This Encounter Isn’t Over Yet: The Importance of Debriefing

The term debriefing often suggests a team-based discussion after a sentinel event. This practice originated from the military process of reviewing one mission to gain lessons for the next and has since expanded to other high-stakes industries, including medicine, in which it has been shown to improve team performance and patient outcomes.^1–3  Debriefing is a form of experiential learning in which the learner reflects on past experiences as a source of new learning and transformation.⁴  Recent studies reveal that debriefing need not be limited to team settings and can also be successfully used 1:1 in a teacher/learner dyad.³  Although most literature on the topic comes from the simulation arena or after critical events, there is a recent impetus to include debriefing within everyday clinical care as a teaching tool.⁵ 

In this article from the Council on Medical Student Education in Pediatrics series on great clinical teachers, we provide an approach to debriefing an individual learner. We define debriefing as a dialogue between individuals whose goal is to reflect on thought processes and behaviors surrounding aspects of a clinical scenario to implement improvements in future encounters.⁶  Debriefing requires several steps.³  The first is a focus on a specific clinical encounter or event, not a series of events. The second is fostering a safe learning environment. Next is reflective learning in which participants actively engage in self-discovery. The final step of debriefing is to provide feedback to the learner.

Usually what triggers a debriefing is a critical event, such as a transfer to a higher level of care, near-miss event, or incorrect/delayed diagnoses. Although the literature around debriefing suggests the need for a triggering event, there is value in using a debriefing strategy for lower-stakes events that lie in our routine clinical work. Our suggestion is that the debrief should occur shortly after a singular interaction in which the learner is involved in identifying something suboptimal that occurred and then considering ways in which the intended goal could have been achieved. Although these goals revolve around patient care, they may reflect elements of clinical reasoning, procedural skills, leadership, teamwork, or communication.⁷ 

For debriefing to be effective, learners need to feel they are in a safe environment to help make sense of events that transpired and codify their learning. Psychological safety is “the perception that an environment is safe for interpersonal risk taking, exposing vulnerability, and contributing perspectives without fear of being shamed, blamed, or ignored.”⁸  It creates a space in which people feel comfortable growing through missteps. To create such an environment, teachers can begin debriefing encounters by sharing their own humility and engaging the learner to verbalize their own successes and concerns about an encounter.⁹  Questions can be posed about what went well and what could be changed.¹⁰  In our example, it might look like this:

Teacher: “We have a few moments before our next patient. Let us do a quick debrief of this event. This was a tough visit. I think we have all been in that position before, with a parent who is upset. What do you think went well? What could be changed?”

Learner: “Yeah, that definitely didn’t go as planned and I was anxious to even bring it up. I think I did okay talking with the mother when we were called back but I wish I had explained it better the first time around. Hearing you say it was a tough visit does validate my struggles, though.”

Reflective learning occurs when a learner considers the present experience to gain insights that can be applied to their next encounter.¹⁰  Reflective learning may be used in debriefing to help reveal motivations and reasons for decisions, behaviors, or actions.¹  A helpful framework to use is advocacy/inquiry, which combines 2 effective communication techniques. Advocacy, in this context, is the statement of one’s views. Inquiry is asking questions related to that view to facilitate conversation.¹¹  The preceptor can use the following 3 prompts to facilitate a conversation with the learner: “I saw…I think…I wonder.” As highlighted in the example below, this approach allows for a balance of inquiry, discussion, and mutual learning.¹¹ 

Teacher: “I saw you choose your words carefully just now when we went in together. I think that demonstrated thoughtful communication with mother. I wonder if that was the same conversation that happened earlier?”

Learner: “Things went smoothly, and she seemed to understand medical terms this time. Looking back, I don’t think I was careful enough with my words initially. I used the word ‘injection’ which may have led to confusion.”

Feedback and debriefing are often used as key facilitators for reflective learning.¹²  Although feedback is defined as “specific information about the comparison between a trainee’s observed performance and a standard,”¹³  we use it as the final action in our debriefing framework. Feedback helps bring the learning points together to formulate a specific plan to improve future performance.¹⁴  Feedback should be timely and optimally offered immediately after the clinical encounter and certainly before the event has been forgotten. If deferred too long, the learner may have forgotten the context or may not have the opportunity to practice and demonstrate improvement.¹⁵ 

Teacher: “That’s very insightful that you realized you may not have been careful enough with your words. We often use medical words that are unfamiliar to patients or that patients do not understand. You can use a common word, like ‘shots’ instead of ‘injections.’ In the future, you can try asking patients what their understanding was of your conversation by using phrasing such as ‘I want to make sure I explained everything fully - could you please tell me what you have understood and what is still unclear?’ at the end of your time with them.”

Learner: “Thanks. Can I try that with our next well check patient?”

Debriefing is a simple and effective teaching tool that can be completed in 5 to 10 minutes immediately after a clinical encounter to improve the effectiveness of individuals as well as teams. This 4-step framework, pairing the right clinical encounter with a safe learning environment, reflective learning, and feedback, teaches toward an identified need and affords suggestions for improvement that can be incorporated into practice.

We would like to thank Robert A. Dudas, MD, and Michael S. Ryan, MD, MEHP, for their valuable comments and thoughtful review of this article.