CHAPTER 11 TEACHING POINTS: BECOMING A TRAINER EXERCISES

Challenging Training Situations

Purpose:

For each of the cases listed, please consider various ways that you might respond as a trainer. These exercises are meant to build your skill and adaptability to difficult clinical, behavioral, ethical, and clinic flow issues in training while keeping in mind the unintentional biases that enter into these situations.

For each of these scenarios, take a moment to consider the trainee’s background and perspectives in terms of how these might affect their response or communication. Also consider how your own identity, background, and biases may shape your assessment of the learner.

1. A start off with the values clarification exercises with a trainee who is shy but friendly. After a brief introduction, they tell you that they are struggling over whether or not to provide abortions. They feel it is hard to “help someone commit a sin.” They would feel better if only they could spend a lot of time with each patient to make sure that they thought abortion was the right decision for that patient. They especially wanted to avoid doing abortions for those who “use it as birth control”. The trainee states, “Clearly some patients make bad decisions for themselves, so I cannot trust that they are making the right decision about this.”
   • Review the Reproductive Justice framework and provide the trainee with resources.
   • Ask them about how their identity or background might affect their care for a patient in this situation (use your own identity as an example if you feel comfortable doing this).
   • Consider asking more about how they perceive sin and forgiveness, and how they weigh the relative difficulty of decisions in this realm.
   • Consider asking if they believe in a broader platform such as the importance of respecting patient autonomy, reduction of stigma, or a clinician’s duty to ensure a patient receives care.
   • Explore other scenarios that may evoke provider bias in relation to childbearing versus abortion (e.g. substance-use disorder, HIV/STI, sex work, unstable housing, poverty, disability (mental/intellectual/physical), refusal of blood transfusion, prior C-section refusal, etc). Explore biases in both directions (who is and who is not considered “deserving” of personal reproductive choices).
   • Do values clarification, some counseling observations, and then reassess.
   • It’s important to give them the space to work it through in a way that doesn’t adversely affect the care of your patients. Offer to help organize the continuation of this discussion with reproductive health trainers/ faculty.
   • We recommend evaluating trainees on their ability to render non-judgmental care. When trainees are unable to do so, we need to give an objective evaluation and let the residency faculty know what areas still need work.

Return To Exercises

2. A trainee frequently asks to leave early and expresses interest only in procedural skills. They tend to sit back and avoid saying much during counseling sessions. You notice toward the end of the day that they demonstrate even less engagement with patients of color.
   • Share your observations with the learner and engage them in self-reflection. For example, “I noticed you have expressed more interest in procedures compared to counseling. Can you tell me more about those priorities?” You may invite them to reflect on how that behavior might affect their care.
   • If the behavior continues, share your observation that their disinterest in counseling has been occurring more often with patients of color. Invite them to reflect on this observation and how their differential behavior could be interpreted by patients and staff.
   • Take opportunity to discuss an RJ framework and resources, such as Reproductive Justice Briefing Book.
   • Ask other trainers if they have had a similar experience with this learner.
   • Focus on basic expectations of the rotation.
   • Evaluate the trainee as objectively as possible.

Return To Exercises

3. You are assisting a trainee with a patient who desires a medication abortion. While reviewing the chart you notice that the patient’s listed pronouns are he/they. While observing the trainee counseling, you hear the trainee misgender the patient using she/her during the counseling session. You step in promptly and say, “Oops, so sorry we just got your pronouns wrong–can we confirm that you use he/they as I see here in the chart? Reflect on this encounter and how a trainer can model being an ally.
   • It is very important to acknowledge the misgendering in front of the patient while being supportive of the trainee. In this example, the trainer has modeled how to address misgendering with consideration and respect for both the patient and trainee. Being an ally means you correct the misgendering as soon as possible.
   • It is also important to attempt to find time to process this encounter with the trainee and highlight the importance of correcting the misgendering of patients. Invite the trainee to reflect on the encounter and your response to it. Invite the trainee to reflect on the patient’s experience and how this encounter will inform future patient interactions.
   • If the trainee has not yet brought up language, discuss the importance of using gender neutral and trauma informed language, as well as asking the patient from the onset of the visit what language they use when discussing reproductive anatomy.

Return To Exercises

4. You have a trainee joining you today at the clinic who is a Black woman. This is her first training day and she is very excited to begin her abortion training. She arrives a few minutes late to the huddle, her hair is down (which you have not seen before) and she seems a little frazzled. Just after she arrives the clinic manager leading the huddle, makes a comment about professionalism, specifically about tardiness and appropriate appearance. When the huddle is over the resident apologizes and explains that she was not able to find parking, but you note that her demeanor seems off for the remainder of the day. The following training day the resident still seems a little off and you note that her hair is again pulled back. How do you proceed?
   • Take a moment to contextualize the trainee within their overlapping identities and background (race, gender identity, any other background/identities that you are aware of) and how this might affect their role/response/communication.
   • Take a moment to ask yourself about your own reactions to this scenario. What makes you uncomfortable about this situation? Explore why you didn’t speak up in the moment? How does your identity play a part in your emotions? What assumptions might you be making?
   • Consider naming the microaggression that occurred in this situation. A 2021 publication: Imposter Syndrome? No. Just Racism argues that if Black students in science are experiencing feelings of alienation and imposterism in academia, the leadership of their institutions should recognize this as a sign of a racially hostile work environment.
   • Find an opportunity to sit down with the trainee and to carefully discuss your observations. Be as transparent as possible, making an effort to create a safe space in which the trainee has the power to decide whether or not they would like to discuss the situation, and verbally acknowledging how your own identity enters this space.
   • A restorative justice approach of centering the person who was harmed (the trainee) and exploring their goals could help inform how this plays out.

Return To Exercises

5. You are assisting a trainee in a procedure on a patient who shared during counseling that they are anxious about pain. During the dilation, the patient starts fidgeting and becomes noisier. The patient then becomes more active on the table, withdrawing from each cervical dilation by the trainee, and starts crying loudly in the middle of the dilation. How do you proceed?
   • Have the trainee pause during the procedure so you can assess the situation clinically and check in with the patient.
   • If the procedure seems safe, reinforce patient techniques of relaxation including breath, stabilizing their hips on the table, visualization, and talking them through the procedure. Assess whether more medication may be helpful for the patient.
   • Ask for an assistant to be more active or step into the doula role yourself. Make eye contact, hold the patient’s hands, breathe with the patient, let the patient choose music, or use guided meditation.
   • Sometimes getting the case done as quickly as possible is best for the patient and you may have to complete the procedure. Make this transition using a subtle signal so the patient doesn’t become alarmed.
   • Discuss the case after you finish, giving the trainee the first opportunity to assess and problem-solve, and explain why it was important if you needed to take over the case. Offer positive and then constructive feedback.

Return To Exercises

6. A somewhat new trainee continues to dilate beyond appropriate size and use too much pressure with their instruments. The trainee suddenly has a look of discomfort, and mentions quietly “I felt some obstruction and a slight tearing feeling.”
   • You need to assess what the trainee has done, making the transition as smooth as possible to preserve safety, and not to alarm the patient.
   • Subtly communicate the need to switch places.
   • Help reassure the patient if there is a change in their procedure/status.
   • Have a low threshold to use ultrasound guidance if available.
   • Consider the following preventative steps:
     • Practice with simulation models like the papaya, an IUD model, or even a trainer’s fisted hand as a pretend cervix if no other model is available.
     • Consider requiring comfort with a model BEFORE a real patient, to set a learner up for success during an actual procedure.
     • Introduce the trainee gradually to the procedure.
     • Prepare the trainee for “moments of caution” including the first dilation.
     • Work closely next to a trainee, assisting with your hands on theirs, verbalizing the moment of passing through the internal os to familiarize the learner.
   • Give feedback after the case, starting with the opportunity for self-assessment.
   • Recognize the trainee for having asked for help when feeling resistance, which contributed to the patient’s safety.
   • Give ideas for improvement, and steps to take that will help prevent or manage this challenge if it arises again.

Return To Exercises

7. The last couple days in your training clinic, you’ve noticed the clinic flow seems to be less than optimal, with longer patient waiting times, and your staff having to stay an hour longer each day this week. How might you approach this problem?

• • Acknowledge that training can slow down the clinic, and ask staff how you/trainee can help things move quicker. Offer doing things like helping with rooming patients, ultrasounds, giving pre-meds, and other ideas listed in Clinic Flow Strategies.
  • ‘Bookmark’ topics to finish reviewing at the end of the clinic day.
  • Use a debriefing session after clinic to ask staff to share their perspectives and brainstorm strategies for improvement. See Clinic flow strategies.
  • Help keep the case moving by helping with that or the next step (for example, if the trainee is struggling to put adequate pressure on the dilator, add the additional pressure on their hands, so they appreciate the appropriate pressure needed).
  • Consider agreeing ahead of time with the trainee on a time limit after which the trainer intervenes (for example, if the case is going on > 8-10 minutes). This can help to depersonalize trainer interventions, and ensure that concerns about flow are addressed in an ongoing way.
  • Consider having one trainer whose focus is the learner, and another provider whose focus is flow and keeping waiting times minimized.
  • Talk with the staff about the long-term benefits of training. Enlist their support in its success.