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Clinical teaching in a busy emergency department: Strategies for success

DOI:10.1017/S1481803500007545
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Rick Penciner at University of Toronto
Rick Penciner
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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.
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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).2The 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.3Decide 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.5Teaching 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.8Avoid 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.7The 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.4Trainees 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.
References
1. Irby DM. Clinical teacher effectiveness in medicine. J Med Ed
1978;53:808-15.
2. Irby DM, Ramsey PG, Gillmore GM, Schaad D. Characteristics
of effective clinical teachers of ambulatory care medicine. Acad
Med 1991;66:54-5.
3. Chambers R, Wall D. Teaching made easy: a manual for health
professionals. Abingdon: Radcliffe Medical Press; 2000. p. 111.
4. Ende J. What if Osler were one of us? Inpatient teaching today.
J Gen Int Med 1997;12(suppl 2):S41-8.
5. McGee SR, Irby DM. Teaching in the outpatient clinic: practical
tips. J Gen Int Med 1997;12(suppl 2):S34-S40.
6. Rubenstein W, Talbot Y. Medical teaching in ambulatory care: a
practical guide. New York: Springer Publishing Company;
1992. p. 13-29, 60-68.
7. Brancati F. The art of pimping. JAMA 1989;262:89-90.
8. Ende J. Feedback in clinical medical education. JAMA
1983;250:777-81.
9. Bayley T. Learning principles. In: Bayley T, Drury M editors.
Teaching and training techniques for hospital doctors. Abing-
don: Radcliffe Medical Press; 1998. p. 1-8.
10. Irby DM. Teaching and learning in ambulatory care settings: a
thematic review of the literature. Acad Med 1995;70:898-931.
11. Orlander JD, Fincke BG. Soliciting feedback: on becoming an
effective clinical teacher. J Gen Int Med 1994;9:334-5.
12. Knight JA. Our physician forebear Sir William Osler as teacher
to emulate. In: Edwards JC, Marier RL editors. Clinical teaching
for medical residents: roles, techniques and programs. New
York: Springer Publishing Company; 1988. p. 35-49.
13. Rowe MB. Wait time: slowing down may be a way of speeding
up. J Teacher Ed 1986;37:43-50.
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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November 14 & 15, 2002
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Speakers for the Detroit Trauma Symposium
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The art of teaching is difficult to master. When teaching in small groups, as often happens in clinical medicine, there is an opportunity to find out what works by speaking directly with students. The information they provide can serve as an invaluable guide, permitting refinement of skill over time. There are, however, significant barriers to this process. The art lies in finding an approach that is comfortable for both parties. The authors refer to this activity as soliciting feedback. They offer guidelines for soliciting feedback as an aid to improving teaching efforts.
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The Art of Pimping
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  • Aug 1989
IT'S HARD work becoming a revered attending physician in a university hospital. The task daunts the newly appointed junior attending as he strides down the corridor of his first ward with his first team. Oh, he's made some changes in anticipation of his new position. He's wearing a long coat now, an all-cotton coat with razor-sharp creases and knit buttons. The stained, shrunken polyester white pants and tennis shoes have given way to gray, light wool slacks with a cuff and polished loafers. Framed certificates bear testimony to his intelligence and determination. He should be ready to take the helm of his ward team, but he's not. Something's missing, something important, something closer to art than to science. When physicians talk about the "art of medicine" they usually mean healing, or coping with uncertainty, or calculating their federal income taxes. But there's one art this new attending needs to learn
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Teaching and Learning in Ambulatory Care Settings: A Thematic Review of the Literature
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A thematic review was conducted of the 1980-1994 research literature on teaching and learning in ambulatory care settings for both undergraduate and graduate medical education. Included in the review were 101 data-based research articles, along with other articles containing helpful recommendations for improving ambulatory education. The studies suggest that education in ambulatory care clinics is characterized by variability, unpredictability, immediacy, and lack of continuity. Learners often see a narrow range of patient problems in a single clinic and experience limited continuity of care. Few cases are discussed with attending physicians and even fewer are examined by them. Case discussions are short in duration, involve little teaching, and provide virtually no feedback. Excellent teachers are described as physician role models, effective supervisors, dynamic teachers, and supportive persons. Rather than block rotations, students and residents prefer longitudinal teaching programs, which offer continuity-of-care experiences with patients and preceptors. Although little can be concluded about learning outcomes, the studies indicate that some medical students and residents have deficient skills in interviewing, physical examination, and management of psychosocial issues. Based on the reviewed studies, the author recommends facilitating learning by increasing continuity-of-patient-care experiences and contact with faculty members, encouraging collaborative and self-directed learning, providing faculty development, and strengthening assessment and feedback procedures. The author also recommends further research to learn about medical specialties other than internal medicine and family medicine, to describe the knowledge and reasoning of both teachers and learners, and to assess the influences of various educational programs on learning and satisfaction.
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