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Clinical teaching in a busy emergency department: Strategies for success

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Abstract

Clinical teaching is an integral part of emergency medical practice. With the growing number of medical students and residents in the emergency department there are increasing expectations for clinicians to teach. But there are many challenges and obstacles to overcome when teaching in a busy department. By incorporating diverse strategies and techniques, we can become more effective and efficient emergency medicine teachers.
286 CJEM • JCMU July • juillet 2002; 4 (4)
ABSTRACT
Clinical teaching is an integral part of emergency medical practice. With the growing number of
medical students and residents in the emergency department there are increasing expectations
for clinicians to teach. But there are many challenges and obstacles to overcome when teaching in
a busy department. By incorporating diverse strategies and techniques, we can become more ef-
fective and efficient emergency medicine teachers.
RÉSUMÉ
L’enseignement clinique est une partie intégrante de la pratique de la médecine d’urgence. Avec le
nombre grandissant d’étudiants en médecine et de résidents au département d’urgence, le besoin
de cliniciens enseignants se fait de plus en plus grand. En intégrant diverses stratégies et tech-
niques, nous pourrons devenir des professeurs de médecine d’urgence plus efficaces et efficients.
EDUCATION • ÉDUCATION
Clinical teaching in a busy emergency department:
strategies for success
Rick Penciner, MD
*
Introduction
Emergency physicians teach residents and medical students
for many reasons. Some teach because they gain knowledge
and skills through these interactions. Others believe it is
their professional responsibility to train a new generation of
physicians. For some, teaching is a condition of employ-
ment — a requirement to maintain hospital privileges.
As the popularity of emergency medicine rotations in-
creases, so have the number of trainees in the emergency
department (ED). The ED is recognized as great training
ground not only for family medicine and emergency medi-
cine residents, but for most other specialties also. As a re-
sult, more trainees are being placed in “teaching hospitals”
and in busy community hospitals for their emergency med-
icine rotations. More emergency physicians are sharing
teaching responsibilities.
Physicians face unique challenges and obstacles when
teaching in busy EDs. Patients often have serious illnesses
requiring immediate expert care, and emergency physi-
cians must maintain patient flow, care quality and patient
satisfaction while teaching. Physicians may feel uncertain
about their ambiguous role with the trainee. Are they a su-
pervisor, mentor, teacher or evaluator? And clinical teach-
ers face challenges involving trainees at different levels,
trainees from different specialties, and “difficult” trainees.
To complicate matters, few physicians are trained as teach-
ers and even fewer are paid to teach.
Although there is a fair body of medical literature on how
to teach in the ambulatory setting and on the wards,
1,2–5
there
is essentially no guide on how to teach in the ED. How can
emergency physicians become more effective and efficient
clinical teachers? This article outlines strategies that will help
create a more effective and efficient teacher in a busy ED.
This article has been peer reviewed.
Received: Mar. 7, 2002; final submission: May 5, 2002; accepted: May 7, 2002
From the Department of Emergency Medicine, North York General Hospital, Toronto, Ont.
*Assistant Professor, Department of Family and Community Medicine, University of Toronto
Key words: clinical teaching, effective teaching, trainees, students, education
This paper is based on a presentation made at Mount Sinai Hospital, Toronto, Ont., Nov. 28, 2001, as part of a faculty development work-
shop on teaching in the emergency department.
Strategies for success
Researchers have identified the most common characteris-
tics of an effective clinical teacher in medicine and ambu-
latory care medicine,
1,6
as perceived by medical students,
residents and faculty. The best clinical teachers are de-
scribed as being enthusiastic, clear and well organized, and
adept at interacting with students and residents. They are
actively involved with the learner, promote learner auton-
omy and demonstrate patient care skills.
To succeed in the ED, physicians need to be effective,
efficient teachers. The emergency physician should de-
velop and use various strategies when teaching. A good
strategy for organizing ED teaching is to think in terms of
“How will I teach?” and “What will I teach?”. The former
refers to teaching style, and the latter to learning domain
(knowledge, skills, attitudes).
2
The following strategies are
based on published literature, feedback from colleagues
and trainees, and personal observations.
Get to know the trainee and plan the shift together
At the beginning of the rotation or shift, get to know the
trainees. Address them by name. Enquire about their pro-
gram, level of training, objectives for the rotation and their
emergency medicine experience. Communicate your ob-
jectives, expectations and evaluation criteria for the
trainee.
3
Decide together whether this shift will have a par-
ticular emphasis. One shift might focus on treatment plans,
another on procedures. Encourage more efficient and less
frustrating interactions with the trainees by telling them
how you want them to present their cases. Provide guide-
lines to make the presentations more concise, complete
and thoughtful.
4
Listen more and talk less
William Osler was a remarkable teacher, known for clarity,
precision and economy of words.
5
Teaching style may in-
clude telling (didactic), asking and showing.
7
Didactic teach-
ing is an inefficient and passive way to learn. Asking ques-
tions can be done using the Socratic Method, where the
trainee is gently led to the answer, or in a more direct fash-
ion — the latter being more common in medical teaching.
When questioning a trainee, be sure to ask questions that are
clear, brief, focused, and that have more than one acceptable
answer. Then allow the trainee time to respond. Researchers
have found that, in many cases, teachers wait less than 1 sec-
ond for students to respond. By prolonging this wait time to
at least 3 seconds, students’ responses become 3 to 7 times
longer and contain more logical arguments and speculative
thinking.
8
Avoid pimping. This age-old teaching method oc-
curs when the teacher asks essentially unanswerable ques-
tions in rapid succession.
9
Showing the trainees is effective
but time consuming. This might include demonstrating pro-
cedures or teaching at the bedside.
Encourage trainees to commit themselves and allow
them to make mistakes. Have them write down treatment
plans and orders, no matter how wrong they may be. Toler-
ate errors and review their charting regularly. This is a
great source of teaching material and it can be done at any
time.
7
The chart can serve as a focal point for case review,
to stimulate a teaching point, and to guide further reading
or teaching.
Seize the teachable moment and provide
early feedback
Every case has a teaching point. The teaching point should
be brief; it should not include everything the teacher knows
about the subject. It should address the patient’s concerns
and the learner’s needs.
4
Trainees often complain about the
lack of feedback.
10
Feedback should be given frequently
and in a timely fashion, either formally or informally. It
should be specific and based on first-hand observation.
11
Allowing the trainee to self evaluate first will make your
role easier. Tell the trainees when you are going to provide
feedback and invite similar feedback from them — to im-
prove your teaching performance.
12,13
Allow trainees — especially junior trainees — to have
successes while working. Set up positive patient interac-
tions and be sure they can answer at least some questions.
This builds confidence and enthusiasm for the remainder
of the rotation. Encourage self-directed learning by sug-
gesting the trainee seek answers to clinical questions that
arise. Excellent teachers stimulate learners’ curiosity and
engender an excitement for learning.
13
Finally, try to directly observe the trainee. Although
this is time consuming, it will pay off immensely for the
July • juillet 2002; 4 (4) CJEM • JCMU 287
Clinical teaching in the ED
Researchers have found that ...
teachers wait less than 1 second
for students to respond. By
prolonging this wait time to
at least 3 seconds, students’
responses become 3 to 7 times
longer and contain more logical
arguments and speculative
thinking.
Penciner
288 CJEM • JCMU July • juillet 2002; 4 (4)
trainee and the teacher. You will have a better assess-
ment of how the trainee actually performs indepen-
dently.
13
Direct observation should not be limited to pro-
cedures. The ED provides a unique opportunity to
observe trainees performing histories and physical ex-
aminations of patients.
Expose trainees to good “teaching cases”
Direct them selectively to interesting and appropriate cases
for their level of training. Encourage them to do proce-
dures or tasks that might otherwise be delegated to nursing
staff. Trainees should give tetanus immunizations, fit pa-
tients for crutches and apply slings. Tell trainees about in-
teresting cases that they are not directly involved in. Share
educational x-ray, EKG and physical findings with them.
Improve efficiency and maximize your teaching
In a busy ED when time constraints are a reality, physi-
cians must be efficient yet still provide an effective learn-
ing environment. Teach more than one trainee at a time
when appropriate. Allow senior trainees to teach junior
trainees (this creates a valuable learning experience for the
seniors). Encourage other ED staff to teach trainees. For
example, a nurse can teach how to start an intravenous, and
an orthopedic technician can teach how to apply a cast.
Conclusions
Clinical teaching in a busy ED is both challenging and re-
warding. By incorporating multiple and varied strategies
we can become more effective and efficient teachers. Be-
cause only some of these strategies may work in any given
situation, it is important to be flexible and creative. Re-
spect and acknowledge your own teaching ability, knowl-
edge and style.
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Competing interests: None declared.
Correspondence to: Dr. Rick Penciner, North York General Hospital, 4001
Leslie St., North York ON M2K 1E1; rick.penciner@utoronto.ca
SYMPOSIUM
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Margaret Campbell, R.N.
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Sr. Janet Hudspeth
M. Margaret Knudson, M.D.
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Stewart C. Wang, M.D.
November 14 & 15, 2002
at the Detroit Marriott Renaissance Center
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Speakers for the Detroit Trauma Symposium
... The emergency department (ED) is arguably the richest clinical teaching laboratory for medical students in medical education today, secondary to the high volume of patients with a broad range of undifferentiated complaints, and varying need for evaluation, stabilization, and diagnosis. 1,2 Limited time, regular interruptions, and a lack of institutional rewards for education, as well as other barriers, contribute to the challenges of clinical teaching. [1][2][3] The education of medical students within the ED demands a successful balance between providing high quality, efficient medical care to patients while creating outstanding educational experiences for learners. ...
... 1,2 Limited time, regular interruptions, and a lack of institutional rewards for education, as well as other barriers, contribute to the challenges of clinical teaching. [1][2][3] The education of medical students within the ED demands a successful balance between providing high quality, efficient medical care to patients while creating outstanding educational experiences for learners. [2][3][4] Currently, more than half of the medical schools in the United States require students to rotate through the ED during their undergraduate medical clerkships. ...
... [1][2][3] The education of medical students within the ED demands a successful balance between providing high quality, efficient medical care to patients while creating outstanding educational experiences for learners. [2][3][4] Currently, more than half of the medical schools in the United States require students to rotate through the ED during their undergraduate medical clerkships. 5 Most of the required clinical emergency medicine (EM) clerkships take place in the fourth year of medical school; however, many schools offer clerkships in the third year. ...
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Introduction: One published strategy for improving educational experiences for medical students in the emergency department (ED) while maintaining patient care has been the implementation of dedicated teaching attending shifts. To leverage the advantages of the ED as an exceptional clinical educational environment and to address the challenges posed by the rapid pace and high volume of the ED, our institution developed a clerkship curriculum that incorporates a dedicated clinical educator role - the teaching attending - to deliver quality bedside teaching experiences for students in a required third-year clerkship. The purpose of this educational innovation was to determine whether a dedicated teaching attending experience on a third-year required emergency medicine (EM) clerkship would improve student-reported clinical teaching evaluations and student-reported satisfaction with the overall quality of the EM clerkship. Methods: Using a five-point Likert-type scale (1 - poor to 5 - excellent), student-reported evaluation ratings and the numbers of graduating students matching into EM were trended for 10 years retrospectively from the inception of the clerkship for the graduating class of 2009 through and including the graduating class of 2019. We used multinomial logistic regression to evaluate whether the presence of a teaching attending during the EM clerkship improved student-reported evaluation ratings for the EM clerkship. We used sample proportion tests to assess the differences between top-box (4 or 5 rating) proportions between years when the teaching attending experience was present and when it was not. Results: For clinical teaching quality, when the teaching attending is present the estimated odds of receiving a rating of 5 is 77.2 times greater (p <0.001) than when the teaching attending is not present and a rating of 4 is 27.5 times greater (p =0.0017). For overall clerkship quality, when the teaching attending is present, the estimated odds of receiving a rating of 5 is 13 times greater (p <0.001) and a rating of 4 is 5.2 times greater (p=0.0086) than when the teaching attending is not present. Conclusion: The use of a dedicated teaching attending shift is a successful educational innovation for improving student self-reported evaluation items in a third-year required EM clerkship.
... The learners range from medical students to residents and fellows with the different learning needs. 19 The Mini-CEX was introduced in our residency training program in 2013. Before the introduction of Mini-CEX there were informal feedback sessions provided by the supervising faculty. ...
... Studies have shown that it has been applied to specialty training like dermatology, neurology, Anaesthesia, Internal Medicine, Psychiatry and Cardiology. 17,[19][20][21][22][23] The ED Residents reported (Table 1) overall satisfaction with Mini-CEX as an assessment tool. A total of 61.2% agree that they were satisfied with Mini-CEX as an assessment tool, and it helped them uplift their personal development and focus on their weak points. ...
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... A new norm should be established, knowing that the new disequilibrium can catalyse conflicts, misunderstandings, frustrations, avoidance, panic, anxiety, confusion and even fear. These must be anticipated and planned for early, addressing them through strategic plans, interventions and communications (3)(4)(5). Leaders, supervisors and faculty can help to facilitate the adaptation. They can help by ensuring early engagement with the healthcare staff. ...
... During pandemics, we have to rethink about how medical education is conducted and delivered. There would probably be an increase in the use of technology, but this has to be of the correct balance and combination in order to maintain realism, credibility and capabilities (5,9). At the same time, issues of maintaining confidentiality and ensuring cyber-security must be mainstreamed (10,16). ...
... 48 Although it may not be feasible to observe every patient encounter during an ED shift, the educator could select one patient encounter or specific components of several consecutive encounters (eg, updating patients and family members, obtaining consent) to observe. 49 ...
... After the patient encounter, begin with clear, brief, and open-ended questions that have more than one acceptable answer. This method establishes rapport with the learner before progression to more difficult questions; 13 for example, the following: ...
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Teach effectively in the Emergency Department (ED) by leveraging the challenges of the ED environment to create spaces and opportunities for learning. Use a framework to start your teaching—this helps learners approach patients in a systematic way to create learning opportunities on every case. Employ a strategy of “planned spontaneity” that allows for interruption. Effective teachers use the unpredictable, undifferentiated patient to help learners become more comfortable with uncertainty and the management of the sick, undifferentiated patient. Finally, take advantage of the communication skills required to practice emergency medicine well, and use them to teach important interpersonal and communication skills.
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Introduction Strategies versus traits Models to guide emergency department teaching Diagnosing the learner Summary References
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