhorst and Heather Davis. These are two incredible educators who have come to us to talk about the topic of remediation. And I want to start by having them introduce themselves and then ask Ginger to kind of kick off the topic. Ryan, tell us about yourself.

Rob: Dr. Heather Davis from UCLA and Dr. Ryan Batenhorst from Crichton University make a compelling case that remediation isn't something that should happen after a learner fails. It's something we should be thinking about from day one. In fact, the most striking takeaways is that many students aren't struggling because they lack ability. They're struggling because they're overwhelmed. Ryan shares fascinating research showing the stress of being evaluated.

Ryan Batenhorst: Thanks so much, Hillary. My name is ⁓ Ryan Batenhorst. I am Nebraska. I am currently the

Hilary: And tell us about your EMS career. How long have you been in it?

Ryan Batenhorst: ⁓ gosh. I've been in EMS for around ⁓ g almost thirty years. ⁓ worked clinically for about twenty years in the in the mostly nine one one in Florida, Kansas City, Nebraska area. Started ⁓ in the community college world in education and moved into to Creighton. continued on and got more educated, got a bachelor's, masters and a doctorate degree all in the last ten years or so. So

Rob: Can be more significant than many of the traumatic clinical experiences students encounter during training. You'll also hear Heather introduce a wonderfully practical framework for identifying why a learner is struggling. Is it a knowledge gap, a motivation issue,

Ryan Batenhorst: Lots of school, lots of ⁓ stuff to to to try to help students be better paramedics. So that's Yep.

Rob: Or is the learning environment getting in the way? Rather than jumping to conclusions, she encourages educators to diagnose the problem before prescribing the solution. A lesson that should resonate with every clinician listening. There are practical gems throughout this episode. You'll hear why slow is smooth and smooth is fast applies, just as much to education as it does to patient care.

Hilary: Thanks, Ryan. ⁓ so that's two PhDs in the room. Go ahead, Doctor Heather Davis.

Heather: Hi, thank you for having me. ⁓ my name is Heather Davis. I am the Director of Student Assessment in the David Guffin School of Medicine at UCLA. But most of The friends I have in EMS are familiar with me from the work I did at the UCLA Center for Pre-Hospital Care, where I was the paramedic program director for many years. I spent almost 20 years at the center in various roles, including the director and associate director of the center. ⁓ my career started in as a volunteer in Iowa. ⁓ and I thought, phew.

Rob: You'll discover why breaking learning into manageable pieces builds confidence, competence, and ultimately better clinicians. And perhaps most importantly, you'll hear why psychological safety and academic rigour aren't opposites. They're partners. My biggest takeaway: great educators don't simply teach clinical skills, they create environments where students feel safe enough to learn, confident enough to ask for help, and supported enough to grow into exceptional clinicians. Whether you're a classroom instructor, a field preceptor, a training officer,

Heather: I gotta get out of here if I'm gonna run any calls. And so I did, loaded up everything I owned, which sadly fit in my Ford escort at the time, which tells you I was a poor college student and moved to New York to get an education in EMS and did that and from New York ⁓ to Colorado and then back here to sunny California where I actually grew up as a kid.

Hilary: I didn't know the New York thing about Heather until we were at a conference once and she started chatting with a New Yorker about the time that they ran calls together and I just stood there saying, Wait, I I thought you were always California I was so confused. It was very cool.

Rob: or a medical director, I think you'll come away with ideas you can apply immediately. Listen along with me.

Ginger Locke: I al also always thought she was California because look at her. Look at Dr. Davis. You're just like the sunny disposition. Well, I'm really excited to hang out, ⁓ Ryan and Heather with both of you. ⁓ this is a topic that really came about because Maya ⁓ inspired us by saying, you know, she's ⁓ is a medical director of a paramedic program, like

Hilary: ⁓ I mean

Ginger Locke: you know, wanted to learn more about remediation. And as I think about remediation, to me it is ⁓ a term that we don't want to hear because usually that means we're at an inflection point in the learner's experience. So we're we're like comfortable with all this feedback and teaching and coaching, but then there's this moment where we've decided we are naming and we're now naming this remediation. kind of like this this ⁓ big kind of sentinel event. ⁓ and so I'd love to hear ⁓ from both of you. where where do you land on that when you hear the word remediation? Is it still like a big ⁓ scary word for you? And how do you get your students ⁓ to get comfortable with that word? Do you even use that word? So Ryan, let's let's start with you. What is remediation look like ⁓ in your program?

Ryan Batenhorst: Hmm. Well remediation for me is a lot more probably complicated than it seems to other people. ⁓ I don't know how where to start with this other than from the beginning a little bit. I don't want to take a ton of time, but my dissertation study was really about post traumatic stress symptoms for paramedic students. ⁓ doing clinical rotations, ⁓ which I thought pretty straightforward. I thought it had something to do with their childhood trauma. So I thought high trauma h childhood trauma, low potential resilience, thought maybe a lower threshold for post traumatic stress symptoms. Well, as I learned through my mixed method study was really that there's more to it than just the clinical rotations that's causing stress for students and really the thought of being evaluated is a lot more stressful to them than I thought. So ⁓ that came about a lot of times that clinical rotations were stressful a lot of times because of they were just being evaluated by people. So then I that kind of moved into the rest of our program. Well what about the lecture stuff? What about exams? What about the simulations and and the lab where we tell them that don't worry, the lab's a safe place to fail. Well is it? So ⁓ I started looking at our remediation policies and what we do with that and I don't I don't necessarily think the lab is a safe place to fail from their mind because they're generally shown that that wasn't right, you can't do it that way, you did that wrong, rather than looking at different incidents as a as like a a whole thing rather than just one experience. So sorry, I could ramble about that for hours. So anyway, I'll stop at that for now.

Heather: to me the word remediation comes from the Latin root of remediaire or the word remediaire, which means to heal or to cure. ⁓ and I don't like to think of a learner needing healing or curing, but the if you go further in the definition, it also means to take appropriate measure. ⁓ that's the piece I like is to take appropriate measure to sort of solve whatever is happening right now, ⁓ as we go through the conversation today, I think we're going to explore is something. Sometimes a learner issue, and sometimes an environmental issue, and sometimes the it's the preceptor that needs some ⁓ appropriate measure, and that there it's a multifactorial complex sort of situation. ⁓ but I was so struck recently when I heard Ryan talking about his approach to remediation, which was much more preventative and much less much more proactive. And instead of waiting for somebody to fall in their face, it was what could We do to help learners succeed and all the components that we know are so important about efficacy and confidence and performance and learning and motivation. Ryan was doing on the front end. And I thought, well, we'd need a whole lot less of this remediation if more of us were doing in our program systematically for all learners what Ryan has already figured out how to do. And so then I thought it that idea about take appropriate measure. might even have less stigma to your point, Ginger, about like people being concerned about being on a remediation plan. It's the same way an employee gets concerned about a plan for improvement. ⁓ we could have less of that if there were more setting folks up for success. And that's why I got so excited about what Ryan's doing.

Hilary: ⁓ I need to just say something that came to me that I don't think I've ever thought of. That ⁓ one of the things I remember when I s joined the fire department from ⁓ my previous career as a high school teacher was ⁓ tremendous anxiety, fear, and ⁓ wide eyed unknowing ignorance. Like I I I really didn't know what I was getting into and I didn't understand the culture or anything, right? So that was just ⁓ stress inducing and anxiety inducing Ryan, as you just described. But I had a little bit of experience as a teacher because when you're learning how to be a teacher, you're observed and people watch you and judge you and evaluate you as you're learning how to be a teacher, and they often record you. So even back in the day they would bring in the big camera and put it in the back of the classroom and you'd watch yourself in the classroom, which is terrifying. No one likes that. And and then when I was watched in the sim lab or on a call with my preceptor or in front of, you know, 10 grown humans who have done it for much longer than I and a family and a scared patient and all of that. ⁓ how do we even prepare people for that job? Right. And ⁓ I think I'm just having an epiphany now about the ⁓ extraordinary ⁓ situation that we're placing humans in as adult learners when they become decide to become EMS clinicians or public safety personnel where they're ⁓ in this ⁓ scenario of being watched and judged and classified and remediated and measured.

Ginger Locke: Ryan, you were talking about PTSD and I was curious ⁓ if that is PTSD from their learning experience or from the clinical, you know, cases, actual calls that they're running, or were you able to sort out ⁓ when you were doing your investigation, like what what are you talking about when you were talking about PTSD?

Ryan Batenhorst: So when I thought just like any good researcher, you already think you know what the results are gonna be. And ⁓ I definitely found out that the answer to your question is yes, ⁓ all of the above. So there's so many things I I didn't think about that would be so potentially stress inducing. Now naturally, you know, the calls I go on when especially if these are sixteen, seventeen, eighteen, twenty year old kids, as I would call them, we're seeing things that are pretty traumatic. However, again, I would be remiss if I didn't say this again, but the fact that they're being evaluated is another big stressor. We kinda don't really think about what's going on outside in their life before they even come to school, which is a a huge part. You know, if it doesn't matter what you see in your clinical rotations, if you're having trouble paying your, you know, electric bill, you Your threshold is already lowered. So that is another thing. Collaborative environments where you're with the fire department and then you go to the ER and then you are around physicians. Just that sort of ⁓ interdisciplinary thing is another issue for them that they don't understand really how to do. So if you know, if your program doesn't we have at where I'm at, we have a huge focus on interdisciplinary learning. And at first I was like, Why is this such a big deal? And then I find out that my students are having trouble with it. Whenever I really thought of it that it could be traumatic so ⁓ or at least stressful for them. So lots of that is is a big part of it. We we actually even put together sort of a peer support group where we'd sit down and talk about calls and things like that and talk about lab and they would always bring up, you know, I'm just having trouble because I I I I don't have enough money to work and go to school and all this other stuff. So there that's a big foundational part that I don't think we take ⁓ so much consideration in as we send them through what is usually a very rigorous paramedic program. So that was very interesting to me, all of the things that were stressful to them.

Ginger Locke: Heather.

Heather: Was struck hearing Ryan talk about the peer support group and how learners were really bringing up cumulative stress or everyday stressors. They weren't really talking about the critical calls that they were going on. It was really how do I handle life on top of or underneath what is happening at school? And I remember when I used to teach about ⁓ wellness topics or stress management in the fire service law enforcement EMS. And I would give people a blank piece of paper and ask them to draw, I would put the word stress. up on the front and say draw what that means to you, draw the what represents this word to you. And 99 out of 100 times they were it was time, money, family, traffic. ⁓ very occasionally would it be ⁓ an actual fire or a pediatric call or something that we would consider a critical incident. Almost always it was cumulative stress. And I think it underscores Ryan's point about we can't forget about the really taking care of the human first before we expect any kind of learning or performance to happen.

Ginger Locke: Yeah, and just to bring this back to remediation, that's like a great foundation for imagining the student, right? And the last word they want to hear is remediation or to get this s kind of experience or knowledge that they're in a high stakes scenario or something that's going to have, you know, some type of permanent pro problem that they can't overcome. And so, ⁓ Heather, you're talking about that Ryan had a framework, I think, or maybe you referenced a framework where you try to peel back the onion and figure out like what what are the layers, what is the cause of this performance gap or knowledge gap?

Heather: Yeah, and if you're not quite scared, those are taken over here. Yeah, that's right. I use I call it like ⁓ the layers of the onion, pulling back the layers of the onion, or you might also refer it to it as the last known well time. And so it's sort of when it when you're trying to solve what is going on and it gets complex in internship or when they're, you know, do doing a lot of have a lot of responsibility when the learner has a lot of responsibility. This could be when you're in the part of the program that is high fidelity sim or in internship, but when you're thinking about when they're trying to do a lot of things. It gets very difficult to sort of sort out: is this a knowledge problem? Is it a performance problem? Is it happening because of the environment? So the framework that I use is KMO or Knowledge Motivation Organizational Culture. And when we think about those things, just remember that knowledge might not just be a learner knowledge problem. It could be. And I was visiting with Ginger about this earlier. I said sometimes I feel like knowledge problems often get best solved at the school. That might be a time where it is appropriate to bring the learner back because we often are the experts at helping them solve knowledge problems and we have the best resources to do that at the school because we have all the PowerPoints, we have all the books, we have all the lessons, we have all the sim equipment. So if you discover that there really is a deficit that somehow this learner got past all of your exams, all of your tests, maybe they weren't using the right learning strategies. They were cramming and they could perform on the test, but now it has evaporated. They can't access it when they need it, that sort of thing. It's just not there. And you do need to fill a knowledge gap. I often find that we at the school are sort of better equipped to fill that gap than asking the preceptor to do so while they're trying to take good care of patients and also sort out what exactly is this gap and what it were you actually taught. Because of course learners are like, I never learned that. And then they're calling the school going, did you really not teach them pharmacology? And you're like, please. ⁓ so you have that whole thing to sort out. But sometimes it's also a preceptor knowledge gap about what is perhaps a current policy, or maybe they missed an update and they might be out of date on their knowledge, their medical knowledge. And sometimes that requires me to insert myself and be like, ⁓ so we're still operating on 2014 guidelines. Okay. ⁓ here's a little update. ⁓ so it's sometimes it's that, and it also might be a preceptor knowledge gap in terms of learning and motivation strategies, like how do they approach this? learner kind of thing. But moving forward then to motivation, when I think about motivation issues, choice, persistence, effort, those are the three indices of motivation. So we start thinking about is this an efficacy issue? do we need to reinforce mastery experience? Where have they done something like this before? And sim is probably the answer. Like you've they did a ton of stuff to meet their matrix of competencies before they left. So you have relevant examples to help them see like this isn't you've not ev it's not like you've never seen this before. You have when that slide carousel spins around and drops down something in place, it might feel like it's an outline or a sketch, but you actually have seen this before and we're kind of reminding them about those intentional learning moments that we had in the controlled setting of class and how well they did and that they were able to handle it. And if not Vicarious learning is the next best one. So who else in class, or were they on a team? Maybe they weren't leading that call, but they were on a team when their team had a successful learning event like that, or they've already had a call earlier in the internship that was like that. And the other is social persuasion when we're building efficacy. So it's encouragement. And you know, it's sort of Mark Twain, I think, who said, I I can live on a on two months on a good compliment. You know, so like don't be stingy with praise when it is due. ⁓ so those are some things, but also expectations for success. ⁓ like do they think they can do it? And do they believe you that you believe they can do it? And probably more importantly, do they believe the preceptor can do it? you know, the do they believe that the preceptor thinks they can do it? Or are they getting it getting messages from the preceptor like, maybe you're not cut out for this? ⁓ maybe this isn't just, you know, maybe this isn't right for you. I mean, sometimes we get those messages for folks who are an army ranger, an Olympic athlete, ⁓ I mean, high performing people who clearly likely can do this, but we need to figure out like what is causing the problem right now. Bunch more stuff in in motivation there, but I'm gonna move to org culture just so I don't take up too much time. The last one is ⁓ organizational culture. And when I say organization, it certainly could be the department or the agency or the hospital they're at. ⁓ where they're writing or where they're doing clinical, but it also could just be the shift, the station, the crew. I mean, it could be something as micro system as that, where there's some sort of conflict. And one of the first things I want to see when I come out is where's the intern sleeping? Where are you studying? Where do you spend your time? Are they getting integrated? And are there weird rules? Like you have to be there at five thirty, even though shift change is not till seven. Okay. What are we doing? And are are you allowed to sit at the table to eat? And are they, you know, are the is there an environment that says this is this is a welcoming positive learning environment? Or was the message when they got there, we have an intern? nobody told us and it's clear that that in turn hasn't been welcome from the beginning. Of course those things are going to affect learning and motivation. And so some of what we're seeing in terms of performance problem might not actually be a knowledge gap or something like that. We it might be an environmental issue that we can then address. The big part about trying to figure out if it's KMO is just making sure that we're applying the right solutions to the actual problem and not putting wrong solutions on something that is not actually the problem.

Hilary: If you take nothing else away, that acronym is so helpful, Heather. I think I've heard you talk about it before, but I'm so glad we captured it here. Thank you for sharing such a a great, not algorithm, but a great ⁓ approach to ⁓ understanding the being objective about what's happening. It reminds me of a little bit about when I was teaching community paramedicine and we were talking about motivational interviewing and talking to patients and and asking them to participate in their own care and shared decisions. making and one of the things we referenced was a book that Oprah had written, co-written with a ⁓ I think a psychologist, ⁓ called What Happened to You. And it's less about saying What's wrong with you or why did you screw up and instead having ⁓ I always try to say this anytime I'm in the presence of ginger or Maya, unconditional positive regard for our humans, for our students who are in front of us and know that they're trying as hard as they can and they don't want to do a bad job and that there might be something going on. And ⁓ oftentimes there is. ⁓ and if we say, Are you okay? and that's how we start, ⁓ it's gonna be ⁓ a lot more revealing than if we ⁓ assume malice.

Ryan Batenhorst: I say one thing to that quick. ⁓ it's pretty it's a lot more abbreviated than what Heather just said, but ⁓ it's kind of on the same lines that I talked to our faculty about. I said, you know, when I'm trying to introduce them to this thought of remediation being not so punitive or feeling that way, is I'm like I always say, think about behavior and performance as data, not character and preparation. Because if you can't you if you're stuck in your sympathetic nervous response, you're gonna have a lot of hard ti you're gonna have a hard time ⁓ retaining information or anything. So let's work really hard to keep our students out of their sympathetic nervous response and look at behavior as a pattern and as data rather than what's going on at this moment. And they always kinda look at me like Well, that's kinda deep. Well but think about it. And it matters. So

Ginger Locke: Yeah, it is data. It it's the outcome of the system, right? It's like you have this whole system, all these all millions of parts and pieces, is like Heather was saying, like there's all these things to look at, almost like differential diagnosis. Yes, th their knowledge or their performance is the end outcome, but ⁓ what all happened upstream and what's happening around them in their environment.

Ryan Batenhorst: First.

Ginger Locke: You mentioned ⁓ earlier that, you know, we we say like, ⁓ the lab is a safe place ⁓ to fail, but are we really creating that? Any any tangible takeaways, anything that you can think of that you specifically do or would hope is being done in your labs to communicate that rather than just say the words that it's actually playing out ⁓ in practice?

Ryan Batenhorst: Well, for me, another example I I give is like think about taking a baby and that can crawl and making them stand up and say, All right, I need you to stand up and then let go. They're gonna fall and they're just gonna cry because it's like I can't stand up. Well, okay, well how how do how did all we how did we all figure out how to stand up then? You know, and I think we as educators are in that place with students that are we're trying to teach them to stand and ultimately we want them to be able to walk when they leave. But I think we get so you know, like, hey, if you're not a pro athlete, by the time you leave here, you're never gonna make this profession or be this profession. But yet let's let's focus on I mean, when you don't know what else to do but sit there and cry because you c I I don't know how to crawl very well yet, let alone stand. So, you know, let's look at different ways to do that and and to get that in small biteable, you know, chunks, if you will. I I'd like to if you tell them what to expect and what is your expectation and w what is it that we want you to know at the end. A lot of people think that's sort of cheating. If you give them what they're supposed to know, they're never how that you know, they're not gonna be able to be prepared for everything in the field. Well, we're not in the field yet. We're still trying to learn that. So I I like to be as transparent as possible with students as we go through skills and that sort of thing so that they know what to expect and we keep them out of their sympathetic nervous response. I could bring that back to everything, unfortunately, I guess. So I don't know i if that answered your question completely. That's kind of where I'm at.

Ginger Locke: It did. It did. And another one I had was if if we're talking about remediation, would a student in your program know like of remediation is happening? Or do they think it's just part of the education? Like is there a piece of paper that says this is our remediation plan or is it what does that look like? Like if a preceptor were to say, you know, they need to go back to school and work on XYZ reading E K Gs or whatever that might be, is it Yeah, is it a f is it formalized or named?

Ryan Batenhorst: Well as a site visitor, of course it's formalized a name. but but y I I I think our students would know when they're being remediated, but they're also don't know when they're always being remediated because we're always looking at everything as to what how they perform there. Did did did we think that they were really prepared or we were ready? For them to be evaluated yet? Even was anyone really on the same page here? And even with taking exams, a lot of our exams are creating scenarios and looking at scenarios that have issues with them, because you know, they're gonna use AI for different things. I want them to be able to identify issues as well as create things as well. So ⁓ I think doing a scenario that's an exam where they write out scenarios and have all the pathophysiology involved and the physiology, I think they're being remediated right through that. Whether, you know, 'cause I'm now I know where we're lacking from ⁓ educators as to what they're missing in creating a scenario. They don't just have to pick a a multiple choice to item. So

Hilary: g it's like you're getting the information that is lacking from the beginning so that you can anticipate the need for remediation ⁓ instead of until they fail and then saying, Oops, did that wrong, now I gotta go back and reteach it and spend more time with them ⁓ that ⁓ be fraught with sympathetic nervous response and instead ⁓ understanding where gaps are from the beginning, ⁓ so that the space is safer throughout.

Ryan Batenhorst: That's a good point. Good. Well said.

Ginger Locke: love to hear your thoughts on this. One of the things we do with remediation, ⁓ again, with the skills stuff, is we will bring in a third party. So it's not the lead instructor, it's not the student, it's it's like it's actually what we call the mentor. And so this person is like someone by definition we've established like they are your teammate, right? Is still professor learner or teacher learner ⁓ setup, but it's they're your coach. They're on your on your sideline with you. ⁓ in that third party, they kind of talk to the student like, Where you think's going on? You know, where do you think your deficits are? And then the the educator that saw the deficiency or area that needs growth, what do they what do they see? ⁓ and then ⁓ maybe simulating it or doing something in lab or doing further kind of diagnostic stuff to figure out where is the rub here. ⁓ and I think that third party, that neutral party has been r really big for us because it's Just a fresh set of eyes almost. It's almost like an expert consult in a way to like bring in someone else and like that's gonna collect all that data you were referencing earlier.

Ryan Batenhorst: ⁓ no I think it I think it is a good question though that you say if you bring in another person, I think you're creating a culture that's making it okay to ask for help and to ask someone else's opinion. I think I don't know about you guys, but when I went to paramedic school like We're supposed to know everything about everything. I mean every pediatric dose, every but yet we know we continue to make pediatric dosage errors because we it's a it's a high fre high frequency, low occurrence skill. So if we create a culture that it's okay to ha ask other people's opinions and have other people watch and say, Hey, how could I have done this better? And what's your thoughts? I think it creates a culture of interdisciplinary ⁓ practice. I think you create a better clinician at the end. I think you have remediation happening r live the whole time. And all of a sudden it doesn't feel punitive at all. It's like we're a group here and it feels safe and it feels and I think ultimately the patient has the the outcome that's but that's better. So my thoughts. Heather raised her hand.

Heather: I was just thinking about this creating a learning culture and I think in hearing some of the things that you've been doing in your capstone course while they're in internship but zooming in to meet together to talk about some of these challenges, whether it's an ethical issue, a leadership issue, sometimes that they s had personally when they were trying to lead calls, but also something that they witnessed that felt icky to them or that surprise to them or what have you and write about it. Then bring it for discussion. Those pieces I think are really helping with ⁓ these sort of what would I do differently next time? Which is of course the purpose and power of reflection, you know, that whether you're using a Gibbs or a Miller cycle of reflection, it the outcome is always would you do anything differently next time? How do you think about this? How do you frame it? What happened there? How much of that do you own? Was there anything? Was there a moment in which you could or should Have spoken up, changed your behavior, done something. But all that said, what did you learn? And so what would you do differently next time? And then while you were talking, it was reminding me, thinking about this: like, where where does learning culture come from? And Dan Batesy and I, many of you are familiar with Dan and I were partners on the ambulance in New York. ⁓ we worked together when we were very young paramedics. And we were trained in different places. We went to paramedical in very different places, but then came together and but had this sort of learning culture. So we would bring a patient into the hospital, stay in and sort of see what everybody was saying, look at the labs, look at the x-ray. We didn't really know how to read the x-ray yet, but we were just picking up little nuggets, right? From the ear. And then when we would we were in a system where you would often transport back to one of those receiving facilities later in the day, and we would want to know like how did what happened? And sometimes we would Set a learning goal at the beginning of the shift. What do we want to learn today? Who intentionally are we going to seek out in the hospital to teach us something we didn't know? And I really feel like that atmosphere, that learning culture in the cab of our ambulance went a long way for both of us in our careers, but also for the interns who experienced us, who had us as preceptors along the way.

Hilary: That's that's a culture of lifelong learning, right? That you never stop learning and that it's safe to ⁓ talk to each other. Heather taught me ⁓ once at a conference that she and ⁓ some of her friends and colleagues would sit in the audience and give ⁓ each other tips on their speaking ⁓ and say the things that they did well and say the things that they thought they could do better. And I remember just thinking, that's so vulnerable and amazing. And will you give me those tips? I wanted them so bad. people really yearn for feedback.

Heather: Mm. I think. I just told Ricky that I was in Michael Caduce's session a week or so ago, two weeks ago at ⁓ EMS Live and ⁓ I said, ⁓ I gave Caduce some feedback and he said, Did he ask for that feedback or did you give it unsolicited? And I laughed and said, No, no, he asked for some and he's like, Because you have this habit of giving people feedback whether they want it or not. So ⁓ it tickled me, but no, he really did ask for it though.

Hilary: Yes, yes, I promise. Yeah, Ginger Ginger has taught me that you gotta be ready for feedback, right? You gotta make sure the other person is ready, I should say, before you give the

Ginger Locke: ⁓ Heather, question for you. Can you you use this phrase the other day, so c can you tell me more about what you mean when you're talking about dose dependent control during internship? Like what would you say to preceptors who think it's too slow?

Heather: Yes. Well, ⁓ let me define dose dependent first and then I'll tell you what I would say to preceptors who think it's too slow. I think our job as educators and preceptors is to manage this high cognitive load environment until some elements of the whatever they're doing, the skill, the sim, the internship, have been automated so that they don't take up so much cognitive load, right? That's one of our strategies to manage cognitive load is to automate things. But automation takes practice. Like you have to do something over and over. Over and over again, just like driving a car. When you started driving a car, remember you used to where you put your hands, checking the mirrors, how to manage the clutch, like all of that took all of your attention. Now, I mean. You you don't think about any of those things and you can talk on the phone and you can take a sip of your beverage. Not that you would do any of those while you're driving, but you could if you wanted to, because you've automated those behaviors. So thinking about the preceptor or the school in terms of dose-dependent means you're only allowing the intern to do the things that they have demonstrated they can do or are working on right now. So I whether you call them stages or phases or what have you, you're sort of doling out responses. In measured chunks in a way that they can handle those. So the beginning, you know, whatever, three to five shifts, they might be responsible for scene management and the primary and turn around and report those findings. That's it. That's all they're doing. And everybody's gonna go, ⁓ I want to see if they can do everything. And that's exactly what happens: they show up and they go, You wanna show us what you got? You wanna give it a try? The intern has no choice but to say, Yes, of course. I'll give it a try. And then they fall flat on their face. Efficacy is low. And then you are now as the preceptor going, ⁓ my gosh, what a disaster I've got here. But of course they were gonna fail. We just asked them to do all the things, right? There's a lot of things involved in here. Instead, reel that back and dole out the dose. Make it a controlled dose of what you expected them to be able to manage. And after they've shown you that repeatedly, and now they have the flow. ⁓ Of how it's supposed to go in your department, at in your battalion, on your shift, in your area, whatever the context is, that will some of that will automate. It won't be so high cognitive load. And now you can add additional responsibility. In that next phase that might be another five shifts, now you can add history of present illness, past medical history, and delegation of all the things that need to happen, ⁓ vitals, oxygen monitor, all of that. And so they do the first part and now you've added this next piece. When there is a performance bobble. repeal the last thing that you asked them to do. Repeal the last things that you added on. It will likely correct itself almost immediately. And then you kind of know what was the problem. It was the extra stuff you added on. So okay. So take some of that away, get a few calls under their belt where they build that confidence back up, like, whew, I'm not a total disaster. I can do this. And they can add on the next couple of things and and so so it goes. And you sort of build that way. Now, I often preceptors will say, ⁓ it's too slow. They'll never get through the whole thing and whatever amount of shifts that you have or hours that you're allowed. And I would say that slow is smooth and smooth is fast. And also less frustrating for you. It's less hassle. It's less paperwork. It's less documentation. It's less meetings with me. ⁓ let's face it, you I will come less often to the station if you're having fewer problems with the interns. So ⁓ it all of this is better for everybody. Everybody wins when you use this sort of dose dependent. And really, people do at the slope of learning is much faster. Why? Because it builds efficacy, they feel like they can do it, confidence is competence, and competence also breeds confidence. So all of those things work together in your favor, and you get all these things done in whatever the minimum time was. whether was twenty shifts or four hundred and eighty hours or whatever it is in in your system.

Ginger Locke: Well now I know what to say when they they say this is too slow. I'll say I have a podcast for you to listen to. Ryan, any any thoughts there?

Ryan Batenhorst: Yeah, so I have the same sort of thought process from the classroom. So I teach cardiology or electrophysiology, whatever you want to call it today. And I've had faculty like be nearly combative about this because my class, I want to teach them how to read an EKG. That is all. I don't want to have them treat it. I don't want to have them do They don't need to know what amioderone is if they don't know what a P wave is. So we focus on one rhythm a day. And today we're going to learn about sinus rhythms. Next week we'll or next class we'll learn about atrial rhythms. And that is all. And when we're done, that's it for today. And I I don't know how many times I've had faculty say, ⁓ my, that's it. Like, what does that take you? Ten minutes? No, it takes hours. Cause then we're going to practice them. And then until this is Fine. And you know what? I always wondered how when I first started this, how why they could never grasp junctional rhythms. And it was because they learned sinus and atrial the same day. They had sinus down, we took a break, come back and did atrial, now the whole thing's a mess. Because their cognitive overload light is on, not beeping, but on. And then junctional rhythm, they Like I I I don't even know what flutter waves are and now you're telling me this doesn't even have a P wave? So ⁓ I learned to slow it down just like you said, Heather. ⁓ slow it down and let's focus on this today and that's it. And then go home and spend ten minutes a day. Don't spend two hours every day, just ten minutes. Make it normal. And now I don't have problems with people understanding even heart blocks because we just they're it's four rhythms. It's not Let's focus on just that and really foc again. Here we go again, Ryan. Sympathetic nervous response. Keep ⁓ out of that. Because all of a sudden they're like, ⁓ my God, how will I ever know this? And everyone this is ACLS. ⁓ my god, I can't I'll never get this. Well, if you just have to figure out what a P wave is today, well then it's manageable. So when you said that about I was like, ⁓ my gosh, cardiology, I have to fight about this all the time. They can learn about medications and treatments in the medical section. We're just learning about heart rhythm too.

Hilary: Reminds me of ⁓ sports and all the things that we would do as an athlete or a beginning athlete that we wouldn't that we would find ridiculous if we said, all right, ⁓ you just learned how to put on your skis. Now I need you to go jump off the mogul and do a 360. No, first you need to learn how to turn. ⁓ and we're gonna work on turning for a very long time before we send you off of a mogul. ⁓ and so why isn't learning ⁓ out of a book that way? It it should be. I also love the ⁓ axioms here like the ⁓ s you know s ⁓ slow is smooth, smooth is fast. I can hear all of my preceptors with their little quirks, you know. ⁓ one of my well I I used to I could never plug something in, I can't remember what it was on the monitor and my preceptor would say, finesse, not force. ⁓ and I I could hear him saying that all the time. ⁓ those are fun. Those are fun things to remember because they your brain does go back to them. at at those points. Ginger, what's yours? Do you have do you have any funny statements from being on the truck or in the classroom?

Ginger Locke: Both of those that you just said I use regularly in the lab. ⁓ let's see. Let me think. Gimme gimme ten seconds. I feel you all looking at me.

Ryan Batenhorst: Yeah.

Ginger Locke: I say be here now a lot and that's kinda corny. But I I'll tell them just be here now 'cause they'll get so ahead of themselves and like this ⁓ activated sympathetic nervous system. Like they're like, ⁓ it's a like we're in week four or five right now of, you know, the whole semester and they're already talking about do what should I go ahead and drop or like, you know, and and ⁓ just let's just do today, one step at a time. So I say be here now a lot.

Hilary: I love that. Ryan, your sympathetic nervous system reference again. I remember one of my interns when I ⁓ said to him on the way to the call, Yeah, you're just gonna run the whole thing today. Yeah, just run the whole thing, right? And it was a sick patient and I remember watching him and if I had slowed down slowed it down, it was almost like in slow mo. I remember watching him and he was completely hamstrung and flummoxed and had this look on his face and I could see the blood rise in his neck and then his face and then his brain. And I and I wish I had had a heart rate monitor on him because he was, you know, sinus tack immediately. And he couldn't say a word. He didn't say anything to the patient. And when of course when we debriefed, he said, I completely froze because I was not here now. And I was thinking about all the things I was gonna have to do. ⁓ and I apologized to him and that was terrible. That was a terrible I mean it was good that I learned that and didn't do it again, but that was a terrible way to treat a a new learner. Well, I think we ⁓ are ready for one of my favorite parts of our podcast, which is when we get the the nitty-gritty advice and the what can an educator do tomorrow ⁓ to put into practice some of these amazing philosophies. So ⁓ no pressure. This is a big question, but ⁓ but it really boils down to doing ⁓ maybe just a few things. ⁓ Especially for those educators, Ryan and Heather, who might not have any say in a curriculum redesign or a program redesign, but who are still fighting the good fight in the classroom every day and wanting to bring the best to their students and help them succeed? What would you say to them in terms of kind of thinking about remediation, best approaches? What helped you when you were ⁓ really having these ⁓ different thoughts about how to help struggling learners? Ryan, can we start with you?

Ryan Batenhorst: Sure. ⁓ I think the biggest way that I would sort of end this would say that, you know, students don't need less rigor. ⁓ I think a lot of people think that remediation or making this trauma informed curriculum is lessening the rigor. And that is not the case at all. In fact, I think I would argue that the rigor is more ultimately. But I think they need rigor that is survivable. So and what I mean by that is I think that the a graduate who learned in an environment where growth was possible will show up differently for a patient ⁓ than one who learned to survive throughout their program. So I think that if if if they were focused on, you know, ways to care for the whole per patient I often say that if we as paramedics can learn well so I I don't mean to ruin this thought, but we're in the college of nursing and that is bumpy at times. And I think that what I say with nurses care for people and paramedics care for patients. And I think if we can be better at caring for the whole person, not just the patient, that will be better. better clinicians at the in the long run. And I think that happens through enhancing rigor that is manageable and not survivable.

Hilary: Nice words. Thank you. Heather?

Heather: ⁓ that was really beautiful. Thank you, Ryan. I one wonder if I could just offer one other practical suggestion before I go to advice, and that is around trying to figure out if it's a learner preceptor or environmental issue. I do think that this gives people trouble and trying to like sort that out. And these are very practical kinds of ideas. Like, ⁓ so something I ask myself is: has the preceptor tried anything yet? Like, what is the preceptor doing to try to solve this problem before? They got me or the school involved. Like, are they giving quality feedback? Is there regular few formative feedback after every call? Are they up to date on their documentation? Because if we're three or four or five shifts behind on getting the daily run reports or the daily however it works in your system, but usually there's some sort of daily evaluation. If if the learner doesn't have documented feedback that they can read and go home and work on and see all day there was probably verbal diarrhea of feedback. So the the point of that daily evaluation is to really prioritize what needs to be fixed before you come back tomorrow or next shift. And when the learner is three preceptor is several shifts behind in giving that to the learner, that's problematic and that goes in my you know brain as like, hmm, that's I'm leaning towards this could be an environment or a preceptor issue. Are they doing things like trying to rerun a call at the station? So let's say a call doesn't go very well. One of the most powerful fixes can be let's come back and fix it right now, not hope we get another one Two weeks from now, that was kind of like this call. Let's come back right now and try to set that call up to the best of our ability and have success where we could pause and go, that was the moment. That was the critical either decision making moment or behavioral moment in which this call went south. Let's fix that and smooth that over and rerun it so that the learner feels like, okay, now, now I understand what I should have done differently. And the next time we do get that call, whether it's the next run or tomorrow or two weeks from now I got it I can do it rather than just piling up all the fails like piling up all the disasters and is the preceptor like sort of practicing coaching conversing teaching rather than just saying you're disorganized you've got to fix that primary are they modeling are they demonstrating are they offering how they want to see it done are they ⁓ giving permission to use a job aid are they saying write it out and and put that you know have a handout have a little pocket card I'm allowed You to use that, like whatever. Are they coming up with solutions, or are they just you know saying what is not working? ⁓ so are they actually teaching? So, those are things that help me understand whether this might be a preceptor issue or a learner issue. And then when I think about learner responsibility, I'm wondering: is the learner managing all the distractions in their life? Like, have they had a conversation with their family about being needing to be fully present and not getting a bunch of phone calls during the day? And do they have support at home? And are they doing as minimal shifts as possible, not working a ton of overtime if that's possible? And those kinds of things. ⁓ have they communicated any personal things going on, like insecurities or instabilities with childcare or housing or food to either me or to the pre sector? Like so so that we all can come together as a village and help with that, because it is going to make it very difficult to learn and perform if we've got those actual issues, life issues happening. And then are they following up on like any home. Assignment. So if they've been asked to research this or take care of that, practice on the mannequin 10 times, write this up, prepare a drill. Are they doing those things? Are they coming to the school to borrow equipment? Or are they showing up every day with excuses? And so that might also show me: like, okay, we've got either it might be a motivation problem, it might be a performance problem, but it seems like the preceptors are doing their piece and this is. is a learner issue and we'll get to the bottom of what's driving the issue K ⁓ and O ⁓ knowledge motivation or or culture but that is it feels like the preceptors are doing what they're supposed to. So those are the pieces about like how do I tell the difference and kind of know where to go. ⁓ I'll pause and then say ⁓ what advice would I have and it is to change your mindset because it's the one thing you can control. So if if I had advice it would be change your mindset. Assume the best. In people. I like to say treat people as if they are what they ought to be, and then you help them become what they're capable of being. And that works for both learners and for preceptors. I believe that preceptors don't want to suck at their job. They don't want to be awful. Nobody wakes up every day and thinks, I'm just gonna be do this terribly. Probably if they're not being great preceptors, they've not been taught how to be great preceptors. They ⁓ in our system, eight hours, that's how much formal. training it requires to be a preceptor. And it's not a volunteer system. You get voluntole that you are getting an intern. And so it may be difficult to know how to solve this problem or what to do. And preceptors don't like feeling like they're bad at it either. So I assume that they would like tools in their toolbox. And for learners as well, learners need champions. They need support and patience and encouragement and solutions to problems, not just a laundry list of things they're doing wrong. So those are the things that we, the school as educators, we can control. And so that that's what my advice would be, change your mindset about what's creating this problem. And I think we can help everybody do their best work.

Hilary: So much better to live in that posity and optimism rather than negativity and ⁓ assuming that ⁓ humans are evil or bad or malicious. So ⁓ I appreciate that so much. This has been an incredible discussion. ⁓

Ginger Locke: I I loved hear I knew this was gonna be a great conversation. I loved hearing from both of you. Ryan talking about rigor. I think that's a really great message from a person who it sounds like you've done a lot of work and trying to understand, you know, ⁓

Hilary: Yeah. Yeah.

Ginger Locke: how to create psychologically safe environments and some people confuse that for softness and or academic lack you know being lax. ⁓ and so I think that's a a great message as we we leave is that rigor and and high standards actually are are comforting to learners. It's it's us showing to them that you know we we expect a lot from them. ⁓ and then anytime Heather is talking I just try to absorb it all. Thank you for everything that you both have shared.

Hilary: That's right. The the ⁓

Heather: Thank you for having us.

Hilary: Yeah, the the thing about becoming soft, the analogy that happened in my when I was a recruit was ⁓ we added in a day of yoga to our five day a week ⁓ CrossFit. So we stopped doing CrossFit five days a week, which really results in not being able to walk. ⁓ and ⁓ added a day of yoga and the entire department said, ⁓ they're going soft, they're treating them soft. But no, we were even more rigorous because look at all the things we were doing with our yoking our mind and body together to really understand. how to use our breath and and you know mindfulness and those types of things so ⁓ yeah i'm on board with ⁓ rigor getting higher as we give people more skill and ⁓ more skills and more use more evidence based methods to ⁓ to make it make us better clinicians thank you ryan and heather for being here and ⁓ as rob would say bye for now