Table of Contents
Title Page
Copyright
Dedication
Editors and Contributors
Preface
Section 1: Background/Introduction
Chapter 1: Adult Learners in The Emergency Department
Learning Theories
Learning as a Child
Learning as an Adult
Learning as an Adult—Malcolm Knowles' Theories and the Arguments Against Them
Educating Adults
Adult Learning in the Emergency Department
Conclusion
References
Chapter 2: Obstacles to Teaching in The Emergency Department
Obstacles Inherent in The Emergency Department
Conclusion
References
Chapter 3: Teaching and Patient Care in Emergency Medicine
Introduction
Motivation for Teaching Emergency Medicine
The Beginning Educator
The Seasoned Veteran
The Master Educator
The Benefits of Teaching in Emergency Medicine
Improving Patient Care and Safety
Conclusion
References
Chapter 4: Mentoring in Emergency Medicine
Mentor and Mentoring Defined
Why Mentoring is Important
Benefits of Mentorship
The Mentoring Process
Successful Mentors and Pitfalls of Mentoring
Role of Mentoring in Medical Education
Goals of Mentoring
Career Guidance
Summary
References
Section 2: Teaching in the Emergency Department and Beyond
Chapter 5: Bedside Teaching in The Emergency Department
What is Holding us Back: Barriers to Bedside Teaching
The Basics: Characteristics of Effective Bedside Teachers
The Framework: The Experience versus Explanation Cycle
Implementation: The Art of Bedside Questioning
Closure: Effective Feedback as It Relates to Bedside Teaching
Summary
References
Chapter 6: Teaching Invasive Medical Procedures
Prepare to Teach and Learn
The Process of Learning
Putting Theory Into Practice
Creating a Procedural Education Elective for Preclinical Medical Students
Assessing Competence
References
Chapter 7: Providing Feedback in The Emergency Department
Guidelines for Providing Effective Feedback
Additional Feedback Methods and Tools
Feedback and the Accreditation Process
Faculty/Trainee Development
Conclusion
References
Chapter 8: The Computer as a Teaching Tool
Improving Patient Care by Locating and Implementing Evidence-Based Clinical Guidelines
Performing an Effective and Efficient Evidence-Based Medicine Literature Search for Clinically Meaningful Answers During a Busy Shift
Improving Use and Interpretation of Diagnostic Imaging
Enhancing Systematic Interpretation of Electrocardiograms
Enhancing Understanding of Drug Toxicity, Interactions, and Treatment
Introducing a Systematic Approach to Describing Skin Lesions
Enhancing the Neurologic Examination, Understanding The NIH Stroke Scale, and Knowing The Indications/Contraindications for Tissue Plasminogen Activator for Stroke
Enhancing The Student's Use of Scoring Systems, Calculators, and Decision Rules to Provide the Basis for and Documentation of Care
Preventing Medical Error
Improving the Student's Understanding of Normal Changes in Pregnancy, Pregnancy Complications, Radiation Risks in Pregnancy, and Contraindications to Medications in Pregnancy
Reinforcing the Importance of Clear Communication and Use of Fluent Translators for Non-English-Speaking Patients
Understanding Uncertainty in Medicine
Using Online Video in Emergency Medicine
Online Spaced Education
Summary
References
Chapter 9: Educational Technology: Web 2.0
Introduction
“Really Simple Syndication” or “Rich Site Summary”
Wikis
Blogs
Microblogging
Podcasts
Social Networking
Learning Management Systems
Web-Based Applications
Social Media Risks
Conclusions
Recommended Reading
References
Chapter 10: Teaching the Intangibles: Professionalism and Interpersonal Skills/Communication
Communication and Professionalism
Recommendation 1: Establish and Evaluate Explicit Standards, Beginning with The Selection Process
Recommendation 2: Discuss The Benefits of Professionalism
Recommendation 3: Promote Openness to Continual Growth Through Feedback
Recommendation 4: Observe and Discuss Negative Encounters
Recommendation 5: Outline Key Components of a Patient Encounter, Including the Initial Introduction, Patient-Centered Interview, and Concluding the Visit
Recommendation 6: Promote Effective Leadership Through Positive Communication with All Members of the Health Care Team
Recommendation 7: Communicating Clearly, Respectfully, and Confidently with Consultants
Recommendation 12: Be the Role Model of Professionalism
Remediation of Learners having Difficulty with Professionalism and Communication
Conclusion
References
Chapter 11: Teaching Lifelong Learning Skills: Journal Club and Beyond
Incorporation of Research-Enhanced Practice Into Graduate Medical Education
Worldwide Access to Biomedical Information via The Internet
Characteristics of Poor Evidence-Based Medicine/Journal Club Curricula
Attributes of the Successful Evidence-Based Medicine Curriculum and Journal Club
Conclusions
References
Chapter 12: Medical Podcasting 101
Summary
Further Reading
Chapter 13: Use of Simulation in Emergency Department Education
History of Simulation in Education
Why Use Simulation?
Basic Simulation Tools
How to Set Up a Simulation Program
Debriefing
Assessment
Challenges to Simulation
Conclusion
Section 3: Teaching Specific Groups
Chapter 14: Teaching Medical Students
Reasons to Teach Medical Students
Unique Educational Experiences During an Emergency Medicine Rotation
Qualities of an Effective Teacher
Adult Learner Themes
Educational Curricular Components
Clinical Teaching
Techniques for Overwhelmed Students
References
Chapter 15: Teaching Residents from Other Services in The Emergency Department
Introduction
Advantages of having Off-Service Residents in the Emergency Department
Suggested Educational Goals
Models for Teaching Off-Service Residents
Practical Tips to Improve Models of Teaching
Conclusion
References
Chapter 16: The Education of Resident Physicians in Emergency Medicine
Emergency Medicine Residency Infrastructure and Support
The Core Competencies
Paradigms for Teaching Residents
Tailoring the Individual Resident Experience
International Considerations
Conclusion
References
Chapter 17: Teaching Residents How to Teach
Starting The Shift: Expectations and Enthusiasm
Assessment
Capturing Observations and Organizing Patient Care as A Teacher
Conclusion
References
Chapter 18: Teaching to An International Audience
Background
Technical Considerations for Teaching International Audience
Style Considerations
Thematic Considerations
Context and Content Considerations
References
Chapter 19: The Emergency Department Consultation: Teaching Physician–Physician Communication to Improve Patient Outcomes
Introduction
Importance of Consultations
Taxonomy of Consultation
Barriers to Successful Consultations and Communication
Improving Communication in the Emergency Department
Approaches to Consultations in the Emergency Department
Future of Consultations
References
Section 4: Improving as an Educator in Emergency Medicine
Chapter 20: Characteristics of Great Teachers
What Do Learners Want From Their Teachers?
What Do Medical Educators Believe are the Characteristics of Great Teachers?
What Styles and Strategies Do Great Teachers Use?
What Are The Barriers To (And The Solutions For) Successful Teaching?
Conclusion
References
Chapter 21: Effective Presentation Skills
Introduction
10 Principles for Becoming a Memorable Speaker
Now That You Have Got It All Together: Practice, Practice, Practice
Conclusion
References
Chapter 22: Small-Group Discussion Skills
Opportunities for Use of Small Groups
Types of Small Groups
Characteristics and Techniques of A Good Facilitator
Starting A Small-Group Discussion
Challenges of Small-Group Discussions and Their Solutions
Assessing the Discussion
Conclusion
References
Chapter 23: Faculty Development As A Guide To Becoming A Better Teacher
Definitions of Faculty Development
Practicing in An Academic Setting
Necessary Knowledge and Skills
Clinicians as Teachers
Process for Faculty Development
Developing a Customized Program
Finding Resources
Promotion
Conclusions
References
Section 5: Teaching Techniques and Strategies
Chapter 24: Strategies for Effective Clinical Emergency Department Teaching
Introduction
Strategies Versus Traits
Models to Guide Emergency Department Teaching
Diagnosing The Learner
Summary
References
Chapter 25: Pearls and Pitfalls in Teaching: What Works, What Does Not?
Introduction
Teach for the Right Reasons
Keep it Simple
Clarify Expectations
Learn What They Need To Learn
Teach, Do Not Taunt
Practice Safe Learning
Engage Your Learners
A Little Autonomy Goes A Long Way
What Are You Thinking?
Food For Thought
Conclusion
Index
This edition first published 2013 © 2013 by John Wiley & Sons, Ltd.
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Library of Congress Cataloging-in-Publication Data
Practical teaching in emergency medicine / chief editor, Robert L. Rogers ; associate editors, Amal Mattu … [et al.].— 2nd ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-470-67111-5 (pbk.)
I. Rogers, Robert L. II. Mattu, Amal.
[DNLM: 1. Emergency Medicine— education. 2. Emergency Service, Hospital.
3. Teaching— methods. WX 18]
616.02′5— dc23
2012023221
A catalogue record for this book is available from the British Library.
Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.
First and foremost, this book is dedicated to my beautiful wife, Tricia, and my two wonderful children, Harrison and Gabriella. Without their love, guidance, and constant support, this book would not have been possible. Family comes first.
I dedicate this book to all of the educators of emergency medicine in USA and around the world: may this book inspire you to educate how to teach our craft and deliver the best patient care possible.
To the emergency medicine residents and students at the University of Maryland: you are the reason I drive to work with energy and enthusiasm for teaching.
I would like to thank my mom and dad for their encouragement and love throughout life. I am where I am today because of them.
To Linda Kesselring, who edited the book and transformed its contents into an amazing work. The success of this book is due in large part to her tireless efforts.
Rob L. Rogers
My thanks to my family for their constant support; my colleagues, residents, and students for their inspiration to teach and to learn; and to all those who spend their time teaching emergency medicine around the world … may your efforts continue to help our specialty flourish.
Amal Mattu
To the medical students and emergency medicine residents at the University of Maryland for making me look forward to my shifts and to Lisa, Nicholas, Dylan, and Luke for making me happy to go home.
Joseph P. Martinez
To Erika, Hayden, Emma, Taylor, and Olivia, for your endless love and support; you are my world and my inspiration for everything. To the emergency medicine residents and faculty at the University of Maryland, it is a privilege to be your colleague.
Michael E. Winters
I am very excited to be involved as coeditor for the second edition of Practical Teaching in Emergency Medicine. My involvement stems from the enormous interest and growth of emergency medicine education, practice and development in the international setting, and from the demand to share the contents of this book with the international emergency medicine community. I would like to offer my deepest thanks to my coeditors, especially Rob Rogers, without whom this material would most likely still reside in the collective minds of our teachers instead of in a book form. I would also like to thank my beautiful wife Kristina without whom I would not be able to do most anything.
Terrence M. Mulligan
Editors and Contributors
Chief Editor
Preface
Considering the success of the first edition of this book, I wondered what important elements could or should be added to the second edition to make it even better. The first edition is already very comprehensive and useful for the physician who wants to become a better educator and learn the skills necessary to teach emergency medicine. So, what could be added to make the book even better? Well, to make sure the book addresses the needs of physician–educators from all over the world, chapters on lecturing to an international audience, using simulation as a teaching tool, how to make journal club work for you, and many other topics were added to the book. Each chapter was updated and reviewed to make sure the content was something that emergency physician–educators could use in any country. This edition is even better than the first, and we sincerely hope that it helps you in your mission as an educator in one of the best specialties in the house of medicine.
The emergency department (ED) is one of the most interesting and rewarding teaching venues in the house of medicine. No other environment offers such a rich blend of undifferentiated patient presentations and diseases. However, because of this diversity, the ED is also one of the most difficult places to teach. Many of our patients are desperately ill, and we must often reset our priorities quickly to meet their clinical demands. In this environment, emergency medicine educators are challenged to provide quality education for medical students and physicians-in-training.
Emergency medicine attendings who wish to hone their teaching skills can find a number of textbooks on educational strategies written by physicians from other disciplines. However, until now, they have not had access to a text written by emergency medicine physicians on methods of teaching that are directly applicable to our specialty. This book was compiled to meet that need. Its purpose is to provide educators in emergency medicine with a resource on best practices in teaching the art of emergency medicine. The contents are organized around the topics of teaching specific groups of learners, teaching in the ED, improving as an educator in emergency medicine, and appreciating various teaching techniques and strategies.
The chapter contributors are widely regarded as leaders in the field of emergency medicine education and faculty development. Authors were given free rein to develop their chapters and write in their own style. They were asked to present their personal views on how to successfully teach the art of emergency medicine rather than review evidence-based guidelines regarding medical education. As a result, most of the chapters have few references. This first-person approach to a multiauthored textbook yields a compilation that varies in style from chapter to chapter and exposes the reader to a variety of communication techniques. The editors hope that readers find useful models within these pages as they refine their own methods for teaching in the spectrum of venues where emergency medicine is taught.
Inherent in the teaching and the practice of emergency medicine are specific challenges not found in other specialties—the unknowns of the ED, the need to identify life- and limb-threatening conditions, the pressure to solve problems and find solutions quickly, and the orchestration of clinical specialists and ancillary services. Because of these unique demands of our practice, books written by clinicians from other disciplines may be helpful but not complete for us. Practical Teaching in Emergency Medicine was written by emergency medicine physicians for emergency medicine physicians. We hope you find the second edition to be a valuable resource toward teaching the art of practicing our beloved specialty.
Section 1
Background/Introduction
Chapter 1
Adult Learners in The Emergency Department
Learning begins before birth and continues to death. Notably, the process of learning changes throughout life. Children study topics because an authority figure dictates that they must. The child may argue the applicability of the topic to the “real world,” but ultimately the child must learn the material.
Adults seek to learn because of a motivation to do so. Adults seek experiences that have an identifiable impact on life. However, the motivation for adult learning is not always from within; external forces also affect motivation. Adults sometimes seek education, not because they are excited about the subject but because they know it is in their best interest. Adults seek learning so as to better interact with the real world. This is the difference between adult and childhood learning.
The purpose of this chapter is to explore the principles of adult education as they apply to teaching in the emergency department (ED). Examples of the principles will be applied to the ED setting. The terms learner and physician-in-training refer to anyone in the position of learning. A “teacher,” an “instructor,” or an “educator” is the person at any level of training who is in the teaching role.
There are three recognized classic learning theories: behaviorism, cognitive learning, and constructivism [1]. Each of these theories influences curriculum design, teaching, and evaluation. Most educators use elements from each theory in any given situation rather than strictly adhering to one style.
Behaviorism is the learning theory commonly associated with the Pavlovian response: a subject performs a behavior and receives a positive result, and the behavior is reinforced. If the result is negative then the behavior is discouraged and eventually eliminated. The behaviorist does not focus on the thought processes of the learner, but only on the response to a stimulus.
The cognitive learning theory is the opposite of behaviorism. It focuses on the learner's thought processes instead of a response to a stimulus. The interest is in how the learner integrates new information and applies it to new situations.
In constructivism, the learner builds, or constructs, new ideas based on existing knowledge. Constructivism focuses on how students interact and learn from each other as well as from their educators.
Pedagogy refers to the learning style of children. Its literal translation from Greek is “to lead the child.” This is a teacher-centered style of learning. Because children are not thought to have sufficient experience to know what they need to learn, these decisions are made for them by their educators. Instructors decide on what material to teach and how to teach it. Young students generally have little choice as to the content of their curriculum. Decisions and information flow cent percent from the instructor to the student.
Aspects of the pedagogical style also apply to some adult learning situations. For example, during the preclinical years of medical school, adult students have little choice regarding content. However, unlike secondary school students, adults have chosen this curriculum because of their motivation to become physicians. The curriculum is a means to an identifiable end, providing motivation.
As the study of learning advanced, adult learning enthusiasts recognized that children and adults receive and process new information differently. This recognition suggested that adults should be taught differently, prompting radical changes in adult education in many institutions. In the mid-1950s, Malcolm Knowles began publishing his work on adult education, which, at the time, was an underexplored subject. He popularized the term andragogy, which he defined as “the art and science of helping adults learn.” He observed that adults need to be involved in their education rather than being “led” to it. Childhood learning is teacher centered; adult learning is student centered. More on his theories is presented later in the chapter.
Pedagogical learning is based on discrete subjects: math, history, and spelling; or anatomy, cell biology, and pharmacology. This is appropriate for building lower levels of cognition, for the development of a foundation of knowledge. However, applying very basic knowledge, acquired in a pedagogical style, to real-world problems is more difficult.
Adult learning is more problem centered—an approach in which the learner pulls multiple bits of basic information from multiple, discrete subjects to solve a problem. Problem-centered learning is very relevant in the ED. For example, the ED physician, faced with a woman with right lower quadrant abdominal pain, simultaneously gives attention to all systems that may cause pain in this region. “Is this gastrointestinal (appendicitis, gastroenteritis), gynecologic (ectopic pregnancy, ovarian torsion, pelvic inflammatory disease), genitourinary (ureterolithiasis, pyelonephritis), vascular (aortic dissection), or something else (shingles)?” The clinician combines basic knowledge of these different systems and conditions with clinical experience to narrow the diagnostic possibilities and begin the appropriate evaluation.
Much of adult learning theory stems from five assumptions about adult learners that were developed by Knowles (Table 1.1). The assumptions reflect that adults are self-directed learners who seek information independently. They reconcile new information with their existing knowledge base and seek to apply it immediately to a known problem. It is important to note that these assumptions have not been validated.
Table 1.1 Malcolm Knowles' assumptions about adult learning.
| Adults are self-directed and autonomous |
| Adults have life experiences that need to be respected |
| Adults want to learn tasks related to everyday life |
| Adults are problem centered and seek to apply learned material immediately |
| Adults are motivated by internal drives rather than external factors |
Adapted from [2] Kaufman DM. Applying educational theory in practice. BMJ 2003; 326: 213–216, with permission from BMJ Publishing Group Ltd.
Before embracing Knowles' theories blindly, one must note the many criticisms of his work. A commonly cited criticism was the inadequate data used for the formulation of the assumptions is a commonly cited criticism [3–6]. This vacuum is of particular concern in today's culture of evidence-based practice.
Norman [3] questions at what point a student transitions from a child learning to an adult learning style. It is not likely an age-based phenomenon, as chronologic and mental ages are not always congruent. He suggests that the transition is not effected by an internal condition of the learner, but rather by a change in learning style, needed to meet a new pressure or situation.
Some suggest that the motivation for adult learning is rarely exclusively internal and that it often stems from external forces [4, 6]. Adults might acknowledge only their conscious internal motivation, neglecting a subconscious external motivation. For example, physicians must receive continuing medical education (CME) to maintain their certification. A physician may satisfy an internal drive to learn more about dental emergencies by attending a lecture on this topic at a conference; the external motivation of receiving CME credits is also satisfied.
The assumption that all adult learning is self-directed is also debatable [3, 6]. Self-direction is a quality of a mature learner. A young learner may possess this quality, while a chronologically older student may not. In addition, before delving into any self-directed learning, students must do self-assessments to identify their weaknesses. Young students often perform inadequate self-assessments. The drive to learn is fed partly by success. Consequently, students are more likely to study topics with which they are familiar, feeding the hunger for success rather than focusing on weak areas. Adult learners facing new subjects may need a little “pedagogical guidance” from instructors.
Another criticism of Knowles' work is that he did not comment on the use of reflection in learning [6]. In reflection, the learner considers the new material, integrating it with preexisting knowledge and resolving conflicts between new and old information. The learner can consider how to approach a task the next time, based on successes and mistakes from the first experience. Taking time to reflect on a newly learned topic ingrains the material into one's mind.
Adults are experienced learners who derive part of their identity from life experiences. Adult learning is enhanced when educators demonstrate respect for adults and their experiences. Any dismissal of the learner's experience is perceived as a rejection of himself or herself [7]. With the learners' cadre of life experiences come habits that are well established and difficult to break [7]. Despite their motivation to learn, adults are generally resistant to changing their habits. Educators must balance respect for the learners' experiences with needed modifications of problem habits. A poor balance risks alienating the learners.
Dependence on the teacher within a pedagogical structure is counterintuitive to adult learners. Adult learners seek to solve problems on their own using their previous experience. Instructors of adult students are seen as facilitators, not teachers. Facilitators are guides who do not merely hand out information but who help students to develop their own questions and to find their own answers. This develops student self-reliance and skills that will be useful in solving future problems. Knowles and others developed recommendations for these facilitators of adult students [2, 8], detailed with examples in the following section.
The ED is a rich, problem-based, learning environment. Most emergency medicine (EM) physicians are “action-oriented” people who say, “I learn best by doing” or “I learn on my feet.” The ED provides the ideal setting for such learning. The educational moments are “live”; they are “now.” Skilled educators exploit these attributes of the ED, incorporating principles of adult education to create rich learning experiences for young clinicians.
However, the ED is not a comfortable learning environment. Constant distractions are normal. Time is limited and precious, creating a significant barrier to education in the ED. Faculty members are under increasing pressure to see more patients and improve documentation, limiting the time available for teaching. The balancing of time between patient care and teaching is simply another form of ED triage. Not all cases need to include an educational moment, nor must every aspect of each case be dissected to provide thorough teaching. Educators must choose their moments, as exemplified in the following sections.
Two environments can be optimized for learning: the physical and the interpersonal. The physical environment of the ED is a constant assault on all the senses, resulting in an array of distractions that is unparalleled in the world of education. Patients and providers are constantly on the move. Noise emanates from all directions. The lighting is harsh. The department is never big enough—patients overflow from rooms into hallway beds or large rooms with chairs and staff members compete for computer and counter space. Supplies run short, textbooks are old, and interruptions are frequent. New learners in the ED also face sheer intimidation. Despite these inordinate challenges, learners must focus on quality, one-at-a-time patient care. It would seem impossible to make the learner to also focus on educational moments, one at a time. Teachers in the ED must choose their moments among the distractions. To the extent possible, distractions should be minimized: spaces away from the main center of the department can be used and nurses should be notified that interruptions should be minimized unless they are truly emergent. It is important to “read” your learner to see if he or she is ready for such a moment. If a student is too distracted with a current situation, you cannot effectively teach. Save the pearl for later.
Interpersonal or relationship setting is the most important piece in the entire educational endeavor. As noted earlier, adults have years of experience for which they expect, and deserve, respect. Establishing an open and respectful relationship with the adult learner is the most important first step in providing adult education. It is this relationship that encourages learners to come to their teachers; it makes the teachers approachable. Learning will not occur if the students do not want to approach or hear from the teacher. In the teaching ED, physicians-in-training must discuss their cases with a supervising physician; thus, it seems that the learners have no choice but to come to the teachers. However, if the learners do not have a good relationship with the teacher, they will modify their presentations in ways to minimize exposure to the instructors. When faculty members try to teach in the setting of poor relationships, learners will be minimally receptive. Tension can worsen with each encounter. Various reviews have described the characteristics of good teaching faculty (Table 1.2). It should be noted that they are all based on the establishment of an open and respectful relationship with the learners.
Table 1.2 Characteristics of effective teachers. [9–14].
|
Enthusiasm
Psychosocial focus
Identifies self as a teacher
Communication skills
Role model actions
Encourages education and independence
|
Goals are the centerpiece of education. To the extent possible, adult learners should assist in determining their learning goals. Learners can reflect on their existing knowledge and identify gaps that must be filled. This strengthens their internal motivation and develops a sense of responsibility for their education. In an ED, goals can be established any time, including during orientation, at the beginning of a shift, or on the fly as a resuscitation is about to begin. However, learners cannot set these goals alone. Goals may emerge after negotiation between the student and teacher. Educator input is also valuable in ensuring that learners have set specific, achievable, measurable goals.
During orientation, off-service rotators and medical students should be asked to consider what they hope to achieve during their time in the ED. Many will have very limited goals. They should be challenged to expand their thinking. The ED is a place for non-EM physicians to face problems outside their chosen practice. Consider having the physicians-in-training establish a goal for the day at the beginning of a shift. It might focus on a portion of the history-taking process, such as asking each patient the nature of his or her employment. Alternatively, the learner can enhance physical examination skills, such as listening for a cardiac murmur in each patient. Educators can help the learners recognize unrealistic goals, such as improving their technique for chest tube placement.
Some non-EM rotators may want to learn all about EM while in the ED. Non-EM physicians-in-training often present unique challenges because they might have goals for the rotation that are different from their teachers' plans to teach them “emergency medicine.” An orthopedics intern might seek musculoskeletal injuries, while an internal medicine physician-in-training might conduct lengthy, inpatient workups on ED patients. It may be impossible to force these physicians-in-training to meet the instructors' desired goals. Negotiation becomes an important part of the process. Attempts to force certain goals on some learners will result in frustration for all. Admittedly, not all readers will agree with this opinion; some clinician educators believe that all rotators should be taught everything about EM.
Learners may struggle to choose goals. Instructors can assist by asking questions to identify areas of weakness. For example, a physician-in-training may say, “I hate eye complaints.” Questioning reveals that this aversion is related to a lack of comfort with performing a complete eye examination. If the physician-in-training is an EM physician, the instructor can ensure the examination is taught during the shift. If the learner is not an EM physician and has no interest in learning the details of the eye exam, then time might be wasted in trying to do so. It might be time to probe again and find a weakness that is of interest.
Involving learners in planning educational activities has many benefits, including helping the facilitators identify possible problems before they become definite issues. Facilitators can redirect learners when they are offtrack and provide recommendations for problem-solving resources.
This technique applies easily to procedures. All care providers have preferred approaches for different procedures. Physicians-in-training may not have a broad-enough exposure to different techniques. Asking one to try a different technique or approach may result in some resistance. Asking “Why do you think it may be valuable to know how to place internal jugular central lines rather than just femoral lines?” may help the learner realize that not all approaches are available in all patients. Consequently, the physician-in-training gains motivation for learning a new approach. Having learners discuss procedures before they are done reinforces the appropriate steps and identifies knowledge gaps before undertaking the tasks. Being present during the procedure is ideal, although often impractical. It is reasonable to consider that different procedures have different levels of risks and thus different levels of need for the teacher's physical presence.
Educating during a procedure or resuscitation is difficult, but these complex scenarios offer new material that can be taught immediately. Educators naturally want to intervene and/or make comments, but doing so may be at the expense of the physician-in-training. These moments require the difficult balance of patient care with education. Intervention by the teacher can embarrass the learner, potentially harming the student–teacher relationship. However, patient care is the most important consideration. There is no easy answer for these potentially conflicting interests; there are no absolutes. Minor mistakes by a physician-in-training can be just as acceptable as the teacher stepping in at a truly life-threatening moment. Those of us who practice EM know that the truly life-threatening moments, where key decisions in a matter of very few minutes will affect life, are few. Usually, there is time for the teacher to discuss the situation with the learner, facilitating and guiding. An excellent location for the teacher is right behind the learner. From this position, the teacher can quietly make comments to the learner, enabling the learner to remain “in charge” by being the one who speaks to the resuscitation personnel. Once the life-threatening moment has passed, mistakes can be addressed during the postresuscitation review. A debriefing after such encounters is imperative. This can be used to address areas of deficiency and needs for improvement and to complement the learner on decisions or actions that were correct.
Many teachers can draw on “canned” brief presentations, such as the causes and evaluation of syncope, the management of asthma when standard medications fail, the emergency causes of chest pain, or how to interpret a chest film. Educators keep these discussions fine-tuned and ready for use when the appropriate moment presents itself. These lectures are brief, usually no longer than 3 min; this helps the learner retain the information (by avoiding information overload) and does not significantly delay patient care.
By evaluating their learning experiences, adult learners identify ongoing knowledge gaps and recognize whether goals were met. These evaluations do not use formalized exams; they may be done with a brief discussion between the learner and the teacher. Reviewing key aspects of patient encounters can be very helpful, especially if it includes comments on previously established goals.
A verbal discussion (or evaluation) is routine during standard patient presentations by physicians-in-training. After the presentation of history and physical examination, a physician-in-training can be asked to formulate a differential diagnosis, can be asked what he or she wants to do from this point, and can be inquired about the thought processes behind both. This gives the educator an insight into the learner's understanding of the patient's illness as well as whether the learner has an appropriate diagnostic approach. This also is a chance for the educator to guide the learner back on track if the plan does not seem appropriate based on the presentation.
A similar recap should take place after the physician-in-training has undertaken a specific challenge, such as a new approach in a procedure. A similar line of query such as “How did you think this went? What did you learn? What would you have done differently?” gives the learner a moment to evaluate his or her own performance, again reinforcing the new material.
Table 1.2