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?
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.