Teach podcast

#19 Check Your Pulse First: Teaching Strategies When Emotions Run High

September 20, 2022 | By

With Dr. Rachel Hathaway and Sara Bailey

Listen as our esteemed guests Dr. Rachel Hathaway (@rhathaw) and Sara Bailey discuss teaching strategies for when emotions run high in the learning environment. We discuss the pyramid of behaviors and emotions, ‘differential diagnoses’ for what may be occurring for learners, and how to approach these challenging situations!

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  • Producer/Host: Era Kryzhanovskaya MD, Molly Heublein MD, Frances Ue MD MPH
  • Cover Art/Infographic: Andrew DeLaat
  • Script/Show notes/CME: Frances Ue MD MPH
  • Audio editor: Clair Morgan of Nodderly
  • Guests: Rachel Hathaway MD, Sara Bailey

CME Partner: VCU Health CE

The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit. See info sheet for further directions. Note: A free VCU Health CloudCME account is required in order to seek credit.

Show Segments

  • Intro, disclaimer, guest bio
  • Guest one-liner, Picks of the Week
  • Case #1 from Kashlak
  • Framework for learners’ behaviors and emotional states
  • Case #2 from Kashlak
  • Strategies in lesson planning and in session circuit breakers
  • Debriefing and Critical Friends Group
  • Outro

Teaching When Emotions Run High Pearls

  1. The physical reactions we see in our learners is just the “tip of the iceberg”.  Beneath this is a range of emotions and reasons for why these emotions come out.  Consider a broad ‘differential diagnosis’ when considering what might be going on with our learners when something unexpected happens in the classroom.
  2. Consider a large toolbox of strategies to set up an emotionally and psychologically safe learning environment.
  3. Seek out a ‘Critical Friends Group.’

Teaching Strategies When Emotions Run High – Show Notes

Framework of learners’ behaviors and emotions

Dr. Hathaway and colleagues have built a pyramid  framework for how to think about what may be happening with learners’ emotional state. 

At the top of the pyramid are various reactions and behaviors observed in learners, the next level is their specific emotional states that drive these observable reactions or behaviors, and then underlying all of that, at the base of the pyramid, is our ‘differential diagnosis’ for the emotional state. We use the word “differential diagnosis” here to prompt us to think broadly and humbly about various root causes of emotions and reactions, though want to be careful here to not imply our learners have medical disorders. 

For example, if a learner is demonstrating anger and frequent interruptions, while we may think that this is stemming from a tough past personal experience with this learner, but really the differential is still broad. They could have had a tough patient case recently,  be coming from an emotionally charged teaching session before yours, or have just gone through a break-up.  There are so many possibilities (Dobmeier 2008, Steinert 2013). 

Strategies in Responding to Emotion

Before the session

Plan curriculum with the overall goal of building relationships with learners and providing room for emotional and learning needs to be articulated.

Some strategies when planning a teaching session:

  • Incorporate trigger warnings before any sensitive material
  • Plan for additional time to discuss learners’ reactions and emotions (Roze des Ordons 2021)
  • Review  the agenda or learning objectives with learners before the session begins
  • Build relational rapport with specific learner(s) if possible.

Take a mindful breath. It is important to be aware of your emotional state as a teacher. (You can’t regulate a dysregulated person without regulating yourself first) (Sottile 2022). When we feel stressed, we need to engage our parasympathetic nervous system, and we can do this through using our breath.

In the moment: Circuit Breakers

Circuit breakers can be used to anchor yourself as a teacher when emotional dynamics are interrupting a session.

Dr. Hathaway’s go-to circuit breaker when the main emotion feels inattentive or distracted, is to invite learners to physically stand up and move around the room, or even take a 5-minute break.

Another strategy is to use a pair-share or breakout group activity in the moment to help contain the distress and area of impact for learners experiencing high emotions or to engage learners who seem disconnected. This may also be a solo writing activity for learners, which could relieve the pressure in the moment on the individual level for each learner.

After the Session: Debriefing and Critical Friends Group

After a session, we as teachers may feel alone in our emotions and experiences. It can be useful to ask for feedback from the learner(s) in question, however, be aware of the power dynamic that exists. It can also be helpful to debrief the situation with a trusted group of few educators in your institution to critically review your teaching practice and help you unpack, get clarity, and find solutions (Carlson 2018). This ‘Critical Friends Group’ is a term borrowed from the education world, specifically from the National School Reform Faculty (NSRF).

First step to creating your own ‘Critical Friends Group’ or as Era names,  ‘Council of Medical Educators’ is identifying 8-12 trusted colleagues who you can bring together to discuss challenging teaching scenarios. NSRF has protocols to help guide discussion so that all members of the group walk away with some meaningful learning.


  1. MedEdPortal article- An Interactive Session to Help Faculty Manage Difficult Learner Behaviors in the Didactic Setting (Schnapp, BH et al., 2018)
  2. Dr. Hathaway’s recommendation: Harry Potter
  3. Sara Bailey’s recommendation: House and the Cerulean Sea
  4. Frances’ pick of the week: Medical London
  5. Era’s pick of the week: Please don’t sit on my bed with your outside clothes


Listeners will identify strategies to teach when learners’ emotions run high in the classroom.

Learning objectives

After listening to this episode listeners will…

  1. Identify the most common affective states in which students and trainees may present. 
  2. Recognize the “differential diagnosis” for several of these states and how our own reaction can affect such a situation.
  3. Employ the presented frameworks and strategies to navigate challenging teaching situations. 
  4. Describe the importance of debriefing to reflect on and identify areas for improvement moving forward in one’s teaching practice. 


Dr. Hathaway and Sara Bailey report no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Dr. Hathaway and Sara would like to acknowledge their collaborators who built the workshop version of this topic, which was presented at this year’s National SGIM conference: Dr. Ariel Majidi at Massachusetts General Hospital and Harvard Medical School, Dr. Priyank Jain at Cambridge Health Alliance and Harvard Medical School, and Dr. Mike McShane at Penn State College of Medicine.


Hathaway R, Bailey S, Ue F, Heublein M, Kryzhanovskaya E. “Check Your Pulse First: Teaching Strategies When Emotions Run High” The Curbsiders Teach Podcast. http://thecurbsiders.com/teach.  September 20, 2022

CME Partner


The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit.

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