Friday, April 1, 2011

The EM Resident as Teacher

Originally Published: Common Sense, Spring 2011
Original Author: Leana Wen, MD MSc

It’s the start of your shift, and every bay is full. There are 37 patients in the waiting area. A bright-eyed third year medical student runs up to you and tells you that he has a new patient. “He’s a 40-year old with lung cancer with a chief complaint of fever and chills. He says he has a cough and hasn’t been eating well at

home and also has some abdominal pain after his chemo. On his physical exam, he had some abdominal tenderness and guarding. I think he has some kind of viral syndrome or pneumonia or sepsis. I’m not sure what to do but I think we should get some labs.” Whoa! All kinds of thoughts run through your head. How sick is this guy? Is he neutropenic with a fever? Does he have a surgical abdomen? What kind of differential is that: viral syndrome or sepsis? This patient is too sick, you decide. I need to take over myself. So you thank the med student and go see the patient yourself. The student doesn’t know what he’s doing, you decide. It’s a busy shift, and you don’t have time to teach.

As we transition from interns to junior to senior residents, a growing part of our responsibility is leadership and teaching. During residency, all of us teach medical students. Even if we don’t stay in academics, teaching is still a critical skill, because we will continue to teach physician extenders, nurses and our patients. Learning how to teach also enables us to become better lifelong learners.

Yet, of all of the skills we learn in residency, learning how to teach is something we are just expected to know how to do. Few programs provide specific training on how to teach — which is unfortunate, because educators know that teaching, like practicing medicine, is a skill that requires training, focus and commitment. This article is by no means sufficient as a guide to teach, but I will provide some
tips and a simplified model for you to teach in the ED.

“But I don’t have time. The ED is busy enough as it is. It’s faster to have a student tag along with me than for the student to see the patient by himself. Besides, I don’t know enough to teach.”

It’s probably true that you can see patients faster on your own. Our attendings can probably see patients faster on their own, too. If everyone thought that way, no one would ever learn! As for knowledge, you will see as we go along that you know far more than you think you do.

Tip #1: Set goals and expectations
Have a quick talk at the start of your shift. Ask them where they are in their clinical training (third vs fourth year, how many rotations they’ve done, etc.) and what their goals are from this rotation (first
rotation of third year vs sub-internship wanting to learn procedures, etc.). Give basic expectations on your end. These might include talking to you before signing up for patients so you can assign them specific people; coming to find you immediately if there are concerning vital signs or any sign of the patient being unstable; and presenting to you within 15 minutes of seeing the patient. Let them
know that your first and foremost goal in the ED is patient care, but you are also committed to teaching — and the two can happen together, even in the busy ED setting.

Tip #2: Enforce the three-minute presentation
Before the student presents the patient to you, make sure the student understands that being concise and focused is key. As such, they should aim to give a presentation of no more than three minutes. This three-minute presentation model was adapted for EM by Davenport, et al, as a way to train students to the EM-presentation style and also help teachers provide specific feedback. Let the student know this is your expectation. Keeping the presentation to three minutes allows you more time to teach the student, as well as get on with your work.

Tip #3: Teach by the one-minute preceptor model

Neher and colleagues developed a five-step interactive teaching process called the one-minute preceptor model. Initially designed for the outpatient setting, it works equally well for the ED. I’ll show how it applies to the example at the beginning.

  • Step 1: Get a commitment
    “So what do you think is going on? Does the patient look very sick? Viral syndrome is very different from sepsis.”
  • Step 2: Probe for supporting evidence
    “What were his vital signs? You said he has a fever, but his heart rate and blood pressure are normal. What do these vital signs tell you about whether he is in sepsis?” “Where do you think his fever is coming from? What about from the abdomen — tell me about the belly exam again?”
  • Step 3: Teach a general principle
    This could be a good time to talk about fever in cancer patients.You can talk about sepsis and the criteria for sepsis. You can talk about the abdominal exam. If you are strapped for time, choose one teaching point and focus on that.
  • Step 4: Reinforce what was done
    “I’m glad you came to get me as soon as you saw the patient. He could be very sick.”
  • Step 5: Correct learner’s errors and make recommendations for improvement
    “It’s important to include vital signs in your presentation. Saying that someone has guarding is very serious, so make sure to do a thorough abdominal exam and provide an accurate description of it.”
Tip #4: Model professionalism
Maybe you’re an intern and you don’t have formal teaching responsibilities in the department yet. Maybe you’re rotating at a hospital without students. No matter what, you are a leader, and part of your responsibility is to serve as a role model for others to those around you. As one of my mentors says, the ED is the modern home of diagnosis. We see the entire breadth of patient problems across the entire range of acuity. The ED is THE place for medical students to hone their history and physical skills and to learn to develop their differential and plans. It is a challenging, but students, our profession and ourselves.

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