This week’s How I Educate post features Dr. Andy Little, the Associate Program Director at AdventHealth Florida in Orlando. Dr. Little spends approximately 90% of his shifts with learners, including emergency medicine residents, off-service residents, and medical students. He describes his practice environment as a busy community EM residency program that sees over 100,000 patients per year. Below he shares with us his approach to teaching learners on shift.

Name 3 words that describe a teaching shift with you.

Malleable, understanding, fun.

What delivery methods do use when teaching on shift?

Post its and fill in the blanks.

What learning theory best describes your approach to teaching?

Experiential.

What is one thing (if nothing else) that you hope to instill in those you teach?

That there is always something you can learn from your patient.

How do you balance your flow with on-shift teaching? Does this come at the expense of your documentation?

There is a time to teach and a time to see patients. When we don’t have a specific topic to discuss, we see patients and focus on specific parts of the history and physical one cannot miss for that complaint. It comes at some sacrifice to charting, but that’s the gig.

What is your method for reviewing learners’ notes and how do you provide feedback on documentation?

I do a mix of on-shift and after-shift notes reviews. I focus on finding trends about how learners chart, and give feedback accordingly.

Do you feel departmental flow and metrics adversely affect teaching? What is your approach to excelling at both?

It can be difficult to sit back and let senior learners struggle what is your approach to not taking over prematurely?

Do you start a teaching shift with certain objectives or develop them as a shift unfolds?

Do you typically see patients before or after they are presented to you?

How do you boost morale amongst learners on shift?

How do you provide learners feedback?

What tips would you give a resident or student to excel on their shift?

Are there any resources you use regularly with learners to educate during a shift?

What are your three favorite topics to teach during a shift?

What techniques do you employ when teaching on shift?

What is your favorite book or article on teaching?

Who are three other educators you’d like to answer these questions?

George Willis, Jenny Beck Esmay, and Jessie Werner.

 

 

Read other How I Educate posts for more tips on how to approach on-shift teaching.

This week’s How I Educate post features Dr. Geoff Comp, the Associate Program Director at Creighton University School of Medicine/Valleywise Health Medical Center in Phoenix, Arizona. Dr. Comp spends all of his shifts with learners, including emergency medicine residents, off-service residents, and medical students. He describes his practice environment as a county hospital with a Level 1 Trauma designation that has both an adult and pediatric emergency room. Below he shares with us his approach to teaching learners on shift.

Name 3 words that describe a teaching shift with you.

Innovative, evidenced-based, fun

What delivery methods do use when teaching on shift?

My favorite method of teaching is hands-on bedside describing and demonstrating different ways to complete a task or procedure with the learner. However, during patient presentations, I use a lot of scratch paper to show flow diagrams illustrating how to develop a differential diagnosis or plan from a chief complaint. I also use previously identified articles to help illustrate a point. Frequently I will pull up the resource on a computer, and then send the learner a copy of what we discussed for them to review after shift.

What is one thing (if nothing else) that you hope to instill in those you teach?

Identify the learning opportunity in every encounter you have on shift. Sometimes learning is focused on a specific patient and their chief complaint, but other times it is related to optimizing skills such as team leadership and interpersonal interaction with other staff in the emergency department. If the learner is provided the tools to identify their own learning points their potential is limitless.

How do you balance your flow with on-shift teaching? Does this come at the expense of your documentation?

This is a super hard one to do. Unfortunately, personal documentation usually takes a backseat during many of my clinical shifts so I can spend more time interacting with patients as well as the learners. However, I try to identify my own methods for workflow optimization and explicitly share that with learners. For example, if I’m working through a particularly complex MDM I will include the resident working on the case with me to discuss my thought process. If I’m having a hard time incorporating the completion of different procedures in a workflow on shift, I will share the thought process of my list of things to do in order stratification with a learner as well.

Do you feel departmental flow and metrics adversely affect teaching? What is your approach to excelling at both?

Occasionally, a busy fast paced ER provides an opportunity to teach more than just medical or scientific topics! You can absolutely teach the learner about your thought process and flow as well as different requirements for when they will be working as an attending. Spend the time talking about why you’re documenting the way that you are, talk about how you keep metrics in mind and share with them details on documentation for billing and critical care time. There is also always an opportunity to create a list of the medical topics that you want to make sure you cover after you get through a bit of the rush or after shift over a quick snack, or at an out-of-hospital meet-up!

It can be difficult to sit back and let senior learners struggle what is your approach to not taking over prematurely?

Do you start a teaching shift with certain objectives or develop them as a shift unfolds?

The teaching goals are pretty individualized. Some learners really respond well to setting the stage at the beginning of the shift and asking what goals they have for learning. Other learners need a little bit of guidance in identifying a tangible goal for the day. Matching the energy and experience level of the learner is important for a successful shift. However, I have my own personal goals when it comes to teaching as well as basic standards that I try to follow for the day. These include making sure that I am constantly intentional about teaching and giving feedback, identifying small pearls in seemingly “easy” cases to advance the learner, and focusing on understanding and patience when I’m working with struggling learners to help them ultimately succeed.

Do you typically see patients before or after they are presented to you?

How do you boost morale amongst learners on shift?

How do you provide learners feedback?

Feedback should be time sensitive, directed towards a specific action/event, and well defined, and it should be provided with strategies for improvement. I start all feedback sessions by saying very intentionally “I’d like to give you some feedback.” I also work to make sure that I identify some sort of resource to either review or have the student look up. I then close the loop at a later time by asking them about their own personal exploration of the topic after our previous feedback session.

What tips would you give a resident or student to excel on their shift?

Identify a measurable goal that you want to achieve by the end of your shift. If you start your shift with the intention of saying what you would like to accomplish you will be able to strive for that goal throughout the entire experience. Also, loop in your teachers and mentors with this process. Let the attending that you’re working with for the day know what your goal is so they know how to provide appropriate feedback at the end of the shift and know what to be looking for!

What are your three favorite topics to teach during a shift?

What is your favorite book or article on teaching?

I really like articles that help explicitly identify different on-shift teaching techniques. It’s hard for me to pick one specific one but a couple that I give to residents with a specific interest in medical education include EM Cases Teaching on Shift and EMRA Resident as an Educator.

Who are three other educators you’d like to answer these questions?

Michael Epter, Sara Krzyzaniak, and Stephani Lareau.

Read other How I Educate posts for more tips on how to approach on-shift teaching.

Name 3 words that describe a teaching shift with you.

Enthusiasm, excitement, and engagement

What delivery methods do use when teaching on shift?

I love a blank sheet of paper. I can list out a differential or better yet, I can draw out a mindmap of a certain topic. I can do this anywhere, at the bedside, in the hallway, or at the computer. I also can give the learner the paper so they can frame it and keep it forever (or at least that is what I imagine happens to this literary gold?)

What learning theory best describes your approach to teaching?

My approach to teaching fits in with a sociocultural theory of learning. I like to not only talk about medicine but to show how medicine fits into actual concrete practices. I give real-world examples of situations I have been in, along with showing learners how these situations and approaches might change when I worked in alternative institutions. A topic I love to teach specifically is workflow efficiency. I feel I can teach this topic as it fits into the actual culture of different practice patterns of different institutions well with sociocultural theory. I also love to invite learners into various communities of practice so that they can further learn topics along with other like-minded individuals who share their passions!

What is one thing (if nothing else) that you hope to instill in those you teach?

That you should never stop striving to continue to learn. Medicine is not just a job, but a way of life. It’s called the art of medicine. You are always learning, growing, developing, and creating art in what you do. Your practice today will not (and should not) be your practice pattern in 10 years. Therefore, I hope that through my excitement to learn, grow and teach, others will share that excitement in themselves!

How do you balance your flow with on-shift teaching? Does this come at the expense of your documentation?

Definitely, my documentation suffers. But I find spending more time thinking about and caring for a patient is more important to me than documentation. Teaching is part of that time spent thinking about and caring for patients, which is why I prioritize it. I am also not afraid to open up my remote access while at home to catch up on notes.

Do you feel departmental flow and metrics adversely affect teaching? What is your approach to excelling at both?

I especially love teaching workflow efficiency, which is the art of departmental flow and metrics. So I use real-world in-the-moment examples to help motivate learners to improve, which directly helps protect against my metrics getting adversely affected. I also find that spending extra time explaining why you do or don’t think something is necessary can save time in the future, which aids in overall efficiency.

Do you start a teaching shift with certain objectives or develop them as a shift unfolds?

I like to ask my learners what they hope to accomplish during a shift and what I can specifically help them on. How hands-on do they need me to be? This helps provide the objectives they wish to achieve during their shift.

Do you typically see patients before or after they are presented to you?

I prefer to see them before. If I can catch EMS as they bring in the patient that is my preferred. Unfortunately, this isn’t always possible.

How do you boost morale amongst learners on shift?

I find that when a learner understands that you are there for them and their learning and betterment, it helps with the overall mood. They are not just worker bees, trying to churn through an endless line of patients. They are there to grow and find meaning in their shift. Therefore by focusing on what they need and showing that you care for them to improve and grow, they often have more gratification from their shifts as a result

How do you provide learners feedback?

My feedback is typically throughout the shift. I try to provide a summary of feedback at the end if time permits.

What are your three favorite topics to teach during a shift?

Efficiency, EKG/cardiology, and procedure tips

Read other How I Educate posts for more tips on how to approach on-shift teaching.

Name 3 words that describe a teaching shift with you.

Collaborative, Safe, Growth-oriented

What delivery methods do use when teaching on shift?

My teaching approaches revolve around the concepts of microlearning and dual-coding. For example, I utilize a shared google doc where as a team we compile learning summaries along with curated links that are meant to be reviewed at a later time, whiteboards for just-in-time learning through reinforcement and clarification of topics, and often post-its or notecards to highlight the highest yield information for relevant topics.

What learning theory best describes your approach to teaching?

As mentioned above, I try to align my teaching to concepts of microlearning and dual-coding theories. With ideas of digestible teaching moments and creative design for knowledge retention, I also try to find balance with cognitive load theory in recognizing when it’s OK to introduce teaching vs. when it’s necessary to help offload tasks and clinical duties.

What is one thing (if nothing else) that you hope to instill in those you teach?

I try and convey to learners and trainees that the identification of a knowledge or skill gap is an opportunity for growth and should not be seen only negatively as a shortcoming. Training years are meant to be protected time for recognizing what to prioritize learning and where to focus attention. I would much rather you let me know early about a knowledge or skill gap so that we can work together to find the answer or deliberately practice maneuvers.

How do you balance your flow with on-shift teaching? Does this come at the expense of your documentation?

The flow of on-shift teaching is dynamic. I like to think about teaching as being a series of bite-sized pieces, able to stand independently but part of a bigger whole. For example, the topic of COPD can be represented by a sandwich that has many ingredients. I may take a bite out of the COPD sandwich and teach on the concept of NIPPV, but then have to task-switch to something else and put the sandwich down. I may be able to come back later and take another bite, maybe on the role of steroids and antibiotics, or I may not. Doesn’t take away from the prior teaching on NIPPV which the learner has already walked away with.

Similarly, you may start a shift and be able to directly address/cover a few different things. Then it gets busy and it’s no longer possible to sit and cover more information rather you spend more time supporting the trainee through the process and tasks of patient care.

What is your method for reviewing learners’ notes and how do you provide feedback on documentation?

I tend to skim the notes on shift for glaring deficits or necessary clarification, but don’t review the note fully until after the shift is done. I also let the resident know that I would encourage them to get the majority of the note done in real-time, but that they are able to edit after shift before I close it out. During the shift, I may provide general suggestions to improve, but often I find myself following up with an email in which I am able to provide directed feedback and corrective examples for what was written.

Do you feel departmental flow and metrics adversely affect teaching? What is your approach to excelling at both?

Even at an academic center, patient care needs can make dedicated teaching difficult. I think the secret is finding balance. Don’t pull the trainee away from tasks for too long to teach or the moment will be soured, but also don’t allow them to work an entire shift without feeling that attention was focused on their growth and learning. I try and evaluate if the moment, the trainee, and the timing are right. If it’s not, then I keep notes about what I want to communicate to or with the trainee and accept that I may not be able to do teaching in the moment, but at a later time, I want to draw their attention to a topic or a suggestion for improvement.

It can be difficult to sit back and let senior learners struggle what is your approach to not taking over prematurely?

Expectation setting is helpful in this case. At the beginning of shifts, I like to directly ask the resident what role they would like me to take that they find most helpful. Would they prefer that I represent a sounding board for ideas, allowing them to think out loud per se prior to my giving them suggestions? Do they want me to hover and follow along peripherally with the understanding that I will jump in for critical correction? Or do they want me to be a safety net available for them at every step? The point is to understand what level of autonomy they are comfortable with, and therefore will benefit from.

Do you start a teaching shift with certain objectives or develop them as a shift unfolds?

If there are learners from various levels, I like to start the shift with a collective understanding of expectations for each role. This allows me to clarify with the senior what their role is in teaching the juniors. From there, I may ask each learner if they have specific goals for the shift. I eventually create objectives that I would like to meet with each learner as their case load develops and I am able to assess where they are at.

Do you typically see patients before or after they are presented to you?

This depends on the moment. If the flow of the department is being managed well by the residents and I know that they will be seeing patients in a timely manner, I tend to review the chart and look at vitals as well as nursing notes while waiting for a formal presentation. If there are multiple new patients or some more critically ill patients, I will try to sneak in to see patients briefly and get a gestalt of their state before the residents see the patient. If there is nothing too critical to be done, I will still allow the residents some time to place orders and initiate management on their terms.

How do you boost morale amongst learners on shift?

I’ve gotten in the habit of taking notes on learners. On my phone, I try to jot down what music they try to listen to, whether they had a vacation recently or upcoming, etc so that I can initiate some nonclinical conversation while we work. It’s not always possible, but I might bring snacks or buy coffee. Often, I offer to take the phone and will try to see a new patient on my own while sending them to get coffee or food with the understanding that they don’t have to rush back. If tasks start to build up, I make sure to ask the residents which of those items I can take off their list so it’s understood who is doing what, and we can work towards a disposition together.

How do you provide learners feedback?

Ideally, I like to provide in-person feedback prior to then submitting a formal written evaluation. This ensures that they are not caught off guard, that they understand what is meant, and even provides an opportunity for them to provide context that may allow me to understand more about their performance that shift (recently ill, tired, got called in, etc). I tend to follow up this in-person feedback with a summary email when it had to do with a more in-depth conversation. With any feedback in-person though, I check in and ask “is now an OK time for some feedback?” This could be at the end of the shift as a summative, but if it happens to be more in real-time during a case I make sure to ask if it’s an OK time and also try to be specific: ‘I had some feedback on [insert specific thing]- is now OK to talk or should we do it later?”

What tips would you give a resident or student to excel on their shift?

Every patient encounter has an opportunity for learning. Growth comes when we purposeful identify where we could improve, and take steps towards doing that. There is learning to be had with going through the stresses of carrying many patients at once, handling those difficult conversations, finding out the best ways to do this and that, but recognizing that we are there as a team. We can do that learning together. Cognitive overload can be detrimental if not done in the right way.

Are there any resources you use regularly with learners to educate during a shift?

What are your three favorite topics to teach during a shift?

If I wouldn’t have become an EM doc, I would have likely become a cardiologist. I enjoy talking about ECGs and dysrhythmias. Also, I enjoy talking about Airway/intubation preparation and troubleshooting.

What techniques do you employ when teaching on shift?

As mentioned above- whiteboard teaching, visual demonstrations, quick reviews, Socratic method of questions to assess learner level, and supported experiential learning.

What is your favorite book or article on teaching?

Books: Make it Stick-Roediger, McDaniel, Brown; The Courage to Teach- Palmer.

Article: Not Another Boring Lecture: Engaging Learners with Active Learning Techniques– Wolff et al.

Who are three other educators you’d like to answer these questions?

Ashley Rider and Leonardo Aliaga

Read other How I Educate posts for more tips on how to approach on-shift teaching.

This week’s How I Educate post features Dr. Fareen Zaver, the Deputy Head of Education in the Department of Emergency Medicine at the University of Calgary. Dr. Zaver spends approximately 30% of her shifts with learners at two tertiary care hospitals which include emergency medicine residents, off-service residents, and medical students.   Below she shares with us her approach to teaching learners on shift.

What is one thing (if nothing else) that you hope to instill in those you teach?

Take the time to give proper and SIMPLE discharge instructions for every patient you see. No medical jargon, clear follow-up instructions, and specific return instructions.

It can be difficult to sit back and let senior learners struggle what is your approach to not taking over prematurely?

I truly give them the time and space to struggle on their own. Though they know I am here to support them, I will not give them the answers or deal with the difficult dispositions or difficult interactions, or bed block issues myself. I will always defer to their decisions and only if there is a risk to patient safety will I correct them in real-time. I will typically wait until they have managed the senior-level issues on their own to discuss my own approach or lessons learned from the decisions they have made.

Do you start a teaching shift with certain objectives or develop them as a shift unfolds?

Both – I always email learners before a shift to determine what their goals for a shift with me are so that I can be prepared (often I have to brush up on a specific topic they want to go over, create an oral board case for them, etc). I always discuss these objectives at the beginning of the shift so we are on the same page. I also check in halfway through the shift to see if we are meeting the objectives, if perhaps based on the types of patients we are seeing or the acuity or bed block of a shift if a certain objective is going to be unobtainable on the shift how to pivot or adjust a goal to something that will be more useful during that shift.

How do you boost morale amongst learners on shift?

With even the struggling learner there is ALWAYS something they do well. I start with those items first and really allow them to feel confident in that particular thing before moving on to any other feedback or teaching.

How do you provide learners feedback?

I provide learners feedback during a shift as well as at the end. The mid-shift feedback is to give them specific, actionable pointers after I have watched them either interact directly with a patient or nursing staff that they can implement immediately with the patients they look after for the rest of the shift. I also give them verbal feedback at the end of the shift. We are also required to give written feedback which I typically fill out either right after the shift or within a day or two as it is easy to forget exactly the feedback you wanted to share with them if I wait any longer than that for feedback.

What tips would you give a resident or student to excel on their shift?

The most important skill set is clear communication with patients as well as with nursing staff. Understanding why a patient has come to the emergency department, and what their fears are instead of judging them for what may seem like a primary care complaint. This often unearths the real reason they came and addressing it likely saves multiple investigations. A patient who doesn’t feel heard by their doctor leads to repeat visits for the same thing. This is the same for nursing staff, taking the time to answer nurses’ questions regarding choices in a workup, what the plan is for a patient, and closing the loop around the disposition of a patient allows for excellent teamwork. It also means they will always have your back!

Read other How I Educate posts for more tips on how to approach on-shift teaching.