This week’s How I Educate post features Dr. Sara Dimeo, the Program Director at East Valley Emergency Medicine. Dr. Dimeo spends approximately 70% of her shifts with learners which include emergency medicine residents, off-service residents, and medical students. She describes her practice environment as a busy, level 1 trauma center in the East Valley of Phoenix, Arizona with an annual patient volume of ~70K. Our sister hospital Mercy Gilbert has a new Women’s and Children’s pavilion where a pediatric ED will be opening in conjunction with Phoenix Children’s hospital. The program is a community-based EM program with all of the bells and whistles of an academic program, and the culture of the hospital makes it a great place to work. Below she shares with us her approach to teaching learners on shift.
What delivery methods do use when teaching on shift?
“What if”…I like to pose hypothetical situations to mentally prepare learners when a critical patient is arriving. For example, a patient who is in cardiac arrest is due to arrive; “What if they just had an orthopedic surgery recently?” “What if they are in refractory v-fib?” “What if the nurses are struggling to get a line?”
What is your method for reviewing learners’ notes and how do you provide feedback on documentation?
It can be difficult to provide note feedback while on shift, depending on the shift. I like to open an email while I sign my charts and take notes to send to learners; particularly if I notice a pattern of difficulty with documentation.
Do you feel departmental flow and metrics adversely affect teaching? What is your approach to excelling at both?
I aim to be somewhere in the upper end of the middle of the pack in regards to patients per hour, etc. I think that choosing opportune times to teach, and running the list with residents frequently to divide and conquer between myself and them which tasks need to be done helps a lot. For example, if we have a sign out list of 3 patients and there are 2 new patients to be seen, I’ll “take” the sign out patients and have the resident go see the 2 new ones.
It can be difficult to sit back and let senior learners struggle what is your approach to not taking over prematurely?
YES- this can be so hard! I was once given the advice that everyone will know you’re an attending if you stand at the foot of the bed to guide the resuscitation. I try to guide my learners to assume this position and encourage them to consciously lead the team. I physically will stand next to them or at the side of the room and put my hands in my pockets. I try to speak up only if I see a patient safety issue or if the learner truly needs help.
Do you start a teaching shift with certain objectives or develop them as a shift unfolds?
I think that the entire idea of developing an objective to learn before a shift can be flawed because often you will see very different presentations of patients than what you desire. However, making sure your learners know how you work is important. Also, creating broad objectives such as: “I want to work on completing my notes in real-time”, or “I want to try to see every patient in the pod” is a sure way to go.
Do you typically see patients before or after they are presented to you?
Depends. If possible, I like to see them before because I can synthesize their presentation and give them better real-time feedback. I also like to directly observe learners because it gives me the best insight into their H&P and decision-making skills, and also kills two birds with one stone (where I don’t have to see the patient later). It also allows you to model certain behaviors or add focused questions, though I think this is best done at the end of the learner’s questioning because otherwise, I’d feel I was interrupting them.
How do you boost morale amongst learners on shift?
Residency is really hard. Medical school is hard but in different ways. For students, involving them as much as possible so they feel they are truly part of the team, and showing them my enthusiasm for learning and discovering is my approach. With residents, I encourage them to get food, coffee, etc. and just try to be a supportive ally in what they’re going through.
How do you provide learners feedback?
I used to struggle a lot with giving feedback, so I made an effort to practice it often and now I don’t think it’s such a big deal. It pains me so much when a resident receives a scathing evaluation and they tell me no one has discussed it with them. It really takes a toll on their mental health. I think the cool thing about residents is that they want to improve, and they usually are the hardest on themselves. I always start with an open-ended question such as “How do you think that went?”, which gives me the opportunity to clarify their thought process about their performance.
What tips would you give a resident or student to excel on their shift?
(1) Put in your orders, then dictate your HPI and PE of your note right after seeing a patient
(2) Run your patient list frequently
(3) Try not to put off procedures or difficult cognitive decisions to the end of your shift….it will just make you stay over!
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?
(1) Love eye stuff! it’s an often neglected topic
(2) STEMI equivalents (though now the guidelines are finally catching up!)
(3) How to give a death notification/difficult patient encounter approaches
What is your favorite book or article on teaching?
If you haven’t read the original Dunning-Kruger paper, I found it to be really fascinating.
Who are three other educators you’d like to answer these questions?
Christina Shenvi, Andy Little, and Molly Estes.