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Clinical teaching in a busy emergency department: Strategies for success



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)
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.
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.
Clinical teaching in a busy emergency department:
strategies for success
Rick Penciner, MD*
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
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.
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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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
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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;
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... 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
... 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. ...
Full-text available
Background: Mini Clinical Evaluation Exercise (Mini-CEX) has been adapted to different specialties in clinical practice but with very little evidence documented about its use for residency training in the emergency department (ED). This study aims to assess its acceptability and feasibility as a formative tool in the busy emergency department. Materials and methods: Both the faculty members and the emergency medicine residents were sent a validated questionnaire using Google forms, and the results were analyzed using simple statistical tools. Results: Forty-nine residents and 58 faculty participated in the survey. The study was carried out over a period of 4 months. The resident's completion rate was 96% (49 out of 51), while faculty completion rate was 96% (58 out of 60). The time for Mini-CEX completion ranged from 10 to 20 minutes. Most of the residents were satisfied with Mini-CEX as an assessment tool. Twelve residents expressed their concern regarding available time during busy clinical shifts. Most of the faculty agreed with the benefits of using Mini-CEX as a formative assessment tool. Several of them commented that they need "protected time" and "more training" to use this tool to provide maximum benefit to the residents. Conclusion: Despite busy nature of ED, Mini-CEX has been identified as an acceptable learning tool for residents in emergency medicine. Based on the faculty's feedback and comments, several faculty development workshops were conducted to improve faculty skills in carrying assessments by using Mini-CEX, and protected time is provided to some faculty members to carry out these formative assessments for the benefit of the residents.
... 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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Clinical teaching is the primary educational tool use to train learners from day one of medical school all the way to the completion of fellowship. However, concerns over time constraints and patient census have led to a decline in bedside teaching. This paper provides a critical review of the literature on clinical teaching with a focus on instructor teaching strategies, clinical teaching models, and suggestions for incorporating technology. Recommendations for instructor-related teaching factors include adequate preparation, awareness of effective teacher attributes, using evidence-based-knowledge dissemination strategies, ensuring good communication, and consideration of environmental factors. Proposed recommendations for potential teaching strategies include the Socratic method, the One-Minute Preceptor model, SNAPPS, ED STAT, teaching scripts, and bedside presentation rounds. Additionally, this article will suggest approaches to incorporating technology into clinical teaching, including just-in-time training, simulation, and telemedical teaching. This paper provides readers with strategies and techniques for improving clinical teaching effectiveness.
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.
Introduction Strategies versus traits Models to guide emergency department teaching Diagnosing the learner Summary References
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In the setting of clinical medical education, feedback refers to information describing students' or house officers' performance in a given activity that is intended to guide their future performance in that same or in a related activity. It is a key step in the acquisition of clinical skills, yet feedback is often omitted or handled improperly in clinical training. This can result in important untoward consequences, some of which may extend beyond the training period. Once the nature of the feedback process is appreciated, however, especially the distinction between feedback and evaluation and the importance of focusing on the trainees' observable behaviors rather than on the trainees themselves, the educational benefit of feedback can be realized. This article presents guidelines for offering feedback that have been set forth in the literature of business administration, psychology, and education, adapted here for use by teachers and students of clinical medicine.
Healthcare professionals as teachers healthcare teaching in context adult learning and self-directed learners educational concepts: the theory behind the practical aspects of teaching and learning curriculum development matching methods with message organising educational activities giving feedback effectively assessment appraisal evaluation the challenging trainee providing supervision and support applying education and training to the requirements of the NHS best evidence and medical education.
The wait time concept has become a significant dimension in the research on teaching. When teachers ask students ques tions, they typically wait less than one second for a student response. Further, after a student stops speaking, teachers react or respond with another question in less than one second. The concepts of wait time 1 (pausing after asking a question) and wait time 2 (pausing after a student response) are discussed in this article by Rowe. She reviews the literature on wait time and describes the efficacy of different training procedures used to enhance the quality of teacher questioning techniques and teacher responses to students. The appropriateness of using wait time with special needs students, particularly handicapped children, is also discussed.
Conclusions One of the strengths of ambulatory education is the opportunity for learners to interact with patients and for teachers to model what they enjoy most about medicine without the intervening technology common to hospital wards. When medical students from the graduating class of 1990 were asked in a national survey what would make the specially of internal medicine more attractive as a career, the most common suggestion was to increase the ambulatory experience and the connections with patients that such an experience provides. More research is necessary to identify which teaching techniques are effective in the clinic.3 Meanwhile, this article makes practical suggestions based on what is known about effective teachers and their behaviors. When teachers ask questions, present general rules, and model interactions, they create brief opportunities for teaching in an otherwise hectic day. Not only do learners recall these general rules, they subsequently want to emulate the teacher's caring attitude toward patients and organized approach to problem solving. Asking questions and modeling interactions help teachers share themselves and their love of medicine with their learners.
Master, mentor, supervisor, facilitator, or all of the above—somewhere in this list lies the role of the inpatient teacher, perhaps the most intense assignment clinician-educators are asked to assume. Always challenging, inpatient teaching currently must meet requirements and regulations that did not even exist years ago. Today's handbook of inpatient teaching includes chapters written by (1) the Accreditation Council on Graduate Medical Education (ACGME) governing training experiences and working conditions for residents; (2) managed care organizations and hospital utilization committees establishing guidelines for admissions, length of stay, and utilization of diagnostic tests, consultations, and other resources; and (3) the Health Care Financing Administration (HCFA) and other third-party payers setting forth requirements that affect the level of the attending physicians’ involvement in patient care and the allocation of their time, and at least indirectly, housestaff responsibility and learning. But the purpose of this article is not to bemoan the new rules and regulations. In fact, each of these requirements in its own way makes sense. Rather, in this article I try to identify solutions to the inpatient teacher's challenges, both old and new. But first we should ask, what is the essence of inpatient teaching ? What about it cannot be sacrificed, no matter how much the environment may change? That question requires that we consider theories of learning and cognition around which personal models of teaching can be built. Second, we should ask, how successful inpatient teachers do their jobs so well. Everyone faces the same dilemmas when they teach on rounds. What is it about the best attending physicians that makes them stand out? And third, what solutions can be applied to the inpatient teaching problems we face today? What can be done to ensure that the inpatient rounds we will make tomorrow are as memorable as the best rounds our predecessors made in the past? Or even, dare we ask, can we do better?
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.
Characteristics of best and worst clinical teachers in medicine are described by a random sample of medical school faculty, residents, and third- and fourth-year students at the University of Washington. The responses were factor analyzed and examined to determine whether the ratings were systematically influenced by professional role, faculty department, and teaching method. Best clinical teachers are described as being enthusiastic, clear and well organized, and adept at interacting with students and residents. Worst clinical teachers lack these skills and are characterized by negative personal attributes. Using analysis of variance, the investigator found no significant differences in ratings on the three variables examined. Six of the seven hypothesized dimensions of clinical teaching were confirmed by factor analysis. The results are discussed in relation to faculty development and evaluation of clinical teaching.
This study identified characteristics of clinical teachers in ambulatory care settings that influenced ratings of overall teaching effectiveness and examined the impacts of selected variables of the clinic environment on teaching effectiveness ratings. A survey instrument derived from prior research and observations of ambulatory care teaching was sent to 165 senior medical students and 60 medicine residents at the University of Washington School of Medicine in 1988. A total of 122 (74%) of the seniors and 60 (71%) of the residents responded. Results indicate that the most important characteristics of the ambulatory care teachers were that they actively involved the learners, promoted learner autonomy, and demonstrated patient care skills. Environmental variables did not have a substantial influence on these ratings.
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
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.