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.