Opportunistic teaching in ED  – my new life as a junior junior doctor

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I’m in an unusual and uncomfortable position this year as I embark on my year of Adult Emergency Medicine. I’ve spent the last 13 years working in paediatrics, and have been working hard to be the best I can be at my job. I’m always learning in paediatrics, so it’s not that I feel I’m the perfect paeds doc, but I had confidence in my clinical skills and decision making and felt I reached a good balance in the whole ‘knowing what you don’t know you know’ spectrum. As part of PEM training, I’m now submerged into a year of adult Emergency Medicine, having only seen adult patients for an unmemorable (or perhaps I’ve blocked the memories out) eight months back in 2003. Let’s just say, it’s a learning curve, and I’m only at the beginning. But that is a post for another time.

It has given me a unique opportunity. To go back to being a very junior and inexperienced member of the team. To go back to being the one feeling unconfident and asking what must seem like completely daft questions all the time. To go back to spending time worrying about how I am perceived by colleagues none of whom I knew previously. Perhaps it’s worse because, in 2003, I really didn’t know much having freshly graduated and being only 23, so that was a relatively normal state to be in. Now, I’m 36 and I have insight into my role and my value to the team. It’s not easy.

I was on my fourth shift when one of my colleagues tactfully pointed out that I was wearing a paediatric stethoscope.

But in 18 months, I’ll be back in my comfort zone, hopefully as a consultant myself or if not, a senior registrar. This is a unique opportunity for me to be on the receiving end, and to work out what kind of educator I want to be in my clinical practice.

 

Is it difficult to teach in Emergency Departments?

The Emergency Department does pose challenges with regards to opportunistic teaching. Departments are busy, and the environment can be stressful and pressurised with patient flow demands adding pressure on staff to move things along. However, the research shows that a busy department is no barrier to good quality teaching. A study by Grall et al (2013) analysed how teaching methods delivered by known excellent ED educators changed depending on the workload, patient acuity and learner level of training. The authors found that most teaching from excellent ED teachers fell into four main categories:

Questioning: either asking questions to obtain information about the case or to assess juniors’ knowledge base. Sometime questions used were broad with the aim of triggering further discussion (“What else should we do for him?”).

Advice giving: this could be advice given after being asked by a junior ‘What do you think the next step in management should be?”; or unsolicited advice given, for example, to help with a procedure (“You may be better using size 6.0 sutures for the face”). There is some discussion as to whether this is really teaching or more just part of feedback.

Limited teaching points: delivering a few key teaching points to answer a specific questions i.e. “What is the first line management of asthma?”

Patient updates: juniors present their patients briefly and this is a basis for seniors to reinforce or amend the management plan.

In this study, the educators adapted their teaching strategy according to the learner’s level of training and the patient acuity. The volume of patients in the department did not affect their teaching strategies. Additionally, as Chris Nickson identifies, in Australia much of the teaching falls on the shoulders of the registrars, who receive little or no training in how to educate.

 

The key to being an excellent educator

There are many skills that make a good clinical educator – being approachable, passionate, enthusiastic, knowledgeable, flexible, a role model, a facilitator, a leader are just a few. There are some broad areas to consider:

Supervision and feedback. This is critical to developing your junior doctors’ competencies. It can help identify areas of difficulty, prevent mistakes, whilst also highlighting strengths. Supervision is an important skills for all trainees to learn, particularly as they come towards the end of their training.

Avoid teaching by humiliation. This should have been largely phased out by now, and yet it is still around. This is the technique of pimping – firing questions at your junior rapidly and often with unanswerable questions. A 1989 article in JAMA highlights the practice and even offers helpful tips for those who are being pimped to survive/bluff their way through the process.

“I must say that pimping accomplished only four things for me: (1) establishment of a pecking order among the medical staff; (2) suppression of any honest and spontaneous intellectual question or pursuit; (3) creation of an atmosphere of hostility and anger; and (4) perpetuation of the dehumanization for which medical education has been criticized.”

– Stanton C. Letter. JAMA 262(1989):2541-2

Whilst many of us haven’t quite taken it these extremes, it iss easy to make a quip to your junior when you’re feeling stressed and annoyed that they’ve asked you something that they should probably know already. I’m embarrassed to say that when I think back I’ve done it myself.

Uphold the dignity of the patients. This is one of the key tenets of medicine. Emergency Departments are an easy environment to let your standards slip. Alcoholics, drug overdoses, obese patients, unimmunised children, teenagers with mental health disorders – seeing patients with these problems every day can really harden your heart and increase your cynicism. The best doctors are the ones who can retain respect for their patients and remind their juniors that people come to the Emergency Department when they are feeling at their worst, their most desperate, or they simply don’t know what else to do. Our role is more than just treating the patients with sepsis or those who are actually dying. We also need to look after the parent who’s brought their child in with abdominal pain for the third night in a row, or the new mum who’s struggling to manage her newborn, or the patient who has had haemorrhoids for 5 weeks but decided to get them seen to on a Friday night. And that doesn’t always mean we need to congratulate them for attending and welcome them with open arms, but we need to offer them the appropriate management, support, advice, or education. It’s not just how we talk to them, but also how we talk about them when we are discussing the cases with our colleagues, or handing them over to the next shifts.

Set the culture. The culture in the Department is set by the consultants. In any work environment, the senior staff lead the way in setting standards. When the consultants put pressure on their senior registrars, then this naturally flows down the chain. The best teaching environments are where the bosses value their role of educator.

Self-reflect. This isn’t just important as an ePortfolio requirement. It’s important because once we become more senior, we need to continue to want to improve. Reflecting on our practice and our conduct with our colleagues allows us to identify weakness and work on them. The reflective process includes: linking previous experiences; considering the experience from multiple perspectives; reframing; identifying lessons learnt; and planning for the future.

I’ve lapsed in all of these areas in the past, I suspect many of us have. It’s easy to exude aloofness to your juniors because it’s less hassle if they are reluctant to approach you. It’s easy to joke as you hand over the abusive alcoholic to the night shift while we wait for him to sober up. It’s easy to be too busy trying to treat your patients’ medical conditions with great clinical effectiveness to work on your educational responsibilities too. But there is more to being a great doctor than knowing the best clinical treatment for your patient. You have to see them as a person and treat them with dignity. You have to see your juniors as trainees like you once were who are relying on you to help them develop into the excellent clinician you have become. And you have to remember why you became a doctor in the first place.

 

Practical guidance on being a good teacher

In practice, there is a framework for registrars to use for teaching – the ADDIE approach (analysis, design, development, implementation, and evaluation). http://www.annemergmed.com/article/S0196-0644(09)01739-9/fulltext It’s summarised in Life in the Fast Lane as follows:

Assessing the learner
Evaluate the learner’s existing knowledge base and begin with clear, brief, and open-ended questions that have more than one acceptable answer.
e.g. “Do you have any specific learning goals for this shift or rotation that I can help you meet?”
e.g “What can you tell me about pulmonary embolism?”

Determining the instructional content
Determine gaps in learner understanding concentrating on one of: knowledge, communication, procedural skills, attitudes and behaviours; and use a patient-orientated approach that can be readily applied by the learner.
e.g. “Let’s talk about D-dimer and its diagnostic value for this patient. Do you think it would be helpful for us?”

Determining the instructional method
Choose an appropriate method for delivering the information (e.g. didactic, Socractic, demonstrative – see the original article for more on these)
e.g. Critical patient encounter: “Pay close attention to my intubation technique.”
e.g. Emergent patient encounter: “What are your first steps in diagnosis and management?”
e.g. Lower-acuity patient encounter: “Let’s do a literature search to find the best answer to this question.”

Determining the effectiveness of instruction
Assess the success of the educational intervention by direct questioning, direct application, or using case-based hypotheticals.
e.g. “How would your management have been different if his D-dimer were negative?”

And Amal Mattu’s talk on Teaching in the ED gave 10 top tips for teaching students in the Emergency Department:

  1. Teach less so that others learn more – don’t try to teach more than 4 things in a session.
  2. Teach the right thing at the right time – i.e. don’t show someone how to draw the coagulation cascade at 4 in the morning!
  3. Listen with your eyes and your ears, and make sure others do too!
  4. Teach others how to learn so they can become responsible for their own learning
  5. Set time-limited learning objectives
  6. Use the ‘What if?’ technique of learning – this helps to develop associations, keep things fun and guard against availability bias (only things that are easy to remember tend to spring to mind); e.g. “What if the patient with X is also on warfarin?”
  7. Use the ‘Hear hoof beats? Think of lions, tigers and bears!’ technique – what are the deadliest differential diagnoses for a presentation?
  8. Don’t be afraid of silence – let the student come up with an answer.
  9. Be specific about what the student did well and provide constructive feedback. Suggest how the student can address their learning needs.
  10. Ask the student, “what did you do well, and what can you improve on?”
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About 

Tessa Davis is a paediatric emergency registrar from Glasgow and Sydney, but currently living in London. Tessa tries to spend time with her 3 kids in between shifts. @tessardavis | + Tessa Davis | Tessa's DFTB posts