Teaching When There is No Time

Author: Robert Cooney, MD (@EMEducation – EM Associate Program Director / Attending Physician, Geisinger Medical Center) // Edited by: Alex Koyfman, MD (@EMHighAK – EM Attending Physician, UTSW / Parkland Memorial Hospital) and Brit Long, MD (@long_brit – EM Chief Resident at SAUSHEC, USAF)

As you walk into your shift, the familiar din that made you fall in love with emergency medicine greets you.  You’ve barely sat down and logged into the EMR, when Jake, one of the interns, asks if he can present a patient.  As he presents, 2 other residents sit down and you can tell from their impatient looks that they too have patients to present.  A quick glance at the board confirms that the waiting room is 20 deep, the ED is holding 50% of its beds with admitted patients, and there are at least another half dozen expected arrivals.  “Well,” you think to yourself, “It’s another day in paradise,” and you begin to prompt Jake along so that you can get him and the other residents back to work.  After taking the 3 presentations, you pause to wonder, “Is there a better way to teach when it’s so busy?”

Between 1993 and 2003, total hospital beds declined by 198,000 while ED visits increased from 90.3 million to 113.9 million and continue to rise.  This loss of capacity within hospitals has caused the burden of care for patients needing admission to fall to the ED.  Academic emergency departments are particularly prone to this problem as they serve as receiving centers for patients in need of critical interventions and specialist evaluation.  Whether overcrowding affects resident education is a matter of debate. Berger et al1 found that productivity and teaching evaluations were not related; and surprisingly, the most productive attendings were also highly rated teachers.  Kelly et al2 found that clinical workload did not affect teaching scores.  Finally, Pines et al3 found no association between crowding and teacher-learner interactions.

While overcrowding may not have an effect on the quality of teaching, the Berger study did find that attending physicians did perceive the workload to interfere with the ability to teach well.  When it gets busy, seasoned educators will often rely on tried and true methods to accomplish effective teaching with minimal time.  Bandier et al4  identified methods that award-winning educators felt made the difference for their teaching.  These include:

Tailor teaching to the learner:

A few minutes spent at the beginning of the shift getting to know your learners is an investment that pays dividends.  This is especially true when working with medical students and off-service residents who are new to the department.  This helps to establish the relationship, determine their learning needs and goals, and you can also establish expectations.  Knowing the learner’s “story” will help you to tailor the teaching as the shift progresses.  Is the student going into radiology? Coaching them on image interpretation for all of their patients reinforces that you understand their interests.

Optimize faculty-learner interaction:

Once you know your learners, you can much more effectively tailor your teaching.  Learning to ask questions properly (https://www.aliem.com/2010/article-review-use-of-effective/)5 allows you to “diagnose” your learner’s level and can guide your learner through the case, improve retention, and structure their learning.  Going to the bedside is another way to optimize the interaction. Muck et al6 found that bedside rounding increased the amount of discussion about differential diagnosis, overall questions, and led to changes in diagnostic workup compared to board rounds.  While it did take longer to complete bedside rounds (4 minutes), the efficiency gained by a more appropriate patient work-up likely negates the time cost.  A full discussion of bedside teaching is outside the scope of this article.  If interested, Twelve Tips to improve Bedside Teaching by Subha Ramani7 is an excellent starting point.

Tailor teaching to the situation and actively involve the learner:

When it gets really busy during a shift, it becomes too easy to dismiss learning opportunities for the sake of speed.  Two tricks can be used when this situation arises.  First, the 1-minute preceptor8 ((Paucis Verbis Card) (https://www.aliem.com/2015/pv-card-one-minute-preceptor-nerds-mnemonic/)).9  After listening to the learner’s presentation, the educator will:

  • Probe for commitment: “What do you think is going on with this patient?”
  • Probe for evidence: “Why; what else are you considering?”
  • Teach a general rule: “The key to making this diagnosis is…”
  • Reinforce what’s right: “Your differential included the key conditions that I worry about when a patient presents with a complaint of…”
  • Correct mistake: “Prior to ordering a d-dimer, make sure that the patient’s pretest risk is in the correct range.”

Another simple way to teach quick pearls is the use the “What if…” question.  This question can change a routine simple case into a learning opportunity.  For example, if a person has URI symptoms, as “What if this person was just traveling in Yosemite (Hanta), or Africa (Ebola), or Puerto Rico (Chikungunya).  A simple case suddenly becomes a hit-and-run learning experience.

Actively seek opportunities to teach:

While on a busy shift, learners often are pulled in multiple directions to see patients, document, deal with consultants, perform procedures, and the list goes on.  Always being aware of the department can help you tailor the learning.  Perhaps you’ve taken a presentation for a patient that will require a more uncommon procedure.  Bring multiple learners into the situation.  What if it’s not busy?  Keep a teaching file.  I use a combination of Evernote and a USB drive filled with images to offer learners the opportunity to review cool cases when the time presents itself.

Whether we like to acknowledge it or not, there will always be impediments to good teaching in the Emergency Department.  Whether competing demands, lack of time and/or resources, or trainee issues such as lack of interest or knowledge deficits, we can use the above simple tricks to improve our teaching.  Our patients will be better for it.

References/Further Reading:

  1. Berger, Todd J., et al. “The impact of the demand for clinical productivity on student teaching in academic emergency departments.” Academic emergency medicine 11.12 (2004): 1364-1367.
  2. Kelly, Sean P., et al. “The effects of clinical workload on teaching in the emergency department.” Academic Emergency Medicine 14.6 (2007): 526-531.
  3. Pines, Jesse M., et al. “The effect of ED crowding on education.” The American journal of emergency medicine 28.2 (2010): 217-220.
  4. Bandiera, Glen, Shirley Lee, and Richard Tiberius. “Creating effective learning in today’s emergency departments: how accomplished teachers get it done.” Annals of emergency medicine 45.3 (2005): 253-261.
  5. Cooney, Robert. “Article Review: Use of Effective Questioning” Available at: https://www.aliem.com/2010/article-review-use-of-effective/
  6. Muck, Andrew, et al. “Bedside rounds versus board rounds in an emergency department.” The clinical teacher 12.2 (2015): 94-98.
  7. Ramani, Subha. “Twelve tips to improve bedside teaching.” Medical teacher25.2 (2003): 112-115.
  8. Neher, Jon O., et al. “A five-step “microskills” model of clinical teaching.” The Journal of the American Board of Family Practice 5.4 (1992): 419-424.
  9. Sudario, Gabe. “PV Card: One Minute Preceptor – NERDS mneumonic.” Available at: https://www.aliem.com/2015/pv-card-one-minute-preceptor-nerds-mnemonic/

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