Teaching is hard, requires preparation time, and rarely comes naturally. If you are teaching primarily for personal gain (e.g., promotion) and not viewing it altruistically, you may find its challenges intimidating. Your learners will quickly recognize your lack of enthusiasm for the task at hand, and your frustration at the workload will be apparent. Ideally, teaching is gratifying for you. To facilitate this, identify ways in which teaching enhances your own skills and judgment. Find opportunities to talk about what you know or to learn more about a topic that you would like to master. Many of us have an area about which we feel passionate or to which we have a connection. Use that passion as a springboard to develop your teaching points. Channel your enthusiasm for the topic into your presentation. Teach as if you care. You may find that personal gain, once de-emphasized, comes more easily.

Consider the powerful and direct effect your teaching has on patient care. Your knowledge and skills imparted to students today are propagated through their care delivered tomorrow and for years to come. You have the potential to affect countless lives with every clinical pearl offered. Viewed in this light, do you need a more compelling reason to teach?

Long lectures and comprehensive reviews are not only tedious but also impractical for the emergency department (ED). Keep discussions and presentations focused on a specific problem, reinforcing your points with relevant background information only. Avoid attempting to convey too many concepts at once. This applies to lecture, bedside teaching, simulation, and any other teaching venue. Select two or three main points, avoid digressions, and repeat to promote retention. The same principles apply when demonstrating a procedure. Break it up into logical components (e.g., indications, landmarks, site prep, execution, troubleshooting), pause for clarification and reinforcement, and allow time for questions.

An effective way to define the teaching role is to establish your expectations for the learner. Well-defined goals, whether they are lecture objectives, your preferred format for receiving patient presentations, or specific tasks you would like to see accomplished, provide a constructive framework for teacher–student interactions and create a positive learning experience. Outline a few important areas on which the learners should focus. These will vary with the trainee’s level of experience. For newer trainees, offer guidance on identifying acute problems, sorting the dangerous from the benign, and recognizing what is germane to the ED. For more experienced trainees, emphasis may shift toward patient service concerns, instruction of junior residents, and departmental flow issues. These clarified expectations make evaluation and feedback more straightforward and give both learner and instructor a sense of progress.

Clarifying expectations is especially important for recently graduated faculty members who are now supervising former peers. They may find it difficult to establish boundaries and provide critical feedback. The crucial intellectual step required of all faculty is to recognize how the responsibility for a trainee’s education, and its impact on patient care, supersedes any desire to “be a pal.” By consistently taking a few moments at the beginning of each shift to set expectations, you will solidify the teacher–learner dynamic.

To create satisfying educational encounters, determine the needs of your audience. Whether teaching at the bedside, lecturing to a crowd, or presenting to a small group, solicit the learners’ goals and objectives to help you align them with your own. Assessing your learners’ needs will allow you to target your instruction, establish your topic’s relevance, and connect with your audience. You may consider showing how your topic will improve patient care, avoid lawsuits, increase efficiency, or, as a last resort, help pass the examination.

Addressing your audience’s goals and objectives is straightforward when groups have a shared level of expertise. Groups with varied levels of training demand a more thoughtful approach. The pitfall is teaching too narrowly. Aim too high and your audience will fail to engage your topic. Aim for the least common denominator and your audience will lose interest. A balanced presentation targets the objectives of your midrange learners and offers pearls to your experts, yet remains accessible to all.

We have all been subjected to that endless line of questioning that starts and ends with memorized medical facts, typically referred to as pimping. Although falling out of favor, it still deserves another kick to the door. The recitation of mere information provides the learner no opportunity for escape or improvement. Pimping promotes a learned helplessness, whereby if the answer is not known, the student is left without recourse. At best, factual questioning establishes that learners already know whatever facts on which you quiz them. Using this method, the most you could hope to contribute to their education is a few more facts, often at the expense of their self-esteem. If you are trying to gauge a learner’s level of understanding, there may be a brief role for factual questioning, but it is otherwise a low-yield technique.

In place of pimping, challenge the learner with questions that demand a problem-solving approach. Use questions that target students’ understanding of broad concepts, rather than mundane facts. Regurgitating Ranson’s criteria is of little use if one does not understand the pathophysiology of pancreatitis. Questions focused on the underlying mechanisms of pancreatitis will prompt students to ponder the processes at work, providing a logical transition to treatment considerations. Students will move from being theoretical to practical independently, experiencing the power of the former to guide the latter. Emphasize understanding over memorization to promote the critical thinking skills that are so fundamental to emergency physicians.

A safe learning environment is paramount for learners to venture beyond their comfort zone. Establishing such a climate requires the same techniques by which we connect with patients. Provide your learner with undivided attention, make eye contact, and protect the encounter from interruption. This approach will let your students feel you are fully focused on them. Belittle your learners and fire snappy put-downs at wrong answers for the sake of a laugh, and you will rapidly develop an audience of passive listeners that fear humiliation and dare not speak up.

By inviting opinions, encouraging questions, and challenging conclusions, you will enhance your learners’ ability to think broadly, stand by their reasoning, and make a commitment. A nonthreatening learning environment can also provide unforeseen benefits to patient care. Students may volunteer information you had not considered, altering the patient’s management. Empowering providers at all levels to voice their thoughts is consistent with the growing emphasis on teamwork training and its impact on patient safety.

Recognize that most adults learn via action, experience, and reflection rather than via the passive absorption of information. If ideal teaching is case based, clinically relevant, and experiential, then opportunities abound in the ED. Sign-out rounds, for example, include all these elements and provide extremely teachable moments. The physician leading sign-out rounds selects teaching points based on the educational benefit to the team and asks questions of the group to establish a collaborative learning approach. Sign-out gives trainees the opportunity to explain not only their management plans but also their decision-making process. This forces learners to use critical thinking skills, review their patients’ management, and take an active role in educating their peers. Conducting sign-out rounds at the bedside can further activate learners by demonstrating physical examination findings and modeling communication skills.

Independent learning, such as researching a topic for a minilecture at the end of a shift, is another effective active learning strategy. Ideally, the topic stems from a clinical question that arose during the shift. Placing students in a teaching role forces them to define the question and present the information clearly. Many good structured case-based clinical teaching methods are described earlier in this book and elsewhere in the medical literature. Regardless of the method selected, their common value is the one-on-one exchange that occurs between teacher and student.

While lecture defies some basic principles of engaging learners, this format can be an effective way to convey information to a large group in a short time. The one-way flow of ideas, from lecturer to audience, can be improved when the material is case based and relevant to the audience’s needs and when the presentation allows open discussion. Judiciously used, lectures can provide a basis from which other teaching methods can be implemented, including small-group discussions, simulation exercises, or procedural skill training. These techniques are examples of more active learning that engage students, facilitate questions, and provide the opportunity for timely feedback.

One of the greatest challenges for the academic physician is balancing patient care with the needs of trainees. A common pitfall is the inability to relinquish control. This may stem from a desire to maintain patient safety or departmental flow. As the shift becomes busier, the temptation to take over patient care directly and have the student “learn by observation” becomes strong. The higher a patient’s acuity, and the less experienced the trainee, the harder it becomes to delegate decision-making responsibility. A student may be immersed in a comprehensive review of systems with a dyspneic patient while every fiber of your being silently screams for immediate “BiPap!” Clearly, patient safety is foremost and you will need to step in. But in other situations, the medical student can be tasked with deciding whether to order a complete blood count, the intern with whether a chest film is needed to assess a patient for pneumonia, and the senior resident with whether the patient in respiratory distress requires intubation. This graded approach can help you as the teacher becomes more comfortable with your trainees’ growing independence.

Let your trainees know that their response matters when you ask, “What do you want to do?” Some trainees will continually defer to you. Guide them with your knowledge, your experience, and the evidence available but resist the temptation to offer your opinion until they have committed to their own plan. This forces them to consider consequences and eventually increases their comfort with the decision-making role.

Conveying your thought process to students is the core of clinical teaching. Just as patients wish to know the reasons for their tests and treatments, so your students crave insight regarding your decisions. Whether based on core medical knowledge, key observations, pattern recognition, or recent evidence from the literature, your thought process is the most powerful mechanism for clinical teaching. Some educators “think out loud” while discussing a clinical case, which gives the student direct access to the differential diagnosis and an explanation for the management plan.

Another effective teaching method is to explain your decision-making process to the patient and student simultaneously. This saves time, includes patients in the discussion, and allows you to model communication skills. This can be a useful technique when you are uncertain as to the appropriate patient disposition or sense resistance from the patient regarding your plan. When students observe you summarize the case, outline the options, solicit the patient’s and family’s input, and reach a consensus plan, they will then see a complete physician in action. They will see not only the medical decisions being made but also a model for how to address clinical, psychosocial, follow-up, and liability issues all in one brief encounter.

Providing appropriate feedback may be the most difficult teaching task. Because most physicians feel uncomfortable offering it, they fall into the classic pitfalls of providing no feedback at all or simply the vague reassurance that a trainee is “performing at a level appropriate for his or her training.” This common criticism of medical education can be overcome with practice, but it requires a constructive framework.

At baseline, there must be a professional culture of understanding. Teachers must recognize their responsibility for students’ improvement. Viewed in this light, feedback becomes an expectation and a guide for professional development, not a judgment of character. Mature learners recognize this; those who become defensive on receiving such critiques may benefit from having this dynamic pointed out.

Clarify at the outset the criteria by which the student will be judged. Set the expectations early. In this way, feedback becomes part of a discussion already begun and feels less awkward. Selecting the appropriate time and place for providing feedback is important. The management phrase “Praise in public, criticize in private” applies here. Feedback should be delivered promptly so that events are fresh in the student’s mind and key points are relevant.

To begin a feedback session, ask the student for a self-assessment. In many cases, he or she will identify the same deficiencies you have, making the discussion easier. Keep the session on a professional level by referring to specific behaviors or actions that can be changed and by using nonjudgmental, descriptive terms. Students will be more receptive to negative feedback if it is balanced by noting their areas of strength. End each session on a positive note, with concrete suggestions that the student can implement to improve.

When giving feedback, do not overlook your strongest trainees. While it may feel easier to evaluate them with a pat on the back, they are as deserving of guidance as their peers. Even the highest performers have room to improve.

The practice of medicine is built on the passing down of knowledge from experienced clinicians to aspiring students at all levels. This custom is a defining feature of the profession, and nowhere is this process more evident than in emergency medicine. High patient volumes, undifferentiated pathology, and supervision by knowledgeable teachers combine to create an environment rife with learning opportunities. Despite its challenges, teaching emergency medicine is intensely gratifying. Our residencies are filled with enthusiastic learners who will apply our teachings to thousands of patients throughout their careers. We hope the pearls and pitfalls offered in this chapter will help you avoid the mistakes we have all made and take advantage of the rich teaching environment in which we are privileged to practice.