How I Educate Series: Molly Estes, MD

This week’s How I Educate post features Dr. Molly Estes, the Clerkship Director and Medical Education Fellowship Director at Loma Linda University. Dr. Estes spends approximately 80% of her shifts with learners which include emergency medicine residents, off-service residents, and medical students. She practices at a university hospital that is a level 1 trauma center, STEMI receiving center, and comprehensive stroke center. Below she shares with us her approach to teaching learners on shift.

Name 3 words that describe a teaching shift with you.

Humorous, practical, stretching.

What delivery methods do use when teaching on shift?

Mostly verbal discussion, the occasional google picture or drawing sketched on the back of my patient list.

What learning theory best describes your approach to teaching?

Socratic. I like to ask a lot of questions to first establish where the learner is at. Then I usually try to help the learner derive their own answer with a series of logical steps. I use a variety of other bedside teaching models too including the One-Minute Preceptor, SPIT, and Teaching Scripts.

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

An inquiring mind :) So much of medicine and medical reasoning is elegant and inspiring, and some of the things we can do are just downright incredible. I hope my learners are able to appreciate the depth of intricacy and sheer coolness of what we do in Emergency Medicine.

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

Most of my teaching is done on an individual basis, is based on the patient being presented, and with very short discussions, typically no longer than 5 minutes at a time. Occasionally if the shift permits it I will gather the learners and do a slightly longer discussion, usually around 10 minutes. This definitely causes documentation to be pushed back sometimes, but in my opinion, it’s worth it.

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

I try to review notes while on shift, but it more commonly happens after shift. If feedback is needed, I will send an Epic message to the resident or talk to them at conference that same week.

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

Departmental flow has been challenging to teaching, particularly as our volumes nationwide are getting higher and staffing is getting more stretched. However, teaching is necessary, and I approach it the same way I do any of the other metric requirements of my position. When you look at it as an essential action, then you make sure it gets worked in as best as possible.

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

Literally biting my tongue. I try really hard with my senior residents to let the process happen. Sometimes it’s necessary to step in early, especially when department flow is beginning to suffer a little. But I try to pick the “safe” situations and patients that allow for a bit of the struggle so that those lessons can be applied in the broader context.

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

Depends on the day, the shift, and the resident. Sometimes we start with goals, other times we don’t.

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

After presentations.

How do you boost morale amongst learners on shift?

Trying to rally everyone together as a team. We all need to feel like what we are doing matters, and even if it’s been a disaster of a shift, we have still made a difference to someone. I try to bring the focus back to the positives of the shift, not harping on the negatives.

How do you provide learners feedback?

Typically verbal and either on or immediately after shift. We do end-of-shift evaluations of residents, so I ensure my written feedback always matches with my verbal feedback.

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

Be humble, inquisitive, and challenge yourself to always learn something new from every patient.

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

No one consistent source, but some of the sources I use are UpToDate, WikEM, Medscape, and various FOAMed resources like LITFL, EMCrit, etc.

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

Dizziness vs. lightheadedness, management of UGIB, and nearly any Heme/Onc topic (yes, I’m quite the nerd with my weird niche interests, haha).

What techniques do you employ when teaching on shift?

One-Minute Preceptor, SPIT, Teaching Scripts, and actually a modified Aunt Minnie model to teach my senior residents department flow as it relates to staffing changes.

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

Lizveth Fierro, Andrew Little, Deena Bengiamin.

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

By Molly Estes, MD FACEP FAAEM|2022-10-04T16:57:00-07:00Oct 12, 2022|How I Educate, Medical Education|

IDEA Series: Ultrasound-capable, 3D-printed central line trainer

Problem: Central venous line (CVL) placement is a key skill for emergency medicine providers. Sites for central line placement include the internal jugular vein, subclavian vein, and femoral vein. Indications include, but are not limited to fluid resuscitation, medication administration, central venous pressure monitoring, pulmonary artery catheter introduction, and transvenous pacing wire placement. Procedural complications can include catheter-associated infection and arterial puncture. Success rates for CVL placement vary based on location and provider experience [1-3]. Point-of-Care Ultrasound (POCUS) increases both success rate and patient safety when used to guide CVL placement [4].

Figure 1. Setup for ultrasound-capable, 3D-printed central line trainer

The Innovation

The ultrasound-capable, 3D-printed central line trainer was created to facilitate realistic training of POCUS-guided CVL placement, specifically utilizing the internal jugular vein. The trainer uses a ballistic gel insert that is ultrasound-capable and replaceable, as needed.

The Learners

The model can be utilized by anyone needing practice and training on central line placement. This includes medical and physician assistant students, residents, and fellows. It will be particularly useful with students familiar with POCUS basics.

Group Size

In our experience, 4-5 students were able to utilize the model before the wear from repeated use began to impact the imaging and structure of the model, necessitating replacement of the insert. The dilation step of the Seldinger technique can be skipped or simulated in order to prolong the life of the gel insert.

Equipment

Description of the Innovation

The initial head model was designed using 2 common 3D modeling software systems: Tinkercad and Meshmixer
A generic head and neck model was imported into Meshmixer. Using the available tools in Meshmixer, the head was rotated to the side and the neck was manipulated to enhance the appearance of an extended neck with close attention to the sternocleidomastoid muscle and clavicle.
The model was then imported into Tinkercad and a section of the neck was removed, inverted, and manipulated inside of a box to create a negative (mold).

Figure 2. Screenshot of head being edited in Tinkercad software

Figure 3. Screenshot of neck mold being edited in Tinkercad software

The head was printed with Polylactic acid (PLA) filament in 2 sections that were then glued together with superglue. The seam was sealed and smoothed with latex caulk. The files for both the head and the mold can be found in this Google Drive folder.
A hole was drilled from the base of the neck through the top of the head. A second hole was drilled in the base of the model.
To make a suitable tray for the ballistic gel insert, a thin plate was printed and then cut to fit the shape of the neck. Finally, that piece was glued to the bottom of the model.
The model was painted using matte spray paint.

Figure 4. Use of matte spray paint to paint the model

The mold was printed next. Two holes were drilled on either side to allow for insertion of latex tubing.
The ballistic gel was heated according to the directions on the box. The gel can be colored using dye or acrylic paint. Caution should be practiced when using acrylic paint. The heated gel can foam up, increasing the possibility of injury from burn.
While the gel was heating, the mold was prepared. The bottom was coated with a thin layer of dish soap to assist with gel release. Two sections of latex tubing, approximately 2 feet each were inserted into the mold. Modeling clay was used to fill the gaps.
Once colored and thoroughly heated, the gel was poured into the mold.

central line trainer mold internal jugular vein

Figure 5. Preparation of the mold in which the heated gel will be poured

Figure 6. The heated, colored gel is poured into the mold

After curing, the latex tubes were removed. The gel neck model was then removed and placed into the accompanying space on the 3d printed trainer.
The latex tubing was fished back through the available holes, and filled with water. As an optional step, a 30 cc syringe was attached to one end of the thicker tube. Tube stoppers can also be printed and used in place of hemostats. Pumping the syringe plunger simulates the appearance of arterial flow on ultrasound.

Video Demonstration of Final Product

Lessons learned

We are currently investigating how best to research this model. The model is inexpensive compared to available commercial CVL trainers. We estimate the cost at approximately $80 per model in materials. This, of course, does not include the price of a 3d printer, 18v drill, or drill bit. Two comparable models available for purchase are both listed for over $1000 [5, 6]. The build time is approximately 1 week with time spent printing, glue-drying, and ballistic gel setting. The model can be used repeatedly and the insert remade many times over.

If another model were to be designed, the top of the head could be sacrificed in favor of an elongated neck section. The top of the head provides no value and consumes 3d printing filament. Furthermore, an elongated neck may be preferable for a new learner by allowing more room to practice probe and hand placement.

Theory behind the innovation

Simulation as a means of teaching has been a firmly established practice across the landscape of medical education. The model in question is high-fidelity and offers the user a realistic experience in a low-stress environment. The model is small enough to be portable and can be used with little preparation, making it an ideal tool for just-in-time training in the emergency department.

Tools that allow the learner to practice multiple steps of a skill during one exercise are invaluable for skill development, competency-based medical education and mastery learning.

Led by series editor, Dr. Mary Haas, the IDEA series showcases examples of what programs worldwide have been doing to make residency conference more entertaining, engaging, and most of all, educational for residents. Read more publications from the series.

References

McGee DC, Gould MK. Preventing complications of central venous catheterization. New England Journal of Medicine. 2003;348(12):1123-1133. doi:10.1056/nejmra011883
Schummer W, Köditz JA, Schelenz C, Reinhart K, Sakka SG. Pre-procedure ultrasound increases the success and safety of central venous catheterization. British Journal of Anaesthesia. 2014;113(1):122-129. doi:10.1093/bja/aeu049
E Portalatin M, Fakhoury E, Brancato R, et al. Factors contributing to unsuccessful central line placement in the neck and chest. Surgery: Current Trends and Innovations. 2019;3(2):1-5. doi:10.24966/scti-7284/100015
Saugel B, Scheeren TWL, Teboul J-L. Ultrasound-guided central venous catheter placement: A Structured Review and recommendations for Clinical Practice – Critical Care. BioMed Central. Published August 28, 2017. Accessed September 21, 2022.
Life/form Central Venous Cannulation Simulator. Universal Medical. . Accessed September 21, 2022.
Blue Phantom internal jugular Central Line Ultrasound manikin. 3012495 – Blue Phantom – BPP-060 – Ultrasound Trainers. Accessed September 21, 2022.

By Taylor L. Fischer, MMS PA-C|2022-09-26T01:52:50-07:00Sep 30, 2022|IDEA series, Medical Education, Ultrasound|

How I Educate Series: John Casey, DO

This week’s How I Educate post features Dr. John Casey, the Program Director at OhioHealth Doctors Hospital in Columbus, OH. Dr. Casey spends 100% of his shifts with learners, including emergency medicine residents, off-service residents, medical students, nursing students, physician assistants/nurse practitioner students, and EMS students. He describes his practice environment as a busy community teaching hospital located on the city’s edge, with a diverse patient population and many socioeconomic challenges. Below he shares with us his approach to teaching learners on shift.

Name 3 words that describe a teaching shift with you.

Use. The. Force.

What learning theory best describes your approach to teaching?

Deliberate practice. I think it’s so very important to identify an area of weakness and target it. I try and focus my teaching energy on areas where learners have blind spots and get them to engage in very targeted practice in that specific area.

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

Always be curious, and not be afraid to challenge your own beliefs – or to have them challenged!

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

I try and teach my more senior residents how to incorporate junior learners and students into their workflow. When a learner locks on to you for a shift you don’t know if you’re getting a parachute or a knapsack…don’t jump out of the plane until you have identified which they are.

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

Nope. Department flow and metrics are part of the learning process. A lot of our job is more than medicine. To be happy and successful in this career long term you have to have a plan to manage these stressors – so better to learn it in residency while you have support from experienced emergency physicians. There will always be faster shifts, slower docs, efficient nurses, and lab slow downs – learn to work through them.

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

Be confident in your own abilities to manage situations, and remember you learned to be better through practice. As long as you are available to support them, and recognize the boundaries of what is safe for the patient and the learning environment, then most learners appreciate this on the other side. Earlier in my career, I probably let learners struggle a little more than I should have, and this is a place where I have learned – and grown – through feedback.

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

I think it’s better to let them develop as the shift unfolds. I will often ask if the learner has something in mind, and if they do I am happy to cover it – but no guarantees!

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

I deliberately shake this up. When I see them before, I will often engage the patient in helping me get feedback on the learner. I will ask that they not specifically mention I have seen them, and give them an area to focus on (like did the resident ask similar questions to what I asked, or did they make them feel comfortable, etc.). I will then circle back and get feedback – you can learn a lot about how residents interact with patients using this method. Also – I love to go into the room while they are doing the exam and interview. Hawthorne effect aside, you can learn a ton about how the learner is doing overall!

How do you boost morale amongst learners on shift?

I work hard to pay attention to the overall mood of the shift and try and throttle accordingly. I am by nature a storyteller and like to share experiences. It’s more than just lip service when we talk about cases where we didn’t do as well as we wanted at something. Human nature is to feel like we are totally responsible for mistakes when almost always there is a substantial mix of exogenous events that lead to failure. Also – I remind learners that whatever they feel in the moment is OK – those feelings about an event change with time and perspective. Windshields in a car are big for you to look forward, and rear-view mirrors are tiny so you can remember past lesions – but focus on what’s next. Additionally….dad jokes.

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

Be nice. Work hard. Stay humble. If you only have enough energy for one on a given day, be nice.

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

ECG interpretation, anaphylaxis, and reading a room

What is your favorite book or article on teaching?

Thanks for the Feedback: The Science and Art of Receiving Feedback Well by Stone and Heen. I guess it’s not really a book on teaching per se, but if you can help people learn this skill (and master it yourself) it can make for a great learning environment!

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

Dr. Katie Holmes, Dr. Deena Bengiamin, and Dr. Kristy Schwartz

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

By John Casey, DO, MA, FACEP|2022-09-03T11:12:21-07:00Sep 28, 2022|How I Educate, Medical Education, Uncategorized|

How I Educate Series: Alex Koyfman, MD

This week’s How I Educate post features Dr. Alex Koyfman, who serves as core faculty at UT Southwestern in Dallas, TX. Dr. Koyfman spends approximately 90% of his shifts with learners, including emergency medicine residents, off-service residents, medical students, and physician assistants. He works clinically at Parkland Memorial Hospital which is the busiest urban ED in the country. He also spends time in their independent urgent care and ED observation unit, both of which also have a mix of different learners. Below he shares with us his approach to teaching learners on shift.

Name 4 words that describe a teaching shift with you.

Autonomy, growth, curiosity, pt advocacy

What delivery methods do use when teaching on shift?

A focused discussion based on the needs of the learner and what is high-yield in our environment.

What learning theory best describes your approach to teaching?

A mixture of multiple which is actually documented in my book The Emergency Medicine Mindset.

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

Excellence in clinical care is the ultimate form of patient advocacy and deliberate practice gets you to mastery.

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

Volume definitely impacts teaching as 1a) patient care, and 1b) education; they feed off of each other. The focus is on impactful clinical documentation for the transition of care, not medicolegal paranoia; it is impractical to achieve excellence in all spheres of practice. We must be thoughtful communicators at the bedside on working diagnoses and degrees of uncertainty. Each piece of information you request, you must account for in the context of the patient.

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

The focus is on decision-making (practical risk stratification). Does the MDM jive with the remainder of the documentation? Have risk factors/red flags been thoughtfully explained? It helps to highlight what to focus teaching on.

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

Mixed bag; I can’t disagree with the more you see the more comfortable you become. Often metrics don’t jive with evidenced-based medicine, however, many of our grads will be responsible for this and judged based on it in their future careers. Thankfully, it doesn’t dominate our practice environment in an onerous manner.

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

Experience teaches you to get comfortable with this. It is very important to get it right for resident development. There are many more greys in EM decision-making than black or white, thus if reasonable then no need to intervene pre-emptively.

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

The learner sets the tone for clinical education. At the same time, I’m not shy to bring up topics based on what we’re seeing.

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

Depends on the stage of the learner + the volume/practical need to move things along.

How do you boost morale amongst learners on shift?

Invest meaningfully in the development of each individual I work with.

How do you provide learners feedback?

Best handled in real-time if flow allows. The next best is right after the shift. Written feedback is a formality, I am not convinced that many learners review these and items can be misconstrued. This is an area that’s easy to avoid, yet crucial to do, and takes a departmental culture.

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

One foot outside of your comfort zone each shift; marginal gains add up. Reflect/be proactive about anything that didn’t go smoothly or caused consternation.

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

Heavy on foamed (emDocs, IBCC, EM Cases, etc.) with PubMed/Google Scholar literature mixed in.

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

EM mindset; decision making; high-risk, low-prevalence diseases; anything critical care; advocacy for our field in the academic arena

What techniques do you employ when teaching on shift?

Adapted from best practices here as well as paying attention to my colleagues.

What is your favorite book or article on teaching?

Thinking, Fast and Slow by Daniel Kahneman; Radical Candor by Kim Scott

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

Brit Long, MD; Manny Singh, MD; Alex Sheng, MD; Marina Boushra, MD

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

By Alex Koyfman, MD|2022-09-20T21:32:20-07:00Sep 21, 2022|How I Educate, Medical Education, Uncategorized|

How I Educate Series: Andy Little, DO

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?

Yes. But being malleable allows me to again teach with what comes through the door and let each patient we see teach us something.

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

This may sound funny, but I count down from 20 in my head. So if I see things going wrong, I count down and then take over. I have found even the learner with the worst struggles can usually course correct in that time.

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

Develop them as a shift unfolds. Remember, malleable.

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

It’s a mix. For my PGY 1’s I want them to see the patient first and ask them to present them as soon as they have so we can focus on their ability to rapidly access and formulate off of their H and P. For my seniors I try to see them first, so when they tell me their plan I can use that time to discuss what they did or didn’t pick up on and how I would change their plan. And everyone else falls somewhere in that spectrum.

How do you boost morale amongst learners on shift?

Focus on the little things they are doing well.

How do you provide learners feedback?

A mix of real-time verbal feedback (towards the end of the shift< post-shift evaluations) and then monthly reviews.

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

Be willing to be wrong. Learning doesn’t happen otherwise.

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

CORE EM, Rebel EM, ALiEM

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

EKGs, procedure tips, and reading plain films.

What techniques do you employ when teaching on shift?

Post it notes, custom made fill in the blanks, and coaching

What is your favorite book or article on teaching?

The Coaching Habit

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.

By Andy Little, DO|2022-09-04T15:33:51-07:00Sep 14, 2022|How I Educate, Medical Education|

How I Educate Series: Geoff Comp, DO

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?

Time, experience, and your own comfort in critical patient care and resuscitation is the key to effective senior learner guidance. We need to know and understand the skills of our senior learners as well as understand when patient safety may be compromised. The true hallmark of a great teacher is to know and understand at what time in each patient case they need to be able to step in. That space between a learner’s knowledge and when you feel like you need to step in is the space for learner growth and allows for optimum learner engagement. The second important component is being intentional with your learner about when you will be taking over because of concern for patient safety. This should always be paired with an active and intentional debrief of the entire patient encounter as soon as the patient has been stabilized. The second step allows for education and learner optimization without compromising patient safety or losing the teaching opportunity.

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?

The timing of when I physically see patients myself is usually tied somehow to the goals of the learner or to help me identify areas of improvement. For new or junior learners I try to sneak in before they present to me to identify key points of the history and physical so I can help guide them in proper presentation style and technique. With more advanced learners I usually see a patient after they present to me to confirm key parts of the history and circle back with them about different components of the case.

How do you boost morale amongst learners on shift?

A positive attitude is a choice and being an example of positivity is the best way to boost morale. Choosing to identify the components of an event that you can modify will allow for a beneficial outcome. By practicing positivity in the face of a challenging shift, departmental pressure, or a difficult case, you are actively demonstrating techniques to the learner. Be the type of attending that you want to learn from. However, I also work to boost morale by doing both individual and group check-ins, as well as debriefing during periods with high patient loads/acuity or after a critical resuscitation. I also work on giving intentional and direct mini-feedback sessions throughout the shift to provide positive encouragement and identify areas for learning.

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?

Resuscitated procedures/resuscitation mindset as well as team leadership, wilderness and environmental medicine, and orthopedic injuries.

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.

By Geoff Comp, DO|2022-09-04T12:42:52-07:00Sep 7, 2022|How I Educate, Medical Education|

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

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

By Graham E. Snyder, MD, FACEP|2022-09-03T10:59:27-07:00Aug 31, 2022|How I Educate, Medical Education, Uncategorized|

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