The Problem

Idea Series LogoEmergency Medicine (EM) residents are responsible for teaching and evaluating junior learners in the clinical environment. According to Accreditation Council for Graduate Medical Education (ACGME) requirements, EM programs must be able to deliver instructional programs to their housestaff on effective teaching principles. Unfortunately, few residents have had formalized training in coaching methods to apply during instances of procedural instruction.

The Innovation

Using LEGO pieces, a one-hour workshop allows EM residents to practice their teaching of technical and procedural skills. Specifically, the workshop leverages the opportunity for residents to practice verbal cueing and procedural coaching techniques.

Target Learners

The workshop is designed for all post-graduate year (PGY) levels in EM. In fact, the workshop can be integrated into the training curricula of other disciplines where procedural and kinesthetic skills require ongoing practice (i.e., obstetrics & gynecology, surgery).

ACGME EM Milestones

Specific EM Milestones require the ongoing assessment of residents’ teaching ability to junior learners, particularly once they reach a higher level of functioning. Such milestones examples include:

Required Materials

  • LEGO pieces:
    • You do not need to purchase fancy LEGO pieces or kits; rather, proceed to the back of your local LEGO store, towards the Pick-A-Brick Wall, where you can buy loose LEGO elements by the cup-full from clear plastic bins.

lego teach procedural skills

  • Scoop up a medley of pieces, of all shapes and sizes.
  • The more varied the pieces, the better. Just be sure to select several of the same pieces.
  • General rule: For a group of 30 learners, 1 large cup and 1 small cup will provide you with enough LEGO pieces to successfully run the workshop. Alternatively, feel free to use your own stash of LEGO pieces you may have accrued over the decades.


  • A box of sandwich bags (6 inch x 6 inch)
  • A stack of blank index cards (of any size) for participants’ note taking

Description of the Innovation

The entire group should be divided into smaller groups of 3, allowing each member to take on a different role: teacher, builder, and recorder.

  • Teacher: instructs the builder to put together a pre-made LEGO structure with the pieces provided.
  • Recorder: notes observations on the index card supplied, which will be shared during the debriefing.

For each group, set aside 30 LEGO pieces. Note – it is important that there are 2 of each piece. This way there are 2 identical sets of 15 LEGO pieces per group.

With one LEGO set, create a random structure. This is where you can use your imagination. No structure is too complicated. Make sure to use all 15 pieces. When complete, place this structure in one of the plastic bags. In another plastic bag, collect the same 15 LEGO pieces but in unassembled form. Create as many pairs of these bags (assembled + unassembled) as you need for the workshop. The structures can certainly vary from group to group.

Figure_6_Bag_Pairs cropped

Assembled (left) and unassembled (right) set of LEGO pieces

Provide each group with a set of bags, along with an index card. The bag with the assembled structure should be given to the teacher; the bag of unassembled LEGO pieces should be given to the builder; and the index card should be given to the recorder. Be sure not to let the builder see the final assembled structure.


Teacher and builder sitting back-to-back to each other, while a recorder observes the communication process

Instruct the teachers and the builders to sit with their backs against one another. The teachers should instruct their builders on how to put together the structure in front of them with as much descriptive information as possible, without physically showing the builders. Recorders should make notes of the process, paying attention to successful cues, as well as potential areas for improvement. Allow 30 minutes for this exercise. It is advised that the workshop facilitator(s) walk around the learning space and make observations themselves.

Once time has elapsed, the facilitator(s) should begin debriefing the activity by asking each group’s recorder to share some of their observations with the larger group. Attention should be paid to the challenges encountered and how they were navigated. If time permits, the activity can be repeated several more times with residents changing roles.

Figure_10_completed cropped

Successful assembly of LEGO pieces using only verbal cues

Lessons Learned

  • Based on comments shared during the group debriefing, groups that planned ahead [and pre-briefed] were most successful. Examples included the builder:
    • Itemizing all the pieces in his/her bag
    • Identifying all of the salient pieces in the structure
    • Defining orientation and direction (i.e., what is right vs. left) before the building process began
    • Creating an atmosphere that was conducive to stopping construction, speaking-up, and asking for repeated instructions
  • Even in groups where specific and descriptive information was successfully provided to the builder, several residents commented on the challenge of not being able to integrate visual information and visual cues into the building process. This highlights that several residents will require a multimodal approach to procedural instruction.
  • Most groups were successful in reproducing the pre-made structure. Groups composed of senior EM residents were the fastest to complete the task (in ≤15 minutes). Groups composed of interns particularly struggled with the time constraint.

Inadvertent assembly of “isomer” structures

  • An interesting finding was noted in several groups that were initially thought to have completed the task successfully. In these groups, the structures were not identical to one another; rather, they were mirror images [or isomers] of one another. During the debriefing, it was discovered that these groups did not define orientation and direction in terms that were mutually understood by the teacher and the builder. During this conversation, several parallels were made with the spatial understanding that is intrinsic to ultrasound and ultrasound-guided procedures. Residents in these groups commented that this outcome would strongly influence their coaching strategies during subsequent procedural instruction in the actual clinical learning environment.

Theory behind the innovation

The educational philosophy of this workshop is rooted in deliberate practice, a critical process for the development of mastery expertise. Anders Ericsson proposed that the number of hours spent in deliberate practice is an important determinant of one’s level of expertise.1 This workshop creates a space for residents to safely practice peer-to-peer coaching skills and procedural instruction, while also receiving feedback from an observer (i.e., the recorder).

Specifically, because teachers are only allowed to provide verbal cues, and learners are only allowed to use auditory information (as will be described in the section below), participants have the unique opportunity to experiment with their communication patterns (i.e., phrases, approaches, word choices) to determine which approaches lead to the most successful outcomes.

The workshop allowed our participants to appreciate the importance of effective and specific communication strategies that shape successful procedural instruction; encourages resident teachers to empathize with struggling learners when information (i.e., visual information, spatial orientation) is limited; and prompts resident learners (i.e., the builders) to speak-up when a difficulty is encountered during the LEGO building process.

Closing Thoughts

Overall, this workshop was well received by our EM residents. Requests were made to have additional sessions across the academic year – especially during intern orientation.

All of the index card comments from the recorders were collected, and used to create a word cloud of themes noted across all groups. The take-home points speak for themselves!


Read more about the IDEA Series.

Ericsson K. Acquisition and maintenance of medical expertise: a perspective from the expert-performance approach with deliberate practice. Acad Med. 2015;90(11):1471-1486. [PubMed]
Dimitrios Papanagnou, MD, MPH, EdD(c)

Dimitrios Papanagnou, MD, MPH, EdD(c)

Vice Chair for Education
Department of Emergency Medicine
Assistant Dean, Faculty Development
Department of Emergency Medicine
Thomas Jefferson University Hospital
Philadelphia, PA
Gretchen Diemer, MD

Gretchen Diemer, MD

Vice Chair for Education
Associate Professor, Internal Medicine
Sidney Kimmel Medical College at Thomas Jefferson University
Philadelphia, PA
Gretchen Diemer, MD

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Abigail Wolf, MD

Abigail Wolf, MD

Assistant Professor, Obstetrics and Gynecology
Residency Program Director
Sidney Kimmel Medical College at Thomas Jefferson University
Philadelphia, PA