POSTED: November 7th, 2016
POSTED IN: Fall 2016,
Kelly Monahan, M.D.
Department of Emergency Medicine, PGY3, University of Missouri Hospital
The standard practice in any residency program is the tradition of graduated responsibility. On the first shift as intern, if you were able to order the proper dose of Zofran, Toradol, or insulin without looking it up, the day was a success. With each subsequent year, we were given more autonomy and responsibility for patient care. You felt your hard work paying off, your education validated, and more confident in your own deductive reasoning and management.
But suddenly, we began our third year with a new responsibility: Teaching! The interns- the newest additions to our little clans. Medical students- not the just-get-me-through-this-rotation ones, but the eager emergency medicine-destined ones with their almost overwhelming desire to please and glean crumbs of knowledge. Faced with the idea of teaching these junior learners, numerous thoughts sprang to mind with the first and foremost being “How am I supposed to teach and care for patients at the same time?” For those of you who are unaware, the University of Missouri-Columbia Emergency Medicine residency is a young one- with the current third year residents as its inaugural class. Our faculty members were wonderful role models, but what I remembered most, as I reflected over the last two years, was how smoothly everything seemed to go and not how they made it happen. I needed help.
Luckily, I found some. In 2009, Houghland and Druck published an article in the Annals of Emergency Medicine with the goal of providing senior residents with a framework for teaching medical students and junior residents in the emergency department. With the hope that it may help provide you, my comrades, with a tool to accomplish the newest challenges of our residency, I’d like to summarize the main points of the article (although the full-text version is available free online from the Annals website).
Houghland and Druck adapted a methodology known as the ADDIE system, originally developed by the US military, into four phases for effective clinical teaching: 1.) assessing the learner, 2.) determining the instructional content, 3.) determining the instructional method, and 4.) determining the effectiveness of instruction. Assessing the learner’s prior knowledge can be done by asking a clear, concise, open-ended questions that will have more than one answer, such as “What is your initial approach to the patient with dyspnea?” You can also ask a more specific question prior to the patient encounter like “How many patients with acute heart failure have you managed?” The most effective method of teaching in medicine is patient-centered according to the most recent research. Applying specific, open ended questions regarding the encounter has the best chance of success. Questions such as “What is the HEART score and how might we use it with this patient?” are encouraged. Remember that deficits in understanding can typically be categorized as gaps in knowledge, communication, procedural skills, attitudes, or behaviors and there is room to teach in each of these categories. However, the authors do strongly recommend limiting significant teaching to one topic per patient encounter in order help avoid “information overload.”
Most unique to the field of Emergency Medicine is almost certainly the wide variety of acuity and care requirements of our patients. For this reason, I found step 3- determining the instructional method- the most interesting and helpful of the paper. Houghland and Druck recommend a change in teaching modality based on the acuity of the patient. During an encounter with low acuity patients or when the department is slower, didactic education may be most useful. A literature search for evidence-based practices should be performed by the senior with discussion among the junior learners to follow. Pimping- or asking numerous rapid fire questions until the learner is stumped- is another form of education, but it is generally discouraged. Instead, choose questions that the learner can answer correctly in a serial fashion and will guide them to the correct conclusion. When dealing with emergent patients, consider asking directed questions regarding the first steps to evaluation for the most likely or concerning diagnosis, and have the learner at bedside with you- both observing and participating in the examination and management. In critically ill patients, instruction may be limited to a demonstrative methodology with guidance as simple as “watch my intubation technique.”
Procedural education can be approached in four ways and are described in a step-wise approach. They include “demonstration,” where the teacher performs the procedure without narration and at normal speed; “deconstruction,” requiring that the teacher demonstrate each step with ongoing narration; “comprehension,” with the teacher performing the procedure, but under the direction of the learner narrating the steps; and “performance” with the learner performing the procedure themselves- with or without narration.
Finally, evaluation of the effectiveness of the instruction can be accomplished by direct questioning (i.e. “What are the risk factors in the Well’s Criteria?”), direct application (i.e. “What components of the patient’s history are concerning for pulmonary embolism?”), and case-based hypotheticals (i.e. “What if the patient is severely hypotensive- how might that change our evaluation and treatment?”).
We did it folks- we survived to our last year of residency. Each of the first two years presented their own challenges and this year will be no different. But at the end of each of those years, we overcame obstacles and rose to meet the next. Acute heart failure, STEMIs, DKA, strokes, and traumas have become familiar territory. Central lines have become common place, arterial lines are a snap, and the laryngoscope handle has started to feel like an extension of your hand. We will overcome this scary teaching stuff. And while some of you may be thinking that resident supervision is all you have time for or interest in, these authors sought to provide you with a heart-string-tugging reminder: “All physicians are encouraged by the Hippocratic Oath to teach trainees in the medical field.” It’s really there- I checked! So arm yourselves with these new techniques or use some from a mentor and let’s get ready to be challenged and to succeed for this- our last year of residency!