Clinical Teaching in the ED

1
Clinical Teaching in the ED
2
Educational Objectives

• Develop skills to become a better clinical
  educator

3
How to

• How to provide effective teaching while caring
  for patients in the ED

4
Residents as Teachers

• Residents play a critical role in medical student
  education
• Professional role models for students
• Impact on career choices
• Better understanding of students needs

5
Residents as Teachers

• General principles of clinical teaching
• Bedside teaching
• Giving effective feedback
• Teaching procedures
• Teaching with High-Fidelity patient simulators
• Teaching effective discussion leading and
  lecturing

Acad Emerg Med. 200613677-79.
6
Precepting Medical Students

• Make decisions at the bedside
• Encourage medical student independence
• Delegate specific tasks to the student
• Encourage responsible behavior

7
The Emergency Department

• Different from inpatient and ambulatory care
  settings
• Complaint oriented specialty
• Unique educational opportunities

8
Opportunities Unique to EM

• The undifferentiated acutely ill patient
• Extremes of age
• The poisoned or intoxicated patient
• Psychiatric emergencies
• Environmental emergencies
• Wound management and trauma
• Patients requiring emergency procedures
• Airway management and ultrasound

9
Teaching Opportunities

• Unique content areas
• Teaching clinical vignettes
• Multitasking and time management skills
• Communication skills
• Role modeling professional behavior
• Reinforce EMC goals

10
EMC Goals Competencies

• Perform complaint directed history and physical
  examinations
• Develop case specific differential diagnosis
• Present cases in a concise and organized fashion
• Appropriate utilization and interpretation of
  diagnostic studies
• Appropriate implementation of patient management
  plans
• Demonstrate medical professionalism
• Demonstrate an adequate fund of medical knowledge
  
• Demonstrate proficiency in basic procedures

Temple MS IV Clerkship
11
EMC Objectives

• Directly participate and document care of at
  least 25 undifferentiated patients
• Directly participate and document care of at
  least 2 patients with each of the following
  conditions
• Abdominal pain
• Chest pain
• Fever
• Musculoskeletal trauma / wound care
• Neurologic case
• Shortness of breath
• Provide document anticipatory guidance for at
  least 5 patients

Temple MS IV Clerkship
12
EMC Objectives

• Perform and / or interpret and document your
  participation in selected clinical skills or
  diagnostic tests
• Interpret cervical spine radiograph
• Interpret chest radiograph
• Perform and interpret 12-lead ECG
• Perform intravenous access
• Perform phlebotomy

Temple MS IV Clerkship
13
Observation of ED HPs
Acad Emerg Med 200342s102
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Observation of Procedures
Acad Emerg Med 200411500
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Direct Observation

• Direct observation of medical students performing
  HPs is uncommon
• Direct observation as a method of teaching is
  underutilized
• Medical students are more likely to receive both
  procedural instruction and assistance if selected
  procedures are directly observed

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Diagnosing the learner
Medical Student - Intern
Independent Learner
Dependant Learner
Intern - Senior Resident

• Assess the learners needs
• Strengths and weaknesses

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Case 1

• 35 year old male presents with CP and SOB

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Case 1

• Interpret the chest radiograph, provide a
  clinical diagnosis
• Document how you would manage this case

20
Case 1

• 61 of students (n192) correctly interpreted the
  chest radiograph
• 95 of the students that correctly interpreted
  the chest radiograph managed the case
  appropriately
• Needle decompression
• Tube thoracostomy

21
Student Patient Encounter

• Student evaluates patient
• Case presentation
• Preceptor verifies data
• Evaluation / management plan is implemented
• Periodic reevaluation / follow up
• Disposition

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Case Presentation Skills

• Improve
• Patient care
• Educational experience
• Learner teacher communication

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Case Presentations

• Precepting pitfalls
• Interrupting the case prior before completion
• Taking over the case
• Inappropriate lectures

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Case Presentations

• Listen carefully
• Allow the presenter to proceed without
  interruption
• The post presentation pause
• Feedback
• Reassurance
• Validation
• What should I do next?

25
Case Presentations

• Brief, focused
• 2 3 minutes in length
• Directed opening statement
• Chief complaint and pertinent PMH
• Description of the HPI, pertinent ROS
• Additional medical history, etc.
• Physical examination
• Differential diagnosis
• Diagnostic and treatment plan

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Assessment Oriented Presentation

• Opening statement includes the diagnostic
  impression or assessment followed by a treatment
  plan
• Followed by historical and physical examination
  data including pertinent positive and negative
  features that support the clinical assessment

Acad Emerg Med 200310842-47
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Method of Questioning
Teaching styles
Assertive
Facilitative
Teacher Centered
Learner Centered
Fam Med 200133344-6
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Assertive Style

• Teacher centered approach
• Can gauge the learners knowledge base
• Asks direct questions
• Provides information
• Gives directions

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Assertive Style

• What antibiotics should we treat this patient
  with?
• What is the dose of _____?
• What is the drug of choice for_____?
• What is the differential diagnosis of RUQ pain?

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Suggestive Style

• Can offer suggestions or alternative methods of
  patient care with questions or statements
• Can share opinions and practical experience

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Suggestive Style

• Although a KUB may be helpful, a non-contrast
  helical CT scan is a better diagnostic test for
  this patient
• Augmentin is a treatment option for strep
  throat, penicillin however is a more cost
  effective choice

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Collaborative Style

• Socratic approach
• Learner oriented
• Explores clinical reasoning and problem solving
  abilities
• Use of higher level questions to promote critical
  thinking

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Collaborative Style

• What do you think is wrong with the patient?
• How should we proceed?
• What diagnostic studies are necessary?
• How should we manage this case?
• Do you think the patient needs to be admitted?

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Facilitative Style

• Elicits and accepts the learners ideas to promote
  self understanding
• May also offer feelings and can encourage the
  learner
• Uses silence

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Facilitative Style

• Ms. Jones shared some personal information about
  her past medical history with you. How did that
  make you feel?

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Reactive Comments

• Ways to redirect and reorient the learner
• The delayed response
• Allows the learner to reflect and reconsider
• Provides an opportunity to withdraw the
  incorrect answer
• Gives the learner a second try

37
Reactive Comments

• Ways to redirect and reorient the learner
• Asking questions containing additional clues
• Modifying the question so that the incorrect
  answer is correct
• Treating wrong answers as possible

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Precepting Models
Traditional Model
One Minute Preceptor
Patient Centered
Learner Centered
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Traditional Precepting Model

• Patient centered
• Inquiry phase is diagnosis driven
• Most time is spent on patient care issues rather
  than learner issues
• The teacher functions as an expert consultant
• Focus on areas requiring clarification or areas
  missed during the presentation

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One Minute Preceptor Model

• Learner centered
• Inquiry phase elicits the learners understanding
  of the case
• Flexible / modifiable
• Used in both the inpatient and ambulatory care
  setting
• Five microskills
• Focus on the learners reasoning

Fam Med 200335391-3
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One Minute Preceptor Model

• Case presentation and discussion process

• Diagnose
• Patient
• Listen
• Clarify

• Teach
• Teach a general
• rule
• Provide positive
• feedback
• Correct mistakes

• Diagnose Learner
• Get a commitment
• Probe for supporting
• evidence

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Get a Commitment

• Provides an assessment of the learners
  interpretation of the history and physical
  examination data
• Data analysis and synthesis
• What do you think is going on with this patient?
• What do you want to do for this patient?
• Commitment may focus on diagnosis, diagnostic
  evaluation, treatment plans, etc.

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Probe for Supporting Evidence

• Exploring the underlying thought process allows
  you to identify any gaps in data synthesis or
  misconceptions
• What findings support your diagnosis?
• What else do you think could be going on with
  this patient?

44
Teaching General Rules

• Instruction is more memorable if offered as a
  general rule
• Teaching scripts for a particular complaint or
  presentation
• Pearls of wisdom
• Teach what learners need to know
• Keys features of a particular illness
• Treatment options
• Approach to a particular complaint
• Reason for hospital admission

45
Teaching General Rules

• You should always consider hypoglycemia in the
  differential diagnosis of a patient with an
  altered mental status
• You should always consider AAA in your
  differential diagnosis of non-traumatic low back
  pain in the elderly

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Feedback

• 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

JAMA 1983250777-81
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Feedback

• Goals
• Praise the learner for a job well done
• Positive feedback
• Provide direction or suggestions on how the
  learner can improve their clinical performance
• Constructive criticism
• Guidance to correct mistakes

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Feedback and Evaluation

• Feedback
• Formative
• Provides an honest assessment of performance,
  including suggestions for improvement
• Evaluation
• Summative
• Describes performance as it relates to the
  achievement of learning objectives
• Course grade

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Feedback

• The way in which feedback is provided will
  influence the perception of its helpfulness
• Praise Criticism Praise

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Feedback

• Nonjudgmental
• Descriptive
• Refer to specific behaviors or actions
• Be consistent
• Well timed
• Ask for self evaluation
• Always start with positive feedback
• Incorporate suggestions for improvement
• Individualized

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Brief Feedback

• Bedside
• Informal
• Unscripted
• Unplanned
• During observation of clinical / procedural
  skills
• End of a patient encounter

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Formal Feedback

• Usually more formal
• May also be unscripted or unplanned
• Usually occurs away from the bedside
• End of a patient encounter
• End of a shift
• Midpoint or end of the clerkship

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Feedback

• July December 2004
• 51/53 MS completed the survey
• 96.1 of MS reported receiving feedback during
  their EMC
• Of the students receiving feedback, 80.4
  reported receiving SFICP
• 93.6 of the students reported the feedback they
  received was beneficial
• 97 of supervising physicians felt that the
  feedback they provided was beneficial

   Ann Emerg Med. 200546S88
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Feedback

• No difference was noted in the frequency of
  feedback and SFICP provided as reported by the
  following groups
• Academic (n16) vs. clinical (n9) faculty
• Senior (n13) vs. junior (n12) faculty
• Male (n24) vs. female (n9) supervising
  physicians
• Senior residents (n8) and faculty (n25)

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Feedback

• The vast majority of SMS report receiving
  feedback
• Most students felt that more feedback would be
  helpful
• Supervising physicians perception of providing
  feedback matched that reported by the students

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Basic Teaching

• Teaching facts knowledge
• Differential diagnosis for specific chief
  complaint
• How to approach a certain clinical condition
• Teaching the technique to perform a basic
  procedure

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General Teaching Strategies

• Tailor specific teaching to the level of the
  learner and the clinical situation
• Get to know the student
• Tailor teaching to students career interests
• Use varied ED pathology to your advantage
• Optimize the interaction
• Focus on one teaching point
• Encourage problem solving
• Incorporate bedside teaching

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General Teaching Strategies

• Seek opportunities to teach
• Interesting physical examination findings
• Radiographs
• ECGs
• Procedures
• Be a professional
• Be a role model
• Establish a friendly learning environment
• Be approachable

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General Teaching Strategies

• Use additional resources
• Hard copy texts
• On-line texts
• Journal articles
• Educational websites
• Prepared cases
• Old ECGs, Xrays, etc.

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Qualities of an Effective Teacher

• Clinical competence
• Explaining the decision making process
• Treating learners with respect
• Actively involve learners
• Promote learner autonomy
• Teach with enthusiasm
• Communicate expectations for performance
• Creates a friendly teaching environment

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Challenging Students

• Less than enthusiastic performance
• Lack of initiative
• Lack of attention to details
• Poor use of time
• Repetitive mistakes
• Defensive when receiving feedback
• Unprofessional behavior

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Alternative Teaching Methods

• Brief structured observation
• Bedside case presentations

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Brief Structured Observation

• Designed to increase teaching effectiveness in
  busy clinical settings
• Easy no preparation
• Brief little time required

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Brief Structured Observation

• Observe the encounter
• Debrief the learner
• Conclude interaction

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Observe the Encounter

• Brief observation
• 2 5 minutes
• Limited to certain aspects of H P
• Preceptor records observations / statements /
  actions performed by the learner

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Debrief the Learner

• Ask the learner what they learned from the
  observed segment
• Can be done in front of the patient
• Directly evaluate
• Fund of knowledge
• Physical examination skills
• Clinical reasoning skills

68
Conclude Interaction

• Feedback
• Point out strengths
• Positive reinforcement
• Give the learner one thing to work on
• Suggestions for improving clinical performance

69
Bedside Case Presentations

• Addresses challenges of teaching
• Effective teaching vs patient care
• Time management
• Assessment of the learner
• Increases patient satisfaction
• Promotes professional behavior
• Mixed reactions from learners

70
Bedside Case Presentations

• Implementation
• Learner and patient preparation
• Use of medical terminology
• Listen to the presentation
• Clarify / obtain additional information
• Have learner present evaluation / treatment plan
  at the bedside ???
• Address all patient concerns / questions

71
EM Clerkship Grades

• Emergency Medicine Clerkship
• Uniform Grading Guidelines

72
Evaluation of Clinical Performance

• Evaluation of acquired clinical knowledge,
  skills, attitudes, and behaviors
• Clerkship goals competencies
• Ability to incorporate these competencies into
  clinical medicine

73
Evaluation of Clinical Performance

• "Criterion based or Fixed standard"
  grading
• Identify goals or competencies
• Determine expected standards of proficiency
• Achievement of the minimum standards of
  proficiency would represent a pass grade
• Performance that is above the minimum
  expectations could earn grades such as High
  Pass and Honors

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•  TUH EM Clerkship Clinical Evaluation Card
• Student Name Date / Shift
• Evaluator Block
• Clinical Skills (Learning Objectives)
• 1. Perform complaint directed history physical
  examinations
• 2. Develop case specific differential diagnosis
• 3. Present cases in a concise and organized
  fashion
• 4. Appropriate utilization and interpretation of
  diagnostic studies
• 5. Appropriate implementation of patient
  management plans
• 6. Demonstrate medical professionalism
• 7. Demonstrate an adequate fund of medical
  knowledge
• Demonstrate proficiency in basic procedures
• Patient acuity High Medium
  Low Varied
• Patient encounters 1 2 3 5
  6 or more

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Feedback on clinical performance
Nonjudgmental, descriptive (refer to specific
cases, performances, behaviors, or actions),
objective appraisal of performance  
Positive feedback (What did the student do
well?)
Suggestions to improve clinical
performance  
Any additional comments
Discussed with student
Yes No
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HONORS

• The outstanding student
• Comprehensive achievement of the knowledge,
  skills, attitudes, and behaviors
• Top 10
• Resourceful, efficient, and insightful

• In-depth medical knowledge base
• Perform detailed but focused H Ps
• Well organized presentations
• Role model
• Strives for excellence even in difficult
  situations

77
HIGH PASS

• Identify major problems
• Perform appropriate but focused H Ps
• Demonstrate professional behavior

• The solid student
• Well beyond minimum course requirements
• Next 25 - 35
• Resourceful and efficient
• Above average fund of medical knowledge

78
PASS

• The average student
• Meets basic course requirements
• Next 50 - 60
• Average fund of medical knowledge
• Perform an adequate H P

• May omit certain portions of the H P
• Presentations generally organized
• Demonstrate professional behavior

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CONDITION / FAIL

• A performance that falls below expected minimum
  standards
• Clinical knowledge, skills, attitudes, and
  behaviors
• Requires specific and detailed documentation by
  senior EM resident and / or attending

80
Expected Grade Distribution

• Rigid cut off values are not used
• Year to year the percentage of students receiving
  a particular grade may vary

81
Summative Evaluation

• Overall shift grade
• Honors (5)
• High Pass (4)
• Pass (3)
• Condition (0)
• Fail (0)

• of patient encounters
• 1 2 (x1)
• 3 5 (x2)
• 6 or more (x3)

82
RIME Evaluation Framework

• Reporter
• Interpreter
• Manager
• Educator

Pangaro LN Uniformed Services University of the
Health Sciences
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Reporter

• Accurately gathers and clearly communicates
  clinical facts
• Medical interviewing
• Physical examination skills
• Case presentations

84
Interpreter

• Prioritizing the patients presenting complaints
• Developing a problem list
• Developing a differential diagnosis
• Interpreting basic diagnostic studies

85
Manager

• Developing a diagnostic and therapeutic plan
• Tailoring the management plan to the patient

86
Educator

• Self-directed learning
• Critical reading skills

87
Barriers to Effective Teaching
88
Barriers to Teaching

• The Emergency Department
• The Teacher
• The Student
• The Patient

89
The Emergency Department

• Overcrowding
• Inadequate patient care space
• Unanticipated emergencies
• High level of acuity

90
Teaching Opportunities

• Unique content areas
• Teaching clinical vignettes
• Multitasking and time management skills
• Communication skills
• Role modeling professional behavior
• Reinforce EMC goals

91
The Teacher

• Lack of confidence
• Little experience
• Little or no formal training
• Not enough time
• Endless interruptions
• Too many other responsibilities
• Expectations?

92
The Teacher

• Every case has a teaching point
• You have more experience than the students and
  junior residents
• Directed learning
• Identify interesting cases
• Task oriented learning
• Act interested

93
The Student

• Different levels of training
• Variable fund of knowledge
• Learning attitude, enthusiasm
• Expectations?

94
The Student

• Identify gaps or misconceptions
• Teach to their level
• Focus on one thing at a time

95
The Patient

• Level of acuity
• Painful injury or illness
• Mental status
• Need for privacy
• Patient reluctance

96
The Patient

• Bedside teaching rounds are generally viewed as
  having a positive effect on patient care
• Most patients enjoy bedside teaching and often
  develop an increased understanding of their
  illness.
• Incorporate patients into the case discussion

97
Effective Clinical Teaching

• No one best teaching style or method
• Teaching principles
• Allow the student to play an active part in
  learning
• Use questions that promote high order thinking
• Offer feedback
• Reinforce positive behavior / actions
• Provide guidance for correcting mistakes

98
The Bottom Line

• Decide what to teach
• Take away point
• History
• Physical examination
• Diagnostics
• Therapeutics
• Be flexible (different levels of training)

99
Author Credit Clinical teachingDavid A. Wald
DO

• Questions

100
Postresidency Tools of the Trade CD

• 13) Negotiation Ramundo
• 14) ABEM Certifications Cheng
• 15) Patient Satisfaction Cheng
• 16) Billing, Coding Documenting Cheng/Hall
• 17) Financial Planning Hevia
• 18) Time Management Promes
• 19) Balancing Work Family Promes Datner
• 20) Physician Wellness Burnout Conrad /Wadman
• 21) Professionalism Fredrick
• 22) Cases for professionalism ethics SAEM
• 23) Medical Directorship Proctor
• 24) Academic Career Guide Chapter 1-8
  Nottingham
• 25) Academic career Guide Chapter 9-16 Noeller

• 1) Career Planning Garmel
• 2) Careers in Academic EM Sokolove
• 3) Private Practice Career Options - Holliman
• 4) Fellowship/EM Organizations Coates/Cheng
• 5) CV Garmel
• 6) Interviewing Garmel
• 7) Contracts for Emergency Physicians Franks
• 8) Salary Benefits Hevia
• 9) Malpractice Derse/Cheng
• 10) Clinical Teaching in the ED Wald
• 11) Teaching Tips Ankel
• 12) Mentoring - Ramundo