How I Educate: Graham Snyder, MD

This week’s How I Educate post features Dr. Graham Snyder, the Associate Program Director at the University of North Carolina and Director of Education for WakeMed Health and Hospitals. Dr. Snyder spends approximately 90% of his shifts with learners which include emergency medicine residents, off-service residents, and medical students. He describes his practice environment as a Level 1 trauma center that sees 125,000 patients annually. Below he shares with us his approach to teaching learners on shift. 

Name 3 words that describe a teaching shift with you.

Practically Academic, Comradery, Rejuvenating

What delivery methods do use when teaching on shift?

YouTube, just-in-time sim task-training, observation and feedback of the resident teaching the student.

What learning theory best describes your approach to teaching?

Cognitive learning

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

Love and an appreciation of the honor of caring for patients in their time of need.

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

Yes. I hire a scribe to offset time for patient discussions. 

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

On-shift. By asking them socratically how different parties, consultants, PMD’s, lawyers, and the patients themselves would interpret their documentation in the event that their diagnosis is correct…or if it was completely wrong.

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

It’s a fine balance. Much like showing compassion and patient counseling, teaching is a corner that could be cut but I choose not to. I also preferentially pick up patients myself that are low yield so I do not need to spend time listening to presentations where I anticipate little teaching opportunity.

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

As a life-long learner and a simulation lab director, I am continually developing my airway and procedural skills in general. I focus particularly on managing learners who are having challenges in completing procedures and this allows me to continue teaching, even when they are struggling while avoiding putting patients at risk.

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

If the residency leadership team has identified a weakness during our monthly reviews, I make that weakness the goal of the shift. Otherwise, I try to huddle with the resident at the start of the shift to see what they have self-identified as a learning goal.

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

After unless I “discover” an interesting patient of my own that I intended to see alone but is just so fascinating that I send the resident in redundantly.

How do you boost morale amongst learners on shift?

I like to both say the words and physically, “take a moment” and point out the countless great wins we have every day: recognition of subtle EKG changes, transforming a terrified patient into a calm one, early recognition and resuscitation of a deadly disease, and force them to not overlook the victories, that can so easily get overshadowed by the frustrations.

How do you provide learners feedback?

On shift, after shift, written and verbal.

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

Up to Date, EM-RAP, and YouTube.

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

Difficult airways, excited delirium, and ultrasound of the hypotensive patient.

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

Jerry Hoffman and Gary Greenwald

 

How I Educate Series logo

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

 

How I Educate Series: Guy Carmelli, MD

This week’s How I Educate post features Dr. Guy Carmelli, who is an Assistant Professor at UMass Medical School and co-leader of their EM Sub-I rotation. Dr. Carmelli spends approximately 80% of his shifts with learners which include emergency medicine residents, off-service residents, and medical students. He describes his practice environment as a tertiary care academic center with trauma, stroke, and cardiac cath capabilities. Below he shares with us his approach to teaching learners on shift. 

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

 

How I Educate Series logo

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

 

By |2022-07-29T07:21:45-07:00Aug 24, 2022|How I Educate, Medical Education|

How I Educate Series: Moises Gallegos, MD

This week’s How I Educate post features Dr. Moises Gallegos, the Clerkship Director at Stanford University. Dr. Gallegos spends approximately 75% of his shifts with learners which include emergency medicine residents, off-service residents, medical students, and physician assistant students. He describes his practice environment as an academic Emergency Department at a medical research institution that serves as a Level 1 Trauma facility. Below he shares with us his approach to teaching learners on shift. 

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?

In the shared Google document, I tend to highlight some of the FOAMEd blogs that are more “to the point” and that I feel are not overwhelmingly in-depth (First10EM, EM@3AM from emDocs, CoreEM, etc).

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

 

How I Educate Series logo

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

 

By |2022-07-29T09:14:52-07:00Aug 17, 2022|How I Educate, Medical Education|

How I Educate Series: Fareen Zaver, MD

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!

How I Educate Series logo

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

By |2022-07-29T07:23:47-07:00Aug 10, 2022|How I Educate, Medical Education|

How I Educate Series: Michael Gisondi, MD

This week’s How I Educate post features Dr. Michael Gisondi, the  Vice Chair of Education at Stanford University. Dr. Gisondi spends approximately 80% of his shifts with learners which include emergency medicine residents, off-service residents, medical students, and physician assistant students. He describes his practice environment as a busy, high-acuity, university-based, suburban hospital with an annual ED census of 85,000. One-third of the patients speak a language other than English and one-third are without health insurance. Below he shares with us his approach to teaching learners on shift. 

Name 3 words that describe a teaching shift with you.

Direct observation & autonomy

What delivery methods do use when teaching on shift?

Hypothetical questioning

What learning theory best describes your approach to teaching?

Relational autonomy

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

Patients deserve comprehensive evaluations. That doesn’t mean sending every test on every patient, but it does mean considering broad differentials and testing when appropriate.

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

Every interaction is teaching, though perhaps it isn’t signposted as such. For instance, how much time I spend with one patient relative to another speaks volumes to those who are paying attention.

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

I read them all, and I point out errors of omission or misstatements that need correction.

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

Absolutely not. Being efficient is one of the most important learning outcomes during emergency medicine training. Metrics are measures of these learning outcomes and are not at odds with training in any way. Residents must learn how to excel as attendings and operational metrics are part of their future.

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

I’ve learned to give a long leash to the senior residents. I stalk the board constantly and read all the notes, both from physicians and nursing. I sneak in to examine patients when the residents aren’t looking. I know what’s happening on my team and can gauge how much autonomy to give my residents.

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

I let the shift play itself out.

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

I try to see as many patients with residents as possible. There are so few direct observation opportunities in training that I try to create them as much as possible. It helps me give better feedback to residents and it improves efficiency.

How do you boost morale amongst learners on shift?

Everyone gets a meal break. I try to help chart or disposition patients when busy. I liken myself to a good second-year resident.

How do you provide learners feedback?

Again, I’m giving feedback constantly, whether it is signposted or not. Simply agreeing with a plan is feedback. I find that I don’t have much to say on end-of-shift feedback forms because I’ve been teaching and giving feedback throughout the shift.

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

Stop for 3 minutes after every patient and write the H&P in the chart. It will save so much time later in your shift. Similarly, complete your entire note before calling report. It saves you and the admitting team a lot of time on the phone.

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

Equianalgesic opioid dosing charts.

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

Running a code, motivational interviewing, and how to remove an ingrown toenail

What techniques do you employ when teaching on shift?

Relational autonomy, direct observation, The Feedback Formula.

What is your favorite book or article on teaching?

Fostering the Development of Master Adaptive Learners: A Conceptual Model to Guide Skill Acquisition in Medical Education

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

Holly Caretta-Weyer, Abra Fant, Sara Krzyzaniak

 

How I Educate Series logo

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

 

By |2022-07-29T09:06:43-07:00Aug 3, 2022|How I Educate, Medical Education|

EM Match Advice 38: Our 2 Cents | The Revamped Standardized Letter of Evaluation (SLOE) is here

EM Match Advice 2 cents episode on SLOE Standardized Letter of Evaluation

This is the 38th episode of EM Match Advice but the inaugural episode for new podcast series host, Dr. Sara Krzyzaniak (program director at Stanford EM residency program)! This quick podcast episode was recorded to coincide with the new, much-anticipated release of the Standardized Letter of Evaluation (SLOE 2.0). We address questions of why the changes, and what is different. In this podcast, Dr. Krzyzaniak and Dr. Michelle Lin speak with 2 key faculty who helped lead the multi-year development of this key piece of the residency application puzzle:

  • Dr. Sharon Bord (Johns Hopkins EM Clerkship Director, 2022-23 President of the Clerkship Directors in Emergency Medicine)
  • Dr. Doug Franzen (Washington University Associate Program Director)

EM Match Advice Podcast: Our 2 Cents about the new SLOE

 

 

View the ESLOE template

 

Read and Listen to the Other EM Match Advice Episodes

Blog posts: https://www.aliem.com/em-match-advice-series/

 

References and Additional Reading

  1. SLOE 2.0, CORD EM website, July 2021
  2. A Path Forward–practical consensus on 2021-2022 EM advising. CORD EM website, April 2021.
     

 

By |2022-07-19T08:52:30-07:00Jul 19, 2022|EM Match Advice, Podcasts|

EM Match Advice 37: EM Program Directors Reflect on the 2022 Match

EM Match Advice 10 year table residency match

In this 37th episode of EM Match Advice, we discuss the results of the 2021-22 EM Residency Match with lots of shocking numbers and surprises to review. The table above lists the trends and data since 2014, extracted from the National Resident Matching Program (NRMP) site [1]. Could this have been foreseen? What does this mean for the 2022-23 EM Match season? In this podcast, Dr. Mike Gisondi and Dr. Michelle Lin host the following esteemed panel of 3 program directors to review this juicy table and discuss the future:

  • Dr. Abra Fant (Northwestern University)
  • Dr. Sara Krzyzaniak (Stanford University)
  • Dr. Bonnie Kaplan (Denver Health)

More Numbers from ERAS/AAMC by Program

emergency medicine EM Match Advice ERAS table

EM Match Advice Podcast

 

Read and Listen to the Other EM Match Advice Episodes

Blog posts: https://www.aliem.com/em-match-advice-series/

 

References and Additional Reading

  1. National Residency Match Program: Data and Reports
  2. Pelletier-Bui AE, Schnapp BH, Smith LG, et al. Making Our Preference Known: Preference Signaling in the Emergency Medicine Residency Application. West J Emerg Med. 2021;23(1):72-75. Published 2021 Dec 17. doi:10.5811/westjem.2021.10.53996. PMID 35060866
  3. Preference/Program Signaling (PS) in Emergency Medicine. CORD website, 2022.
By |2022-05-28T09:30:51-07:00May 11, 2022|EM Match Advice, Podcasts|
Go to Top