ED Registrar’s Guide to Clinical Teaching

I recently mentioned in when the elephant awakens… that much of the teaching of interns and other junior doctors in the emergency department falls to the registrar (aka resident, for those in North America).

So… how can the emergency medicine registrar be an effective clinical teacher?

Help is at hand thanks to a paper (the full-text is free online) in this month’s issue of Annals of Emergency Medicine. Authors’ Houghland and Druck describe the ‘ADDIE approach’ and apply it to 3 common scenarios: the struggling learner, the ‘difficult’ learner and the junior resident. What follows is my synopsis of the pearls that can be gleaned from this paper.

A 4-step method based on the ADDIE approach (analysis, design, development, implementation, and evaluation):

Assessing the learner –
Evaluate the learner’s existing knowledge base and begin with clear, brief, and open-ended questions that have more than one acceptable answer.
e.g. “Do you have any specific learning goals for this shift or rotation that I can help you meet?”
e.g “What can you tell me about pulmonary embolism?”

Determining the instructional content –
Determine gaps in learner understanding concentrating on one of: knowledge, communication, procedural skills, attitudes and behaviours; and use a patient-orientated approach that can be readily applied by the learner.
e.g. “Let’s talk about D-dimer and its diagnostic value for this patient. Do you think it would be helpful for us?”

Determining the instructional method –
Choose an appropriate method for delivering the information (e.g. didactic, Socractic, demonstrative)
e.g. Critical patient encounter: “Pay close attention to my intubation technique.”
e.g. Emergent patient encounter: “What are your first steps in diagnosis and management?”
e.g. Lower-acuity patient encounter: “Let’s do a literature search to find the best answer to this question.”

Determining the effectiveness of instruction –
Assess the success of the educational intervention by direct questioning, direct application, or using case-based hypotheticals.
e.g. “How would your management have been different if his D-dimer were negative?”

The different types of instructional methods include:

Didactic – an effective way of didactically teaching is to give voice to your clinical reasoning processes:

The best predictor of favorable attending physician evaluations by residents was how frequently the attending physician made explicit his or her clinical reasoning

Houghland and Druck, 2010

Socratic – avoid painful punitive pimping— lead the learner to the correct answer through serial questioning:

• craft statements into questions
• craft questions that require synthesis and application of information
• wait silently for several seconds after asking a question
• study closely the learner’s response and body language to create the next question

Demonstrative – use simulation where possible and ask accomplished learners to demonstrate using a hands-on approach. Otherwise, consider using Peyton’s 4-step approach:

• Demonstration — The teacher performs the procedure without narration at normal speed
• Deconstruction — The teacher demonstrates individual steps with narration
• Comprehension — The teacher performs the procedure while the learner describes the steps
• Performance — The learner performs the procedure and narrates

These techniques can be applied to different learner scenarios:

The struggling learner

• identify the source of the problem e.g. insufficient knowledge, poor clinical judgment, inefficient use of time, poor communication, or unethical behavior
• Communicate the learner’s deficiency in a positive, supporting and constructive feedback session that will result in an effective change. Use the ‘quiet chat’ approach:
  • Set time aside (e.g. after the conclusion of a shift)
  • Elicit what the learner believes he or she did well
  • List what the learner did well
  • Ask what the learner believes could be improved
  • List any other things that could be improved and mutually determine an action plan to remedy these issues

The ‘difficult’ learner

• What is a ‘difficult’ learner?
  • “the medical student or off-service intern who is uninterested in emergency medicine, has a poor work ethic, or who is unresponsive to encouragement or feedback” – Houghland and Druck (2010)
• Attempt to change the learner’s attitudes and perceptions:
  • be enthusiastic about the patients the learner sees and the issues that arise
  • avoid complaining about issues involved in patient encounters
  • emphasize issues that make the patient encounter more complex or interesting
  • use the carrot more than the stick — find out what the learner is interested in and try to create relevant opportunities for the learner
  • try to show how an encounter or experience is relevant to the learner

The junior resident

• bring new literature to topics of discussion
• discuss complex cases or scenarios
• model the professional aspects of being an emergency physician

But wait, there’s more…

I also recommend checking out Amal Mattu’s talk on Teaching in the ED as featured on EMRAP: Educator’s Edition (it’s free!). Some of his key tips include:

• teach less so that others learn more — don’t try to teach more than 4 things in a session.
• teach the right thing at the right time (i.e.don’t show someone how to draw the coagulation cascade at 4 in the morning!)
• listen with your eyes and your ears, and make sure others do too!
• teach others how to learn so they can become responsible for their own learning
• set time-limited learning objectives
• use the ‘What if?’ technique of learning to develop associations, keep things fun and guard against availability bias (only things that are easy to remember tend to spring to mind). e.g. “What if the patient with X is also on warfarin?”
• use the ‘Hear hoof beats? Think of lions, tigers and bears!’ technique — what are the deadliest differential diagnoses for a presentation?
• Don’t be afraid of silence — let the student come up with an answer.
• Be specific about what the student did well and provide constructive feedback.
• Suggest how the student can address their learning needs.
• Ask the student, “what did you do well, and what can you improve on?”

Still hungry for more? Check out these ‘Life in the Fast Lane’ links on related topics:

• ED Case Presentation for Medical Students
• Referring Patients from the Emergency Department
• Managing the Busy ED (1) and (2)

Further reading

• Wiesbauer F. Teaching Masterclass: The Psychology of Learning. Medmastery
• Houghland JE, Druck J. Effective clinical teaching by residents in emergency medicine. Annals of Emergency Medicine, 2010; 55 (5): 434-9