This week’s How I Educate post features Dr. Mark Ramzy, an EM attending and Intensivist at RWJBH Community Medical Center in New Jersey. Dr. Ramzy spends approximately 90% of his shifts with learners which include emergency medicine residents, internal medicine residents, and medical students. He describes his practice environment as a split time between the ED and ICU. ED time includes a scanning shift as part of his ultrasound faculty requirements and his ICU time is split across several different units including a MICU, SICU, and CTICU. Below he shares with us his approach to teaching learners on shift.
Name 3 words that describe a teaching shift with you.
Dynamic, Accountability, and Targeted.
What delivery methods do use when teaching on shift?
Drawing on paper/whiteboards and infographics.
What learning theory best describes your approach to teaching?
Toss up between Constructivism vs Connectivism and using Andragogy with a focus on Adult Learning.
What is one thing (if nothing else) that you hope to instill in those you teach?
To trust but verify and not be afraid to question everything.
How do you balance your flow with on-shift teaching? Does this come at the expense of your documentation?
This heavily depends on where I’m working and how the day is going. If in the most critical zone/pod of the emergency department then the teaching is done in real-time with emphasis, repetition, and reinforcement as we go. The content/material is then reviewed at a later time when safe for both the patient at the learner. This typically does not come at the cost of documentation because we have scribes in the emergency department who really help with this.
When in the ICU, many small learning pearls are discussed during rounds. Assuming procedures, consultant discussions, and family meetings are completed and time allows, the afternoon is then reserved for most specific topics that the learners have expressed interest in knowing more about
What is your method for reviewing learners’ notes and how do you provide feedback on documentation?
I review learners’ notes after a shift and take notes myself on very specific items to discuss with them in more detail either via email/text or in person if we are working together within 48 hours. I have this cutoff because that patient (and note) is still fresh in their mind, thus allowing the feedback to stay SMART=Specific, Measurable, Actionable, Relevant, and Timely.
Do you feel departmental flow and metrics adversely affect teaching? What is your approach to excelling at both?
Departmental flow and metrics definitely adversely affect teaching. There has been a greater push across many healthcare systems to “see more patients” or to really prioritize patient satisfaction despite this not necessarily leading to better outcomes. As a result, the teacher and learner are directly impacted. My approach to this starts with a set expectation and in-depth discussion before the shift starts. If the waiting room is packed and there are sick patients that continue to come in, I try my best to have a talk with my learners about the importance of self-driven learning, asking for help, and utilizing resources around them. We set the expectation that the teaching will primarily be “on the go” and to have them write down topics or content that they would like to discuss further when at weekly conference or any other time off a shift. No matter how busy a shift is, learning can always happen. It doesn’t always have to take the form of ventilator settings to reduce AutoPEEP but can look like interprofessional communication, engaging with a family to deliver unfortunate news, or even electronic medical record hacks to work more efficiently.
It can be difficult to sit back and let senior learners struggle what is your approach to not taking over prematurely?
Patience not patients. I talk with my learners thoroughly about their treatment plans and we try to play out what will happen if they carry out wrong/incorrect therapies (without actually doing them of course). This way they can get an expectation of what would happen without causing harm to the patient. When it comes to procedures, I set up or have my own gown/gloves readily nearby. I jump in under three conditions: When the learner asks for help, if they are about to do something that could be detrimental to the patient without knowing or I gage that a complication/failure to complete a procedure will occur (ie. an already difficult airway, failed cannulation on limited vessel access, etc).
Do you start a teaching shift with certain objectives or develop them as a shift unfolds?
I tend to start a shift with certain objectives and explicitly ask the learner, what they would like to work on. I add to it if I’ve worked with them before and observed specific things they could improve. Additionally, we end every shift giving feedback and so we’ll try to work on those same things on the next shift if there’s an area for improvement.
Do you typically see patients before or after they are presented to you?
A mix of both, most of the time I see patients before they are presented to me.
How do you boost morale amongst learners on shift?
Humor and stories from my own experience that were teachable moments.
How do you provide learners feedback?
Also a mix of both. Time permitting, I tend to provide learners with verbal feedback. I then try to build upon that each time we work together. This all then gets incorporated into their written formal residency evaluation feedback.
What tips would you give a resident or student to excel on their shift?
Every moment is a teachable moment. Find the pearl you can take away from every patient encounter, colleague interaction, or conversation. Everything is about perspective and our failure to empathically see other viewpoints is what leads to conflict. Lastly, the best learning you can do is that which pushes you outside of your comfort zone. Learning isn’t easy, it takes time and hard work. It’s a long-term investment in yourself.
Are there any resources you use regularly with learners to educate during a shift?
I frequently reference the EMRA pocket books (digitally or hardcopy). I share many REBEL EM articles and infographics that I’ve personally made so the learner can pay attention to our discussion and then walk away with a summary of it on their phone. Also, Amal Mattu’s ECG weekly is often shared quite a bit.
What are your three favorite topics to teach during a shift?
Ventilator basics and management, pharmacology (usually sedatives), and creating differentials based on data (especially for altered mental status).
What techniques do you employ when teaching on shift?
Creating an optimal learning environment (ie. Psychological safety), spaced repetition and critically challenging learners.
What is your favorite book or article on teaching?