teaching tips to increase student engagement

Dr. Jacqueline Antonovich asked on November 16, 2019, what simple shifts in language improved her followers' teaching and there was a robust discussion that followed. I have copied and curated the responses based on the themes below. When concepts were repeated, I skipped over them. 

There is a lot for me to learn about teaching, and I'm grateful for these folks coming from diverse viewpoints for sharing their wisdom. 

(themes are underlined, quotes attributed to the author using @, all spelling and grammar is as it was posted, ~~ indicates a mini thread within the thread, accessed from Twitter.com on November 24, 2019, at 11:30am)

end of session and generally eliciting questions

• Last year, I switched from asking students, “Any questions?” to “What questions do you have for me?” And it’s made a world of difference. It’s got me wondering: what simple shifts in phrasing, wording, or questioning has helped your teaching? I'm really fond of the idea somewhere on this thread of asking, "What can I clarify? @jackiantonovich
• I asked them the questions. “What’s due this week?” “When is our next test?” Having students say it out loud helped remind them and I could correct misunderstandings. @maggiemchrist
• What sort of feedback would be helpful as you continue to work on this? @and_read
• In lectures: "Does anybody have anything to add?" Sounds simple, but it can open the door for a shy person to give an insightful response.@ASusanChandler
• Instead of asking for questions only, ask for comments and other thoughts on what’s been presented. Sometimes students learn new concepts more deeply by restating (and rehearsing aloud) their own understanding. @LiPurposeFe
• Instead of, "are there any questions" I now ask, "is there anything about which I have not been clear enough so that you will find success?". It has changed EVERYTHING. @lisaannevogt
• This is great! I’ve been trying to make an effort to stay away from “any questions” - the best I’ve found so far is “which part should I go over again?” Seems to have a slightly higher engagement rate bc it takes the onus off them to tell me I didnt explain a concept clearly. @oxidantshappen
• That’s a great idea! I also think saying, “can I clarify anything”, or “sometimes students find *** confusing, is everybody clear” or “was there anything you found particularly enlightening or interesting “ can elicit a question @AuntiK__
• I also find these phrases help me build rapport with students, especially during office hours and review sessions: “What questions can I answer for you?” and “How can I help?” It reminds students we are not adversaries. This seems obvious but some faculty do put up big barriers! @lpjhalfpint1018 ~~ Similarly (this is more a supervision context), I remember hearing somewhere that you should always avoid asking the question “WHY did you...”. A “why” question automatically puts people on the defensive. @TIRscienceblog
• I end every patient interview with “anything I should have asked and didn’t” @whitman_barbara
• “Who understands what I just said?” Instead of “who doesn’t understand?” If no one raises their hands I re-explain. If they’re too shy to say they do understand, they just get to understand better. If too shy to say they don’t, same. Seems more effective. @PersistentSeekr
• In@amandaripley's "The Unthinkable: Who Survives When Disaster Strikes And Why", a police trainer says that he got huge results when he switched from saying "if you don't do this you'll die" to "if you do this you will be safe". Our minds instinctively reach for safety. @jcrichman
• I like, "What can I clarify for you?" which has built in that definitely, something. And a clarification is less than a question, so it's safer/easier for the student. @ElaineLuther
• Share one of 4 things: 1. A question you have. 2. A question you think someone else might have. 3. Something that could use further exploration or clarity 4. A new insight you gained. 5. An interesting application of this concept. @ellementality
• I’ve started saying “I’ve explained it in a way that makes sense for my brain. Did it make sense for your brain? If not, tell me and I’ll find another way to explain it” @super_crazy_kd
• I pause lectures and tell students I need 2 questions from them before continuing. If no one has a question, sometimes students search through their notes to come up with something; a useful trick for review in situ. Sometimes slow, sometimes awkward. But always insightful. @MarrWalsh
• I actually spent a year writing and recording my lectures so the students can listen to it on their own time and I now use my “lecture” time to engage in class discussions, group work, presentations, etc. Not everyone can do this, I also produce a podcast, but it made a big diff. @realFootNotes
• An elementary school I toured did “raise hand” to answer the question thing but also had hand signals for things like “I agree”, “I disagree”, and then for students talking but struggling, a “I support you/am rooting for you/sending you energy” signal. Kids seemed super engaged. @OldPappyThomas ~~ I ask for thumbs up, down or sideways in front of the kid to indicate to me where they are comprehension wise. Used to ask for raised hands but then I noticed the peer pressure of raising hands so as not to seem stupid kicked in. This way I can gauge & differentiate. @HoganBio4Life
• On the first day of class, and again a few times during the term, I ask, what do you need from me? Am I giving you what you need to succeed? Usually opens a dialogue about all kinds of challenges. @_plainKate_
• "This reading brought many, many questions to my mind but I would like to start the discussion with the questions you have." This shows students that questioning is a natural part of reading, not a punishment, not an "assignment," but a normal and fun activity that scholars do. @MichaelSkyer ~~ This is a good shift. I tried that with authors we read ("pretend x was in the room: what would you ask them?") and it's helped a little on that front. @Dave_Parisi
• Similarly, in coaching, after asking an open-ended question, I wait people out longer than Regular Conversation would deem comfortable. Have to make ample space for the answer to come out. Everyone has to make themselves vulnerable for true communication & learning to happen. @FromPhDtoLife
• I also ask at the end of each session ‘What is one thing you have learnt today that you will take away with you?’ - love seeing people making the connection with a new piece of knowleding and how it links into their existing practice (I work with healthcare professionals). @mbishoph_uk
• 1-minute paper by @laz_inc : what is the most important thing you learned during this class? what questions do you still have? ~~ @reneeatsea call this “an exit slip” in her class
• My college juniors write an exit ticket about caring, commitment, or collaboration as future teachers. Examples: how will you apply today's activity in your future classroom? How did you prepare for class today? How were you inspired by a classmate today? @nosodoeo
• I’ll often have my students fill out an “exit card” so they can ask questions or write terms they would like further clarified next class. I have found that my students feel far more comfortable writing down questions than asking during the class session. @dianabottomley
• I ask my students "What questions do you think your classmates might have about this?" It helps the embarrassed ones speak up, because they don't have to worry that someone will think THEY don't know and judge them. @TangibleDaphne
• At the end of discussion: "OK, we've said this, this, this (summarizing points); now, what other perspectives have we missed?" Also instead of "anyQs?," "What else about this?" And "student hours" not office hours. I have a "presence" policy, not an abs.pol. (presence=engaged)@acoldiron1
• Asking “what surprised you” about a reading—low stakes, no correct answer, and often elicits fascinating insights. @ronitstahl
• This is actually something that's changing with online discussion forums if you have any online sections. Instead of having everyone answer the same question (yawn), having them pick something that stood out (good or bad) gets some really interesting response @NaomiRendina
• I've started asking, "What was the most confusing part about what I just said?" so that I'm working from the premise that I don't expect anyone to understand things immediately. @NiemannJanice
• “How do you want to apply what you’ve learned today? @synxiecbeta
• The biggest thing I have started doing is asking people how they’re feeling at the end of a training session; it can be so confronting to learn a new way of doing things, so I like how it encourages people to speak up and say they’re nervous or concerned so I know how to support @jamieschultgren
• I’ve started being intentional with think time and, most importantly, nobody is allowed to raise their hand until I say go. @ms_ostrich
• When a class or an audience falls silent, a feeling of shame or of being inept is so often involved; so, for quite some years now, I tend to ask: „Or, do you have a question from a completely different angle? Maybe one that seems too quirky or too ridiculous to ask?“Again and again, then the really intriguing and substantial questions are asked - and so often a really deep discussion often ensues. @mediumflow
• One thing I learned when at@haverfordedu - when you answer a students question, if you look at the whole class and not just them it makes them feel like everyone benefited from the answer and they'll keep asking if still confused @desikanarayanan
• I like to speak about what questions I used to have about the topic, and outline what my initial confusions were. Then I take a moment of silence which I call "a given moment to process what's on the board". Usually a student will speak up during this time.@boss_graph
• I’ll often start Q and A after student presentations by inviting students to say “one thing I liked about [my classmate’s] presentation is...”. This helps create an environment of building together instead of taking apart. @lopez_wd
• When working with primary sources, I often start with something low stakes, in a conversational way, like "what struck you about this?" "What did you notice?" Things that clearly have no right or correct answer, but that always seem to open the conversation to more. @LadyKateD

flipped classroom

• wrt flipped classroom and getting student buy in: The most effective way is to attach marks. A quick pre-class test on the pre-recorded lecture material is better and fairer than a participation mark. Mark each class out of 10, then give them their average as final mark. Put the test on your LMS with auto marking. @ClaireKaylock
• Getting students into the habit of asking questions is important. I tried to do this via assignment- For any reading they did, they should bring a question about it to class. @RobertLepenies ~~ I tried asking students to bring their own questions for discussion recently, but then what happened was that there were so many questions we didn't have time to discuss them @elinasilta ~~ Yes ! I collect them, put them in a hat and of there’s is time next class, we jointly answer them. I also document them and put them online - good to normalize that you will have more questions rather than fewer when you learn something! @RobertLepenies
• Great tip! I’ve switched from ‘what did you learn from the last lecture?’ to ‘did anyone find any points to be interesting or surprising?’. I’ve found that more students respond, and I get a better idea of how they understood the lecture @MissSusmiPatel
• I give an online students before every lecture day to make sure they did the reading and the last two questions are always "What was most confusing about this topic?" and "What was most interesting about this topic?" It helps me to focus the day's lecture/problems. @zoekatjean
• Oh two magical tricks I've stumbled on in 20 yrs HS teaching: 1. Giving students permission/ encouraging them to openly dislike what we read. It means, of course, that they're engaged & thinking-- I've all the time in the world for that.2. Graded, student-led discussions. Ahead of time, they write Q's for clarity & discussion + identify what they like & dislike. Volunteer student-facilitator takes over, & I get out of the way. Obvi, I'm still in the room, but they speak to each other as if I weren't. PURE MAGIC. @KathrynGuelcher

focusing attention where you want it

• Jacqueline, Great approach! I also sugeest - “This *will* be in the assessment. Everything I help you to learn will be in the assessment.” That should attract their attention and effort! PS You have to make it true. Tell us how it goes! @David_Baume
• Can you tell me how this aligns with your career goals? I taught medical informatics and research to undergrad and grad nursing students who weren't always thinking of what could be applied real world, not just in school. It really improved their focus. @refdeskfacepalm
• Asking ‘what else can I do to help you meet your goals?’ Makes it clear that I *want* my students to succeed and that I stand ready to help, but also reminds my students that I can’t do the learning for them. @CharkoudianLou
• Do you feel prepare to work on this on your own? What is the next step you’ll take when you’re working on this on your own?@amathers80

addressing individuals and pairs or patients for questions rather than the entire group

• I just give everyone Post-it notes, ask them to write down questions anonymously (one question per note, as many questions as they like), and put it in a box. Then I go through the box, pull out the questions, and begin answering them. Amazing how everyone engages with this! @Bhuva_at_UTS (she also notes that using an online portal for this like google docs made it easy for students to be unkind to each other rather than helping them)
• I ask people to write down one question on a notecard then find a partner; both try to answer each other's questions. If they can't, they bring it up front to me. @jasonmstokes
• I do workshops a lot, I make sure everyone has access to post it notes so they can write down questions/notes. Then I collect them up at the end. The conversation in a workshop is often more suited to extroverts so introverts get the ability to still input this way. @thinkfrippery
• “Turn to your neighbor for a minute, what’s your joint question?” Always always always always works Generally, I try to avoid open group discussions (made a lot of mistaken when I first taught). Instead, lots of breaks where individuals get to brainstorm by themselves or in small groups before „reporting back“. Results in more & different ideas + gives people confidence. Open group discussions rarely accomplish much: it’s the same people who speak (the usual suspects, usually trying to impress another or the professor). Any way to break this up is interesting: anonymous/written questions, group work, role play (in groups!), peer grading, etc @RobertLepenies~~ Yes! I use a Think-Pair-Share approach first, then I call the whole class back and ask, “Who can tell us something insightful that your partner said?” Students volunteer someone else’s ideas, which validates listening and collaboration, not individualism and competition. @ClassroomQuips
• I often start class with a question or prompt and have them talk to their neighbor about it. Then I ask “what did you talk about?” Instead of “what do you think?” Total game changer! @vwoodhull938
• I don’t teach but I run plenty of meetings, & one thing that helps *a lot* is asking people’s opinions *directly*, especially of women. Not “does anyone have any comments?”, but “Christina, what do you think?” And of less extroverted people, too. Similarly, tromping on people who interrupt so the speaker can finish expressing their thoughts. Not rudely, but: “Just a moment, Jim; I’d like to hear what Christina was saying and then get your input.” And it’s usually men who do the interrupting. @zack_flux
• When I respond to emails with questions, I close with, “Does this help?” so that if my answer missed part of what they are trying to figure out, it’s easy for them to ask for more information @TheTobstersMom
• When a student says "they said what I was going to say." I now say, that's okay, go ahead (as opposed to "okay / next." And what they say is never actually the same - they often build on it without realizing. @AJP_PhD
• I prime my audience by having them spend 60 seconds discussing what they learned and what I missed with their neighbors. I then ask them questions. makes a world of a difference. @thomasmagaldi
• I do a lot of teach backs with learners and with patients. “I want to make sure I did a good job explaining this in a way that makes sense. Can you tell me in your own words the highlights of what we just talked about?” If there’s a lack of understanding, then it’s my fault! @LPerrytheGeriMD
• I've tried the expression "do you think..." before I propose anything to my students & it does yield positive feedback: 1. It takes the authoritative aspect away. 2. It allows students to participate in the decision making. @OthmanOuaarb
• I did this with patients. You’re right. It does make a difference. I also ask “what can I do for you? I have time” instead of “is there anything I can do for you?” And I make sure to face them instead of facing the door/seeming like I’m on my way out. It matters @Krystigram

ditching “does that make sense"

• Instead of "Does that make sense?" or something similar (which just gets nodding heads), I changed to "Am I explaining this ok or do I need to clarify anything?" That shifts the pressure to me & helps struggling students feel safer saying what they don't understand. @theoriginaledi
• I’m working really hard on replacing “does that make sense?” To “what questions have I just created for you?” Difference is noticeable! @dutchpc99
• Somewhat relatedly, when I’ve responded to a question, I ask, “Have I answered the question that you asked?” It seems to do a better job of eliciting remaining confusion than the simpler “does that answer the question?” @lmgreen42
• In classrooms and at conferences, I switched from "Does that answer your question?" to "Does that respond to your question?" Got lots more followup and clarification with that. I think there's two things. First, an 'answer' implies more finality and authority on my part, which can shut down conversation. Second, for the questioner, 'response' often helps them rearticulate what they were really trying to get at. Makes it more of a two-way thing. @patrick_mj
• Stop using phrases like “if that makes sense” or “is everything clear?”. Even if the answer is no, students dont want to admit it in front of people. Switched to adding small comprehension tests via their phones to see if there are key points to reiterate. @JamesEBartlett

changing language and attitude to increase engagement

• Dropped a habit of “as we all know”. A colleague pointed out. We may not all know. @spartyRx
• “I’m grateful” instead of “Thank you”. Saw it on LinkedIn and it has made my efforts to show appreciation much more meaningful. @HubbsDr
• I always like that in French one asks “which is the problem?” Rather than “what is the problem?” It always implied to me that there were a finite number of problems, which I find reassuring. @pfmcdevitt
• I've been trying to refrain from "behavior management" and even "classroom management," instead focusing on "relationship management.” @BradleyBethel
• I’ve banned the word discussion and replaced it with conversation in my written and verbal communications. @darrinsunstrum
• “Would any groups benefit from 5 more minutes?” instead of “who needs more time?” @BreeTrisler ~~ I say "Who's still working?" and it makes a huge difference. @THEakilahbrown
• Not teaching, but I found changing "what can I do?" to "how can I be helpful?" to overwhelmed colleagues was useful . It helped us think less about something that just needed ticked off a list to what we should actually be focusing on to make progress, so I could be more useful. @Ms_Maladjusted
• My biggest thing (common in IGR/IGD spaces) is using “and” rather than “but” & asking students to try this too. “I hear you are struggling with this content, AND it is really important for us to understand as social workers.” “I hear you disagree, AND what she said is valid.@DrShannaK
• As a lecturer I often say “Please remember, I am here for you, you are not here for me. I am your resource, you are not my audience.” @UoDMHN
• It’s interesting when I take the “you” out. What kinds of questions come up when thinking about this? People ask, Well, someone might wonder about... They don’t wonder but someone might!@PracadAmy ~~ Ooh, I like that! "What questions might come up for somebody if they were hearing this". Thank you! This #teachingartist is gonna think about how to employ that! @DylanFresco
• Shifting from “show your work” to “record your thinking.” It gives Ss permission to communicate in any way that makes sense to them, and not assume that they should be showing a specific procedure or process.@NicoleBridge1
• I do the same to solicit questions. I teach statistics and if a student answers a question incorrectly I either ask how they arrived at that answer or, if I know what error they made, say, “that would be right if [explanation].” @s_ramach
• I used to challenge players to be the hardest worker. One of the kids rephrased it one day to 'Who's pushing themselves to their limits'. The intensity instantly rose and it stuck with me ever since@alike_no ~~ On that, I challenge the players with “Who’s the best player here?” Confident players all put their hand up, to which I challenge them to show it. Works very well with positive reinforcement (they all want to be the star, allows for development of less confident players as stars) @seanie_doyle
• I train new hires for a call center, and started addressing my classes as either "friends and colleagues" or "guys, gals, and non-binary pals." It shows up in my performance reviews as a sign of respect to the people I train. @keyguardactive
• I ask for a “Quiet room, please” when that’s what I want. I also say “a point your noses here” when I want to see everyone’s faces. @chaddavidpape

crowdsourcing data collection

• Instead of asking a student to support their claims with evidence, I ask the class "what would we need to know to determine whether that is true?" That way, the whole class is involved and we consider the topic more broadly. @Lara_Schwartz
• I have done seminars occasionally and the most successful thing I do is “who’s doing what right?” - instead of criticizing any online resource I visit several and point out what each one is doing right. The assumption is that everybody is doing at least something right
• I started emailing my students after class notes that say "thanks for your contributions in class today" or "thanks for asking that question. I think many students benefitted from us all talking about it." They speak up so much now we have to keep a cue. @voice_exit

Figuring out where the learners stand/getting feedback

• When I’m talking about something that I suspect is foundational, I ask students if they know the topic. When they all shake their heads I ask somebody to explain it. They often know the term but not the specifics. I teach leadership and end every class asking for feedback. When I get feedback, I say “Thank you, that’s good feedback.” I also do a midterm evaluation to ask what I should do more, less, and continue. When I receive the results, I present what I heard and what I’m going do. @dani_npe
• When asking for feedback on the class, I ask what "we" can do better, so it's clear the class is a group effort @sidersadapts
• I started asking students what certain words mean during our discussions. Just straightforward definitions. It’s been great bc sometimes not everyone knows. The low-stakes conversation helps open up other kinds of questions: now why would ___ be concerned/thinking about ___? @noahwblan
• When coaching project teams, having them shift from "Are there any risks on our project?" to "What do you think is the greatest risk that might cause this project to fail?" Teams get a lot more creative in identifying and mitigating risks early.@BradRubenstein
• At the end of workshops we ask for “popcorn feedback” - we solicit things the participants liked + didn’t (or wanted more of, ways we can do better, etc.). Every time we get thoughtful ideas for how to improve. Participants leave feeling empowered and that their opinions matter. @ mauanakealic

office hours

• I’ve started referring to office hours as “student hours” to make their purpose clearer. @angelacjenks ~~ Yes! I find that a lot of students - especially first-gen - don't necessarily have any reference point for "office hours", but calling them "drop-in time" has really boosted the number of my students who come and increased the kind of things they'll come talk to me about. @jason_brozek (this was supported by several others in the thread including students who would have appreciated the shift in language)
• I call them drop-in hours too, and I emphasize I keep a loaded snack drawer just for students. They are welcome to come have a cup of tea and snack and chat, or eat and run. So many of my students face #foodinsecurity @FourattCaitlin

when assignments are late

• Last year, I stumbled onto something helpful. I often email students who haven't submitted an assignment (and are earning late penalties). I used to ask "when will you be done?". Now I ask "how's it going, and how can I help?" Makes a world of difference in the responses. @jkhuggins
• When sending email reminding people to follow up or get me something I always write; “How can I help get this finished” or “is there anything you need from me to complete this?” @GeorgeMeade13
• This year after instructions on an assignment I’ve started asking the class, “Okay on a scale of 1-10 how comfortable do we feel” and it’s elicited WAY more conversation than “Any questions?” (I teach K-12, high school English specifically.) @RyanDrawsBirds
• I borrowed the "Sh*t Happens" policy for extensions from another academic on Twitter. My students love it (health/family deaths are separate)-- they know that I know that life gets messy & no ?s asked. I may use it myself! A clause added to my policy on deadlines--allows for one extension per student (up to a week), no questions asked- just email me that "sh*t happened". Medical excuses are separate. @DramaMen ~~ I also added this after seeing it on Twitter, and my students have been really happy. My syllabus lists an "oh shit clause" which students can invoke once per term at any time on any assignment for a no questions asked, no explanations necessary 3-day extension. @MelanieKiechle
• “Who disagrees?” instead of “does anyone disagree?”@AEOsworth
• From friend/colleague @HelenaZeweri : when discussing materials, esp dense stuff, ask your own questions about it (e.g., "Something I wondered when I read this was..." or "Something I found confusing was..."). Helps students see theory is hard & texts can/should be questioned.@kelizaw ~~ Yes! I also admit when I dont know something, which someone commented in my evals doesnt happen with their other profs. I'll have them look something up in real time if none of us know. No one knows everything (my husband would be shocked to hear me admit this) @DrMaryClary ~~Love the idea of showing your own vulnerability to encourage others to do the same #powerful @maunakealic

criticism

• Tip I got from a friend regard comments on essays: replacing “you” with “this essay” to frame criticisms. So saying “this essay loses focus near the end” instead of “you lose focus” - it reinforces that the essay is an object separate from a student’s selfhood. @profhajduk ~~ I do this with grading. Compliment the student, critique the paper. @JennRickert
• I got dramatically different results when I started writing, at the end of my comments on student essays, “In your next essay, I will especially be looking at your handling of [aspect that was weakest in this essay].” Students’ writing improved so much, so quickly. It completely eliminated the problem of students who “never caught on.” Pointing out what they should work on was one thing, but assuring them that I would LOOK FOR their work on that aspect was like magic. @khj5c
• I've come to appreciate the power of "yet". As in "this essay does a good job at __ but does not yet__." It reminds me to give feedback that invites students to view their writing/thinking as an ongoing process/puzzle & view themselves as empowered to shape what happens next @AmyHondo
• My Latin American History professor told me “don’t write the paper I want to read, write a paper you want to write” after I asked him what he was expecting. That phrase made me so happy. @NinaVzqz23
• Last year I started handing out mangoes for a “Meticulous Mango” award on each homework. It wasn’t for the most correct answers, just the most organized and easiest to follow. Let me emphasize that the right answer isn’t all I care about and that effort and organization matter. Plus, not everyone in class had eaten a #mango before, so we had to remedy that. What’s life without mangoes? @DMantartica ~~ I love incentives for good effort, I give my adult students stickers and let me tell ya, not a one has turned either down. @314UXHolly
• When designing assignments/projects for students, I'm trying to get rid of "musts" & "shoulds." If the students' work accomplishes the learning objectives, I shouldn't be overly concerned with how they presented it. @mountain_nerd
• Asking students for self assessments of assignments and discussions with empathetic brainstorms about how we can all do better and learn more going forward. @llmunro

presenting style

• Broke: "Can everyone hear me?" (If they can't, won't answer. If HOH/Deaf, might not want to out themselves) Bespoke: "How is the volume at the back?" (Repeat/Change settings until the response is positive)@topherendress

---

RESOURCES mentioned

ScalableLearning - video and metrics to prep for class

Doceri - to create pencasts

Choice Words - how our language affects our children’s learning

what to do when you get nothing but crickets (podcast) https://www.cultofpedagogy.com/crickets/

on person first language to increase engagement https://thebodyisnotanapology.com/magazine/i-am-disabled-on-identity-first-versus-people-first-language/

Pear Deck - create interactive presentations that allow anonymous student feedback in real time

What the SRPC wants struggling new doctors to know

Two of my colleagues have had rough years. They asked the online forum available through the Society of Rural Physicians of Canada for help. This is an organized version of what was said by many wise voices. It's also a sanitized version to make sure nothing is identifiable because all of these folks allowed themselves to be vulnerable. I honour that and appreciate what they have shared. If anyone wants to be named and credited, I'll happily edit this post. 

Philosophy

• it's normal to feel like we don't know everything in our first year of practice
• lack of confidence is preferable to over confidence, and safer
• expect moments of doubt, feeling inadequate and incapable
• medical training focuses on the criticism of our skills, it makes it difficult for us to trust ourselves
• "It's family medicine, you don't need to have a diagnosis, you just need a plan."
• you can bring patients back if you need or keep them in the ER to observe them, rural medicine gives us that flexibility
• you have nothing to prove to anyone but yourself and your patients, it's not a competition any more
• even if you are the only female
• even if you are the only minority
• perfection is the enemy of good - done is better than perfect
• being a rural doc isn't easy, but it is amazing
• allowing ourselves to be human makes us strong doctors for our patients
• listen to your heart about where you should be spending your time
• "at 72 ... I would say I'm glad I worked less not more."
• evidence changes constantly, it's ok to give yourself a break on not having everything memorized
• rural docs expect to have to sacrifice themselves for their practice - our patients and colleagues don't

Generalism

• just because family medicine is flexible doesn't mean we have to do all the things to be a good family doctor
• skills can be relearned
• there will always be something that you think you could be adding to your practice or missing from your community, let it go
• we need hands in rural Canada, these may be full or part time hands
• it's more important you are able to help with what you can, even at a reduced rate, than to get into a situation where you can't do anything at all
• being a generalist can mean different things to different people; pick the way you want to go;  reprise it as needed
• generalism is a very flexible field
• doing less rather than stopping something, means that your skills will keep up
• "there is no proven evidence based minimum number of times you do a procedure to be competent"

Practice Advice

• a part time practice is OK
• if you don't need an MD to do it, delegate it
• stop the pieces of your practice that cause you too much trouble
• money will come, don't let it drive your practice
• sometimes the reason we come to hate what we are doing because we are doing too much of it, try scaling back
• adapting what is considered to be "the way things are" to suit your needs is reasonable
• covering your practice during times of illness (yours or your loved one; mental or physical) is important, but spending time with your family getting healthy is much more important
• in Ontario, when you need time away, call Health Force Ontario to arrange a locum

Building your Village

• find a supportive group of colleagues that you can ask for advice
• we end up knowing as much as our specialist colleagues
• others will have dealt with what you are dealing with and be able to offer advice on getting through it
• discuss emotional, philosophical topics in a non - judgemental atmosphere
• have a mentor who represents where you want to go in your practice, someone at the same level who will understand how much things suck sometimes, and a mentee or learner who will remind you how far you've come and why you went into this crazy business in the first place
• look for your mentor outside of your practice group so they are able to offer advice without being personally invested in your choices
• know that once you are through your hard times, you will be an amazing resource to your colleagues
• "There is a special place in hell for women who don't defend other women." Secretary Albright
• the SRPC is there for you

Self Care

• the first 6 months of any new job are the hardest and put you at highest risk for burnout
• the entire first year is brutal, be kind to yourself and each other
• we won't always be on our A game, it's OK for us to get the help we need
• get your own family doctor and use them
• use your PHP
• you are allowed to let others care for you
• what an honour and sign of respect to your colleagues to accept their help
• you are not your own doctor, don't self diagnose, don't self medicate
• self care isn't selfish, caring for yourself is important
• taking time away for your health is forgiveable
• follow  your own advice and stick to a schedule that includes exercise, eating well, mindfulness
• see a counsellor
• do the non-medical things that you love (hockey, reading, playing hopscotch...)
• rest is not a 4 letter word (going to have to beg to differ on that one, but the sentiment is strong)
• self forgiveness is essential for self healing; forgive yourself for not being everything for everyone
• once a week go out on a date with your partner sans children
• don't use alcohol to make the day better
• arrange your house so it's easier to live in - big baskets for your bits and pieces can help

Parenting

• maternity leave can be hard on us, talk to those who have done it about what you can expect
• check out www.mommd.com
• lack of sleep affects our brains (babies, stress, work); make sleep a priority
• post partum depression is a real thing, respect it and yourself enough to ask for help
• letting your partner parent can be a blessing
• check out positive parenting
• trust your parenting skills
• "Babies don't need a lot of things - they need carrying and feeding and sleeping and diaper changing. And extra attention when they are sick."

Resources

• it's OK to not know things and have to look them up
• First 5 years of practice Facebook groups  - one national and a whole lot of provincial
• Physician Health Program in your province
• Other MD mommas
• get an UpToDate subscription
• buy an Rx Files
• the Orange Book
• ask a colleague
• consider a small notebook or an app like Evernote to keep things you are always looking up

What I learned I should have asked/done in my first year of practice

If you are taking on someone else’s practice, you will also be taking on their mistakes and successes. It will take time for their patients to trust you.

Booking in Patients: Unfortunately, b/c the Ontario Government can’t get their heads out of their collective ass, you won’t have the luxury of “ramping up”.  Because the patients are going to be coming in at full speed, you will need to have a plan. I made a few hours every day my “meet and greets” where I would get families to come in to meet me and go through their health history to get me caught up. Priorities were patients with diabetes, using narcotics, with cancer, polypharmacy, etc. My staff helped flag them as they refilled their meds. 2 - 3 hours were for seeing acute patients/patients that were booked in over the past couple of weeks. At least one hour for labs, scripts and reports.

No general assessments for at least 6 months. If a patient is due for their pap, either divert to an NP or have them booked in for just a pap. Lots of your patients think they need a general assessment to see you. Have staff ask if a meet and greet will do what they want. 

Spend time with each patient’s chart updating it to fit the way you want to practice. It will save you lots of time in the future. 

Your access time in the first year is going to suck. Get over it. As long as you are treating your patients well when they come in, they will forgive you. 

Med Refills: They will be on meds that haven’t had the appropriate labs set up in ages. Set up standard labs and protocols for patients who are calling in for scripts and have your staff automatically order what you want (e.g. LFTs for statins, metabolic panel for antipsychotics, TSH for Li and synthroid…). 

Decide what your rules will be for certain drug classes (opioids, benzos, etc.). My rules were considered stringent by my patients in my first year. I was very clear about max amounts of morphine equivalents I was comfortable with (200). Anyone above that had to see the clinic pharmacist for a review and to see if there are changes that can be made, if the level of pain management is appropriate. Use the McMaster Pain Guidelines. Having the objective tool makes it easier to be firm. http://nationalpaincentre.mcmaster.ca/opioid/  I asked pain and bento patients to be in q4months. I wouldn’t renew scripts unless they came in. Drug testing was mandatory. 

Money: Get everything in writing. All the little bits and pieces that you are paying for in your overhead. Do any of your billings go directly to the clinic? Who is in charge of your billing? How often do they go for training? How do they deal with billings that get sent back? How is overhead split? Do you have to pay rent for the FHT staff or just your FHO staff? Who exactly contributes to the pot for your clinic? Is it the same people who are using the clinic? If you are working rurally - dose your ER billing go to the same billers? hospitalist? OB? 

Governance: How are budgeting decisions made? What makes a vote go through (i.e. is it majority or unanimous?) How are disagreements within the group managed? (ask for an example) What committees will you expected to be a part of? How many days vacation do you get? How does your team feel about you going on vacation? Are locums expected or will they cover your patients when you are not around? Does the team have a plan for mat/pat leave? How many hours are you expected to devote to in clinic time? Who manages your staff? How is that person evaluated? What sort of observation/probation does your team use?

What to expect in your first year of practice.

Every borderline personality patient will come out of the woodwork and want to be your patient. The kind things they will say, the flattery, the sob stories, oh, my, god, will they make you think you need to take them on. You do not. If they have a doctor, you are covered, so are they. Ask them to apply again in a few years when you are able to breath air again. 

You will see more cancer than you ever thought possible. The patients you are seeing either haven't seen a doctor in 20 years, or have not been followed as tightly as a new doc will. You will see the lumps and bumps that their previous physician missed, not because they are incompetent but because they are too familiar with their patient. 

The number of labs that you are ordering are going to be tsunamic. (Is that a word? It should be.) You think that you need to know everything about every patient. I sure did. I don't regret it. But it did mean that I needed significant amount of time to review it all, then do the follow up labs, investigate the things that went wrong...

You are going to want as much money as you can get as quickly as you can. I promise, it will come. Take an extra 6 months before expecting to pay down significant portions of your loans. Until then, take your time rostering patients. Taking on too many right away will make things impossibly hard and you don't need that. Taking on too many responsibilities (long term care, oncology, etc.) will put you under water too quickly. Don't do it. 

Keep in touch with friends. Everyone says to do it. No one does. Make actual dates and keep them. Spend time with people who are not your patients, employees, colleagues. Gossip about pop stars and athletes. 

Make dates for massage too. At least monthly. And with a therapist. Even if it's spent just getting to know each other initially, there will be times that you need an impartial person to call you out on your bullshit, remind you to complete your self care, to tell you whether or not this medical culture we call home is reasonable or not. They can help you will your relationships. Just get one. Seriously. 

Book all your vacations and conferences as soon as you can. Plan your whole year, don't let it get to the end of the year and you don't have time to get away. This way you can get locums if you want to cover you, get early bird deals, get the vacation you want. Use your maximum vacation and CME time. Do not use your time off to do paper work. That's not time off.

Book an hour every day that is just for you to book. You can book it in advance, the day of, or not at all and use it for napping. Spend the time the way you want to. You may not know at the beginning how you want to spend that time, but eventually you will. 

Retaining your recently recruited rural doc

I. Make them feel welcome. Seems obvious, but encouraging all docs to individually welcome the new doc will make a difference. Honestly. Just do it.

II. Give them a list of things that they need to know about in town. Best place to buy groceries, list of housekeepers, electricians, plumbers, etc., restaurants, good place to go for a quick weekend with their partner, vets. Start the list now. Add to it as other ideas come up. These people are not in the yellow pages or local paper when you are in a small town.

III. Prepare a list of commonly used billing codes in your office, hospital, nursing home, wherever you tend to make your money. Each clinic has different common codes. Never assume new docs know them. They’re not taught in residency, and the codes they used elsewhere may not be appropriate. If your new recruit is making money to pay down the debt they have, they will be happier, promise.

IV. Check in frequently. Have someone who is their designated mentor that actually wants the job. Someone who will make sure they don’t feel like they are bothering the mentor. Knowing which docs to refer for what kind of issue is important. Knowing what to do when that doc then turns down all referrals is essential. Weirdness happens every day in the clinic.

V. Have regularly scheduled check ins. Both of you will be ready for the meetings and know that you are safe to say what you need to. If either of you have concerns, a regular meeting makes it easier for both of you to come up with solutions. If you just chat about a few cases, it will be time well spent.

VI. Be clear about numbers. How many days of vacation? How many months of free rent? How is overhead calculated? Everything needs to be in writing so that everyone knows the rules up front. That way when snide remarks like “but no one takes vacation in their first year” can be taken as the jokes they are meant to be.

VII. Make sure their new office and exam rooms are clean. Seriously. No one wants to work in someone else’s year’s of dust and outdated hand outs. That’s gross and indicates that your group doesn’t care about your new recruit.

VIII. Have a welcome dinner. Make spouses welcome. Spouses are the bomb for making new docs feel welcome. They know what their partners went through and will help make your new recruit feel like they belong. While you're at it, ask those spouses to add to this list.

IX. If you notice your new doc is not making it to the lunch room, it’s not a good sign. Check in to see what can be done to lighten the load. They will want to hear your advice.

X. Help them get a family doc. Know that they will NOT be comfortable with one of their colleagues doing their DRE or pap. Follow up to make sure that your friend actually took them on. You’d be surprised. It took my nurse begging a former colleague to get a doc for my partner and I.

XI. If your recruit comes to you with concerns, deal with it. While it’s true that things get better in 5 years (it’s OK to tell them that), it’s not enough. Help them through whatever is going on or you won’t see how much better they are in 5 years.

XII. Baby docs are just out of residency where they are taught that if they don’t have the answer to something, they’re useless. This will be a hard habit to break, but essential that they feel safe in stopping it. 

XIII. Consider a community meeting/doctor to introduce people in town to the new doc. Getting formally introduced may reduce assumptions and gossip that comes later, or at least keep it kind hearted. 

Why the Ontario MD funding cuts are a feminist issue (a rural focus)

There is a lot of talk among my colleagues on what to expect from the Ontario Liberal government with respect to our fee claw backs. The government’s hope is that by decreasing our fees, that we will work less and therefore the system will be charged less overall. They see lowering access to physicians by patients as the solution to their health care finance challenges. 

Sitting in my rural family medicine office, I see how these actions will spill out into my community. 

First of all, less work by the MDs in the office means less available salary and less work for our staff. Staff cutbacks always seem to be the first suggested when overall income decreases. In my office, and every other one I’ve worked in, this staff is comprised almost entirely of women. These women work full and part time in our office and obviously depend on their wages to keep their family in the black. Many of them live on farms and require the supplemental income.  

Female patients are interrupted more than male patients (1). If there is a push to decrease our time in the office, we will revert back to the one item per visit that was seen before the introduction of FHOs. Our female patients won’t get a chance to be heard. Their “door knob” questions will be left to the next visit, and likely the visit after that since many of our rural patients do not “want to be a bother”. Some of these “door knob” questions I have heard in the past two weeks have included: I was raped last week - can I get tested for HIV? I’m worried about my drinking, how can I cut down? There’s a growth on my back that seems to be getting bigger. I worry that these women will be shooed out the door too quickly to check in on what might have really brought them into the office.  

Women in rural areas tend to be the caregivers for ailing relatives, elderly parents and neighbours, children (2). “Rural women caregivers are faced with such issues as limited access to adequate and appropriate healthcare serves, culturally incongruent health care, geographical distance from regionalized centers and health services, transportation challenges, and social/geographical isolation.” These women have several roles to fulfil - spouse, employee, parent, volunteer, caregiver. Decreased availability of physicians will put their own health at risk as well as that of those for whom they care. This increases the odds that the caregivers and their charges will end up in the Emergency Department and/or admitted to the hospital (where the real cost to the health care system begins). 

Less MDs in rural areas as they look for ways to make their practice lucrative enough to continue practicing will lead to less choice of an MD for families. Having a therapeutic relationship with your physician is essential to good health. As it is, those in my area are happy to get any physician let alone someone with similar ethics and values. Decreasing the supply of MDs will make it even harder for patients to advocate for themselves to get a physician they can connect with. Families need to keep their MDs to ensure that their children are vaccinated on time and will often stay with a doctor for years despite not feeling comfortable with them. I’ve met women who have suffered sexual assault who have gone more than 30 years without a pap because she was too scared to have her (previous) male physician perform it. Her cervical cancer treatment would have paid to have a female physician in their area for at least a year.  

Finally, and least importantly, female physicians spend more time with their patients (3). They are interrupted more than their male colleagues. This means that with the decrease in pay, that their time is worth less per hour than the men in their practice. Already we are dealing with no maternity or paternity leave for physicians. This is a step in the wrong direction, pushing women out of medicine. 

There are many concerns about physicians choosing to leave Ontario, not being available for their patients while they are here. My hope is that the OMA and the Ontario Government can work out an agreement to keep my patients, and all the rural female patients in Ontario, safe and well. 

(1) http://www.ncbi.nlm.nih.gov/pubmed/11456245

(2) Crosato, KE, Leipert, B.; Women caregivers in Canada; Rural and Remote Health; June 5, 2006

(3) West, C; When the Doctor is a “Lady”: Power, Status, and Gender in Physician - Patient Encounters; Symbolic Interaction; Spring 1984 

The MCCQE Part II has Placed a Cap on the First Round of Exams

Below is a rant from a friend in PGY1 of a specialty that diverges from the pack early in residency.

The more I think about the MCC imposing capacity limits for the fall MCCQE Part II, thereby forcing many first years to defer the exam until spring of 2016, the more angry I get. Here's why:

CAPACITY CAPS ARE INAPPROPRIATE

1. The MCC has had ample time to prepare for the high demand

The MCC cites two causes of the high demand this fall:

- No more harmonized exam for family med after 2015
- More candidates in general

The de-harmonization was announced over a year ago. Further, the exam was only harmonized 4 years ago, so the MCC already has experience with a larger volume of applicants.

As for the number of applicants in general, Canadian trained residents make up the majority of MCCQE test takers. The number of Canadian residency positions is easily accessible and is also known over a year in advance.

Despite so much warning, the MCC has only increased fall exam capacity by 7% over last year's fall administration.

2. The MCC's arguments for requiring capacity caps are not supported

The MCC says capacity caps were required to:

- Ensure the integrity of exam scores
- Keep costs down for residents

The MCC has not explained either argument.

Why not hire more people to mark the exam using the extra money from more exam fees? Why not delay releasing the results for a month or so until the scores' integrity has been assured? Why not split the exam into multiple sessions over a few weekends?

As for exam cost, no breakdown has been provided of where our exam fees go, nor how they would be influenced by an increased examinee pool. My impression is that the very steep exam fee of around $2300 should more than cover the cost of one administration. Of course more applicants increase cost (linearly), but they also increase income (also linearly).

3. The MCC is not offering any alternative within a reasonable time frame

The MCCQE is a mandated exam, and it is the MCC's obligation to ensure there are sufficient spots for eligible examinees to take it. This has always been the fall of 2nd year, and by capping spots, they are forcing examinees to wait an additional 6 months beyond that. A couple of weeks I could understand, but not a whole exam cycle.

HOW IS THIS UNFAIR TO RESIDENTS?

1. Many residency programs have a general first year, in part to prepare for the MCCQE.

Therefore, residents who have to defer the exam an additional 6 months are put at a disadvantage. For example, I will have been doing nothing but (specialty) rotations for almost a year before the exam, making it challenging to perform well in a general medicine OSCE.

2. The application process was biased.

An email without any notice was sent out, favouring those with immediate access to the internet and a credit card. Many residents working long hours that day were blindsided as by the time they returned home and checked their email, the exam was already at capacity. The same goes for residents that happened to be on vacation, or residents that needed time to assemble the $2300.00 fee. It also favoured residents on the East coast over the West coast, as signing up at the end of the fday in Halifax is hours earlier than the end of the day in Vancouver.

3. Anxiety
Every resident knows it's stressful to have a major exam looming over them. We had all expected to be done the MCCQE by the end of the year. We now face half a year of more waiting for the test than any group of residents before us.

4. This is the MCC's problem, not Canada's residents'.
I want the MCC to know that they are acting inappropriately. I believe they have failed to address the high demand for their exam properly and are bullying first year residents into accepting their mistakes.