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MEdIC Series: The Case of the Exasperated Educator

Picture courtesy of wstera, Flickr Creative Commons

Image credit: wstera

Teaching in the emergency department can be a challenge. Distractions and interruptions are everywhere and there always seem to be more things to do than there are people to do them. These challenges are magnified when our learners are struggling. In The Case of the Exasperated Educator, we will discuss these issues and how we, as educators in emergency medicine, can address them as effectively as possible.

MEdIC Series: The Concept

Inspired by the Harvard Business Review Cases and led by Dr. Teresa Chan (@TChanMD) and Dr. Brent Thoma (@Brent_Thoma), the Medical Education In Cases (MEdIC) series puts difficult medical education cases under a microscope. On the fourth Friday of the month, we pose a challenging hypothetical dilemma, moderate a discussion on potential approaches, and recruit medical education experts to provide “Gold Standard” responses. Cases and responses are be made available for download in pdf format – feel free to use them! If you’re a medical educator with a pedagogical problem, we want to get you a MEdIC. Send us your most difficult dilemmas (guidelines) and help the rest of us bring our teaching to the next level.

The Case of the Exasperated Educator

by Drs. Lindsay Melvin (@LMelvinMD) & Teresa Chan (@TChanMD)

The day was turning out okay for Justine. She’d gone to the gym this morning at 8 am, and now refreshed, she strolled into the Emergency Department right on time to start her 10am shift. Double-whip mocha coffee frappe in one hand, stethoscope in the other, she was feeling pretty good. Having just started as a junior faculty member at Best University, Justine felt energized as she walked in the doors of the busy trauma bays of A.W. Esome hospital wondering what exciting new cases would be thrown her way!

Setting down her bag, she looked over and saw her friend (and fellow recent grad) Charlie looking quite a bit exasperated.

“Tell me more about the chest pain, Bobbi,” Charlie grunted. The medical student seemed nervous, shuffling papers and trying desperately to find the answers somewhere in her pile of scrap notes.

“More? Well, I, um, well, it is central… it feels like a knife… um, um, he also had it before, too, but a long time ago…” She pauses. “That’s it.”

Charlie sighed. He abruptly grabbed the chart, and started flipping through her paper work. Justine thought he looked especially tired, and quickly looked over to the staffing schedule. She thought she had seen him last night coming in as she left her busy days shift…. Wait… Ah-ha! That’s right, he HAD worked last night until 2 am! And he was back again already for a 7 am shift? That was an extremely short turn around for him, Justine noted.

Charlie flipped the medical student’s chart to reveal a sparse, very messy, note.

“Is that all you wrote?”

“Yes.” Bobbi replies.

“What about the ECG?”

“Um, It was fine. I think…” There was a pregnant pause. “Actually… I don’t really know where it is.”

“Did you look at it?”

“Well… no. I couldn’t find it… um, it isn’t with the chart.”

If the medical student had been nervous before, now Justine was worried she was going to keel over. Her face had dropped, and she was turning a particularly bright shade of pink.

“Bobbi, this assessment is not complete. Go back and do a better job.”

“Okay… but …”

“No ‘buts’. Go. NOW.”

As the medical student stumbles out of the room, Charlie turned to Justine and shrugs. “Man,” he exclaims, rubbing his eyes. “It’s good to see you! It’s been so busy this morning, and we’ve already had two cardiac arrests, and now the department is totally backed up…”

Justine raised an eyebrow. “Uhhhhh… What’s up with that student?”

“Oh, Bobbi? Yeah, she’s pretty rough still…. All her assessments and notes are always only half done, and she never seems to know what’s going on. This is the third chest pain she’s had now, and this one was no better than the last. I’ve told her twice to be more thorough and not to rush. But she keeps coming back with an incomplete history.”

“Hmmm. Sounds like it’s been a tough day,” remarked Justine. “But you were a bit tough on her, no?”

“She’s really very weak. And it’s my third shift with her. I’ve given her all the time in the world with her patients, and still, she’s just not getting it. Of course, I’m going to be honest with her. She needs to stop making excuses, and get the job done…. Why? What was I supposed to say?”


Key Questions

Imagine you are in Justine’s shoes.  How might you handle the situation?

  1. What advice would you give Charlie colleague about handling this interaction?
  2. Is this a learner in difficulty? How would you make that determination?
  3. What other factors are contributing to this scenario?
  4. What are the barriers to dealing with learners in difficulty in daily interactions and how can these barriers be overcome?

Weekly Wrap Up

As always, we posted the expert responses and a curated commentary derived from the community responses one week after the case was published on June 5, 2014.

Click HERE for a link to the Expert & Community responses, which include words from:

  • Dr. Allison Kirkham (@AllisonKirkham) is an educational fellow at the University of Alberta. She is currently also undertaking a Masters of Education
  • Dr. James Kimo Takayesu received his M.D. from the University of California San Francisco, after which he headed north to complete his residency with the Harvard Affiliated Emergency Medicine Residency Program (HAEMR) at Brigham and Women’s Hospital and MGH. He now works at MGH as an emergency physician and is also assistant professor of surgery at Harvard Medical School.

All characters in this case are fictitious. Any resemblance to real persons, living or dead, is purely coincidental.  Also, as always, we will generate a curated community commentary based on your participation below and on Twitter.  We will try to attribute names, but if you choose to comment anonymously, you will be referred to as your pseudonym in our writing.

Brent Thoma, MD MA
ALiEM Associate Editor
Emergency Medicine Research Director at the University of Saskatchewan
Editor/Author at
Brent Thoma, MD MA
  • amywalsh

    This is a tough situation for a lot of reasons. Calling out a peer is always difficult, but in this scenario a busy shift, on little to no sleep it’s less likely to be well-received. If the situation will allow, it might be good to cover for your colleague for a few minutes while he takes a walk, gets a coffee, and re-energizes. Otherwise, I think the response to your peer must be based on if this is a bad day or a habitual issue. As far as advice, if the situation in the department will allow, some pre-coaching for each patient can be helpful talk through the differential before she sees a patient so she can be more targeted in her evaluation, explain the things you need to know for a given chief complaint, and be very explicit about what you want to hear in presentations and see in notes.

    I think that whether this is a learner in difficulty has a lot to do with how clearly the expectations of her were laid out and how she responds to feedback. In the ED, especially when it’s busy, it can be a very sink or swim environment. If no one has laid out the expectations for her, it’s hard for her to know she’s not meeting them.

    In the ED, the big barriers to assisting learners in difficulty are time, it is more time-consuming to coach students who don’t “get it” intuitively (though it is more rewarding once they do get it), identifying learner difficulties is challenging because often we only work with a student once or twice so it’s hard to know if they have a problem or an off day. If you have found a learner in difficulty, it is often difficult to identify where the disconnect is. These are challenges throughout medical education, but I think the ED environment exacerbates it. Unfortunately, I don’t have any great ideas for solutions, so I’m looking forward to hearing what everyone has to say.

    • Hey Anne:

      Thanks so much for your input on the case! You have “broken the ice” on a very difficult case, really…

      As a new attending, I always still struggle with figuring out whether I’m calibrating properly, and I’m always chasing down others to get my own “inter-rater reliability” on what is important.

      I am hoping that the milestones and competency-based frameworks will be helpful in clarifying the objectives/outlines for what is expected of various learners.

      I think you raise a good point re: the contextual factors that may affect how we function as raters/assessors. I think this is important to acknowledge that sometimes a low score on the Likert scale will be a shared cause between both the learner’s performance AND the rater’s state of mind.


  • Nadim Lalani

    I think part of the problem is Charlie’s approach.

    Did Charlie take the time to “take a history” from the learner at the start of the shift? Were there expectations laid out? 3 chest pain patients in a row is a gold mine! Charlie could have demonstrated the correct approach with one patient, observed Bobbi with the next and seen the 3rd patient together as a team.

    If the ER was so backed up – Charlie could have used a tag-team approach [with the learner at his side] until things settled.

    The short shift may have been the ER scheduler’s fault [I’ve seen that before]. The missing EKG is also not a surprise for a busy ER.

    I wouldn’t be so quick to diagnose a learner in difficulty when she’s running on a few hours of sleep, you don’t know her history and there’s been little direct observation of her competence.



    • Totally agree with that, Charlie is in a spot of possibly letting biases cause error in diagnosing the learner. What, then, do you think Justine’s role is in this case? What do you do when you see your colleague who is biased and doesn’t realize it?

  • anne smith

    Having been in both Justine and Charlie’s shoes (and now that I think about it, Bobbi’s too) – this case really resonated with me and I am interested to see the discussion that follows.

    Justine is clearly in a very different space to Charlie and this situation needs a careful approach – factors that may be influencing things are Charlies’ lack of sleep and tough call schedule, with the added stress of teaching and keeping up with clinical demands. Its often difficult to say something when we see our colleagues struggling. Perhaps Justine can suggest practical ways to help – maybe taking over the teaching responsibility for the day or offering to cover certain high risk patients?

    Making the transition from registrar (resident) to consultant (attending) was a massive learning curve for me personally last year – I am sure it is for everyone! What is important is to realise how important it is to look after yourself (work life balance etc) and also to seek advice from mentors and seniors who have been there before. One of the most striking things on our Teaching Course in Baltimore last year was how similar the challenges are for all new faculty, regardless of country or hospital circumstances.

    I am not entirely sure that the learner in this case is in real trouble – however what is certainly clear is that there has been a communication breakdown between learner and educator. Students need clear goals and directives in place every shift or day spent – if they are clearly what is expected and what they can be expect this will go a long way in alleviating frustration on both sides. If recurrent mistakes are made and errors are picked up then the educator should spend some more one on one time with the student to identify where things are going wrong(are they not understanding the instruction? do the not understand the basic science behind the clinical picture? is it an attitude problem?). Then the educator can tailor the approach on how to fix things.

    I definitely agree with Amy re the main difficulties in teaching in the EC.The more mundane problems are time constraints and the demands of a heavy patient load – as faculty/consultant/attending, the buck stops with you so you really have to give your full attention to the clinical situation – but then you are also expected to attend meetings, teach students, engage in research and do everything else too! Creating realistic expectations on both sides is essential – otherwise either the educator or learner will end up feeling let down.

  • Danica K

    This case, above all, brings this article to mind for me.

    “If we are going to create assessment plans that benefit students, perhaps we need to design plans that first takes into account the more fundamental human needs .”