Clinical Teaching in the ED. Society for Academic Emergency Medicine Educational Objectives u Develop skills to become a better clinical educator.

Clinical Teaching in the ED

Society for Academic Emergency Medicine

Educational Objectives

Develop skills to become a better clinical educator


How to…

How to provide effective teaching while caring for patients in the ED


Residents as Teachers

Residents play a critical role in medical student education

Professional role models for students Impact on career choices Better understanding of students needs


Residents as Teachers

General principles of clinical teaching Bedside teaching Giving effective feedback Teaching procedures Teaching with High-Fidelity patient simulators Teaching effective discussion leading and lecturing

Acad Emerg Med. 2006;13:677-79.


Precepting Medical Students

Make decisions at the bedside Encourage medical student independence Delegate specific tasks to the student Encourage responsible behavior


The Emergency Department

Different from inpatient and ambulatory care settings

Complaint oriented specialty Unique educational opportunities


Opportunities Unique to EM

The undifferentiated acutely ill patient Extremes of age The poisoned or intoxicated patient Psychiatric emergencies Environmental emergencies Wound management and trauma Patients requiring emergency procedures Airway management and ultrasound


Teaching Opportunities

Unique content areas Teaching clinical vignettes Multitasking and time management skills Communication skills Role modeling professional behavior Reinforce EMC goals


EMC Goals “Competencies”

Perform complaint directed history and physical examinations Develop case specific differential diagnosis Present cases in a concise and organized fashion Appropriate utilization and interpretation of diagnostic studies Appropriate implementation of patient management plans Demonstrate medical professionalism Demonstrate an adequate fund of medical knowledge Demonstrate proficiency in basic procedures

Temple MS IV Clerkship


EMC Objectives Directly participate and document care of at least 25

undifferentiated patients Directly participate and document care of at least 2 patients with

each of the following conditions; Abdominal pain

Chest pain

Fever

Musculoskeletal trauma / wound care

Neurologic case

Shortness of breath Provide & document “anticipatory guidance” for at least 5 patients



EMC Objectives Perform and / or interpret and document your

participation in selected clinical skills or diagnostic tests; Interpret cervical spine radiograph

Interpret chest radiograph

Perform and interpret 12-lead ECG

Perform intravenous access

Perform phlebotomy



Observation of ED H&P’s

3106 encounters(48 medical students)

2830 (91.1%) (Documentation of H&P observation)

2620 (92.6%) (H&P’s not observed)

157 (5.5%) (Brief or limited observation of H&P)

53 (1.9%) (Entire or majority of H&P observed)

Acad Emerg Med 2003;42:s102


Observation of Procedures

0

50

100

150

200

250

300

ProceduresObserved

InstructionProvided

AssistanceProvided

ABGI & DLaceration RepairPhlebotomySplinting

0

50

100

150

200

250

300

ProceduresNot Observed

InstructionProvided

AssistanceProvided

ABGI & DLaceration RepairPhlebotomySplinting

Acad Emerg Med 2004;11:500


Direct Observation

Direct observation of medical students performing H&P’s is uncommon

Direct observation as a method of teaching is underutilized

Medical students are more likely to receive both procedural instruction and assistance if selected procedures are directly observed


Diagnosing the learner

Dependant Learner Independent Learner

Medical Student - Intern

Intern - Senior Resident

Assess the learners needs Strengths and weaknesses


Case 1

35 year old male presents with CP and SOB



Case 1

Interpret the chest radiograph, provide a clinical diagnosis

Document how you would manage this case


Case 1

61% of students (n=192) correctly interpreted the chest radiograph

95% of the students that correctly interpreted the chest radiograph managed the case appropriately *Needle decompression

*Tube thoracostomy


Student – Patient Encounter

Student evaluates patient Case presentation Preceptor verifies data Evaluation / management plan is

implemented Periodic reevaluation / follow up Disposition


Case Presentation Skills

Improve:

*Patient care

*Educational experience

*Learner – teacher communication


Case Presentations

“Precepting pitfalls” Interrupting the case prior before

completion

Taking over the case

Inappropriate lectures


Case Presentations

Listen carefully Allow the presenter to proceed without

interruption The post presentation pause…

*Feedback

*Reassurance

*Validation

*What should I do next?


Case Presentations Brief, focused 2 – 3 minutes in length Directed opening statement

*Chief complaint and pertinent PMH Description of the HPI, pertinent ROS Additional medical history, etc. Physical examination Differential diagnosis Diagnostic and treatment plan


Assessment – Oriented Presentation

Opening statement includes the diagnostic impression or assessment followed by a treatment plan

Followed by historical and physical examination data including pertinent positive and negative features that support the clinical assessment

Acad Emerg Med 2003;10:842-47


Method of Questioning

Assertive Facilitative

Teacher Centered Learner Centered

Teaching styles

Fam Med 2001;33:344-6


Assertive Style

Teacher – centered approach Can gauge the learners knowledge base Asks direct questions Provides information Gives directions


Assertive Style

What antibiotics should we treat this patient with?

What is the dose of _____? What is the drug of choice for_____? What is the differential diagnosis of RUQ pain?


Suggestive Style

Can offer suggestions or alternative methods of patient care with questions or statements

Can share opinions and practical experience


Suggestive Style

“Although a KUB may be helpful, a non-contrast helical CT scan is a better diagnostic test for this patient”

“Augmentin is a treatment option for strep throat, penicillin however is a more cost effective choice”


Collaborative Style

Socratic approach Learner oriented Explores clinical reasoning and problem

solving abilities Use of higher level questions to promote

critical thinking


Collaborative Style

What do you think is wrong with the patient?

How should we proceed? What diagnostic studies are necessary? How should we manage this case? Do you think the patient needs to be

admitted?


Facilitative Style

Elicits and accepts the learners ideas to promote self understanding

May also offer feelings and can encourage the learner

Uses silence


Facilitative Style

Ms. Jones shared some personal information about her past medical history with you. How did that make you feel?


Reactive Comments

Ways to redirect and reorient the learner The delayed response

*Allows the learner to reflect and reconsider

*Provides an opportunity to withdraw the incorrect answer

*Gives the learner a second try


Reactive Comments

Ways to redirect and reorient the learner *Asking questions containing additional clues

*Modifying the question so that the incorrect answer is correct

*Treating wrong answers as possible


Precepting Models

TraditionalModel

One Minute Preceptor

Patient Centered Learner Centered


Traditional Precepting Model

Patient centered Inquiry phase is diagnosis driven Most time is spent on patient care issues rather

than learner issues The teacher functions as an expert consultant Focus on areas requiring clarification or areas

missed during the presentation


One Minute Preceptor Model

Learner centered Inquiry phase elicits the learners

understanding of the case Flexible / modifiable Used in both the inpatient and ambulatory care

setting Five microskills Focus on the learners reasoning

Fam Med 2003;35:391-3


One Minute Preceptor Model

Case presentation and discussion processDiagnosePatient Listen• Clarify

Diagnose Learner1. Get a commitment2. Probe for supporting

evidence

Teach3. Teach a general

rule4. Provide positive

feedback5. Correct mistakes


Get a Commitment

Provides an assessment of the learners interpretation of the history and physical examination data Data analysis and synthesis

What do you think is going on with this patient?

What do you want to do for this patient? Commitment may focus on diagnosis,

diagnostic evaluation, treatment plans, etc.


Probe for Supporting Evidence

Exploring the underlying thought process allows you to identify any gaps in data synthesis or misconceptions

What findings support your diagnosis? What else do you think could be going on

with this patient?


Teaching General Rules Instruction is more memorable if offered as a

general rule Teaching scripts for a particular complaint or

presentation *Pearls of wisdom

*Teach what learners need to know Keys features of a particular illness Treatment options Approach to a particular complaint Reason for hospital admission


Teaching General Rules

“You should always consider hypoglycemia in the differential diagnosis of a patient with an altered mental status”

“You should always consider AAA in your differential diagnosis of non-traumatic low back pain in the elderly”



Feedback

In the setting of clinical medical education, feedback refers to information describing students’ or house officers’ performance in a given activity that is intended to guide their future performance in that same or in a related activity

JAMA 1983;250:777-81


Feedback

Goals Praise the learner for a job well done

*Positive feedback Provide direction or suggestions on how

the learner can improve their clinical performance *Constructive criticism

*Guidance to correct mistakes


Feedback and Evaluation Feedback

*Formative Provides an honest assessment of performance,

including suggestions for improvement

Evaluation*Summative

Describes performance as it relates to the achievement of learning objectives

Course grade


Feedback

The way in which feedback is provided will influence the perception of its helpfulness

Praise – Criticism – Praise


Feedback Nonjudgmental Descriptive

*Refer to specific behaviors or actions Be consistent Well timed Ask for self evaluation Always start with positive feedback Incorporate suggestions for improvement Individualized


Brief Feedback

Bedside Informal Unscripted Unplanned

*During observation of clinical / procedural skills

*End of a patient encounter


Formal Feedback

Usually more formal May also be unscripted or unplanned Usually occurs away from the bedside

*End of a patient encounter

*End of a shift

*Midpoint or end of the clerkship


Feedback

July – December 2004*51/53 MS completed the survey

96.1% of MS reported receiving feedback during their EMC

Of the students receiving feedback, 80.4% reported receiving SFICP

93.6% of the students reported the feedback they received was beneficial

97% of supervising physicians felt that the feedback they provided was beneficial

Ann Emerg Med. 2005;46:S88


Feedback

No difference was noted in the frequency of feedback and SFICP provided as reported by the following groups: Academic (n=16) vs. clinical (n=9) faculty Senior (n=13) vs. junior (n=12) faculty Male (n=24) vs. female (n=9) supervising physicians Senior residents (n=8) and faculty (n=25)


Feedback

The vast majority of SMS report receiving feedback

Most students felt that more feedback would be helpful

Supervising physicians’ perception of providing feedback matched that reported by the students


Basic Teaching

Teaching facts – knowledge *Differential diagnosis for specific chief

complaint

*How to approach a certain clinical condition

*Teaching the technique to perform a basic procedure


General Teaching Strategies

Tailor specific teaching to the level of the learner and the clinical situation *Get to know the student *Tailor teaching to students career interests *Use varied ED pathology to your advantage

Optimize the interaction *Focus on one teaching point *Encourage problem solving *Incorporate bedside teaching



Seek opportunities to teach *Interesting physical examination findings *Radiographs *ECG’s *Procedures

Be a professional *Be a role model *Establish a friendly learning environment *Be approachable



Use additional resources *Hard copy texts

*On-line texts

*Journal articles

*Educational websites

*Prepared cases

*Old ECG’s, Xrays, etc.


Qualities of an Effective Teacher

Clinical competence Explaining the decision making process Treating learners with respect Actively involve learners Promote learner autonomy Teach with enthusiasm Communicate expectations for performance Creates a friendly teaching environment


Challenging Students

Less than enthusiastic performance *Lack of initiative

*Lack of attention to details

*Poor use of time

*Repetitive mistakes

*Defensive when receiving feedback

*Unprofessional behavior


Alternative Teaching Methods

Brief structured observation Bedside case presentations


Brief Structured Observation

Designed to increase teaching effectiveness in busy clinical settings *Easy – no preparation

*Brief – little time required


Brief Structured Observation

1. Observe the encounter

2. Debrief the learner

3. Conclude interaction


Observe the Encounter

Brief observation *2 – 5 minutes

Limited to certain aspects of H & P Preceptor records observations / statements

/ actions performed by the learner


Debrief the Learner

Ask the learner what they learned from the observed segment *Can be done in front of the patient

Directly evaluate; *Fund of knowledge

*Physical examination skills

*Clinical reasoning skills


Conclude Interaction

Feedback Point out strengths

*Positive reinforcement Give the learner one thing to work on

*Suggestions for improving clinical performance


Bedside Case Presentations

Addresses challenges of teaching*Effective teaching vs patient care

*Time management

*Assessment of the learner Increases patient satisfaction Promotes professional behavior Mixed reactions from learners


Bedside Case Presentations

Implementation Learner and patient preparation

*Use of medical terminology Listen to the presentation Clarify / obtain additional information Have learner present evaluation / treatment plan

at the bedside ??? Address all patient concerns / questions


EM Clerkship Grades

Emergency Medicine Clerkship

Uniform Grading Guidelines


Evaluation of Clinical Performance

Evaluation of acquired clinical knowledge, skills, attitudes, and behaviors *Clerkship goals “competencies”

Ability to incorporate these competencies into clinical medicine


Evaluation of Clinical Performance

"Criterion – based” or “Fixed – standard" grading *Identify goals or competencies

*Determine expected standards of proficiency

*Achievement of the minimum standards of proficiency would represent a “pass” grade

*Performance that is above the minimum expectations could earn grades such as “High Pass” and “Honors”


TUH – EM Clerkship Clinical Evaluation Card

Student Name: Date / Shift:

Evaluator: Block:

Clinical Skills: (Learning Objectives)1. Perform complaint directed history & physical examinations2. Develop case specific differential diagnosis3. Present cases in a concise and organized fashion4. Appropriate utilization and interpretation of diagnostic studies5. Appropriate implementation of patient management plans6. Demonstrate medical professionalism7. Demonstrate an adequate fund of medical knowledge Demonstrate proficiency in basic procedures

Patient acuity: High Medium Low Varied

Patient encounters: 1 – 2 3 – 5 6 or more

Overall grade: H HP P C F


Feedback on clinical performance: Nonjudgmental, descriptive (refer to specific cases, performances, behaviors, or actions), objective appraisal of

performance

Positive feedback (What did the student do well?):

Suggestions to improve clinical performance:

Any additional comments:

Discussed with student Yes No


HONORS The outstanding student Comprehensive

achievement of the knowledge, skills, attitudes, and behaviors

Top “10%” Resourceful, efficient,

and insightful

In-depth medical knowledge base

Perform detailed but focused H & P’s

Well organized presentations

Role model Strives for excellence

even in difficult situations


HIGH PASS

The solid student Well beyond

minimum course requirements

Next “25% - 35%” Resourceful and

efficient Above average fund of

medical knowledge

Identify major problems Perform appropriate but

focused H & P’s Demonstrate professional

behavior


PASS

The average student Meets basic course

requirements Next “50% - 60%” Average fund of

medical knowledge Perform an adequate H

& P

May omit certain portions of the H & P

Presentations generally organized

Demonstrate professional behavior


CONDITION / FAIL

A performance that falls below expected minimum standards*Clinical knowledge, skills, attitudes, and behaviors

Requires specific and detailed documentation by senior EM resident and / or attending


Expected Grade Distribution

Rigid cut off values are not used

Year to year the percentage of students receiving a particular grade may vary


Summative Evaluation

Overall shift grade Honors (5) High Pass (4) Pass (3) Condition (0) Fail (0)

# of patient encounters 1 – 2 (x1) 3 – 5 (x2) 6 or more (x3)


RIME Evaluation Framework

Reporter Interpreter Manager Educator

Pangaro LNUniformed Services University of the Health Sciences


Reporter Accurately gathers and clearly communicates

clinical facts*Medical interviewing

*Physical examination skills

*Case presentations


Interpreter

Prioritizing the patient’s presenting complaints*Developing a problem list

*Developing a differential diagnosis

*Interpreting basic diagnostic studies


Manager

Developing a diagnostic and therapeutic plan Tailoring the management plan to the patient


Educator

Self-directed learning Critical reading skills


Barriers to Effective Teaching


Barriers to Teaching


The Teacher

The Student

The Patient



Overcrowding Inadequate patient care space Unanticipated emergencies High level of acuity


Teaching Opportunities

Unique content areas Teaching clinical vignettes Multitasking and time management skills Communication skills Role modeling professional behavior Reinforce EMC goals


The Teacher

Lack of confidence Little experience Little or no formal training Not enough time Endless interruptions Too many other responsibilities Expectations?


The Teacher

Every case has a teaching point You have more experience than the students

and junior residents Directed learning

*Identify interesting cases

*Task oriented learning Act interested


The Student

Different levels of training Variable fund of knowledge Learning attitude, enthusiasm Expectations?


The Student

Identify gaps or misconceptions Teach to their level Focus on one thing at a time


The Patient

Level of acuity Painful injury or illness Mental status Need for privacy Patient reluctance


The Patient Bedside teaching rounds are generally viewed

as having a positive effect on patient care Most patients enjoy bedside teaching and often

develop an increased understanding of their illness.

Incorporate patients into the case discussion


Effective Clinical Teaching

No one best teaching style or method Teaching principles

*Allow the student to play an active part in learning

*Use questions that promote high order thinking

*Offer feedback Reinforce positive behavior / actions Provide guidance for correcting mistakes


The Bottom Line…

Decide what to teach Take away point

*History

*Physical examination

*Diagnostics

*Therapeutics

Be flexible (different levels of training)


Author Credit – Clinical teaching:David A. Wald DO

Questions


Postresidency Tools of the Trade CD

1) Career Planning – Garmel

2) Careers in Academic EM – Sokolove

3) Private Practice Career Options - Holliman

4) Fellowship/EM Organizations – Coates/Cheng

5) CV – Garmel

6) Interviewing – Garmel

7) Contracts for Emergency Physicians – Franks

8) Salary & Benefits – Hevia

9) Malpractice – Derse/Cheng

10) Clinical Teaching in the ED – Wald

11) Teaching Tips – Ankel

12) Mentoring - Ramundo

13) Negotiation – Ramundo

14) ABEM Certifications – Cheng

15) Patient Satisfaction – Cheng

16) Billing, Coding & Documenting – Cheng/Hall

17) Financial Planning – Hevia

18) Time Management – Promes

19) Balancing Work & Family – Promes & Datner

20) Physician Wellness & Burnout – Conrad /Wadman

21) Professionalism – Fredrick

22) Cases for professionalism & ethics – SAEM

23) Medical Directorship – Proctor

24) Academic Career Guide Chapter 1-8 – Nottingham

25) Academic career Guide Chapter 9-16 – Noeller

Clinical Teaching in the ED. Society for Academic Emergency Medicine Educational Objectives u Develop skills to become a better clinical educator.

Documents

student u

bedside u

completion u

u disposition slide

chest radiograph u

students u impact

trauma u patients

teachers u residents