Reasons to Teach Medical Students

All physicians-in-training were once medical students. As educators, we have a unique opportunity to influence not only medical students’ specialty selection but also their view of our specialty (Table 14.1). Students choose a specialty based on their interactions with faculty, what they observe while on rotation, and their perception of the specialty. We can affect these facets and attract the best students to our own specialty by being professional and clinically competent role models. We can also teach students what our specialty provides within the entire realm of care for the patient. In the same light, all physicians who enter other specialties also start as medical students. Therefore, we have a tremendous opportunity to impart the abilities and limitations of our specialty to these students. In this manner, we can challenge their preconceived notions about our specialty and promote collaboration between specialties for the benefit of patients.

Table 14.1 Why teach students.

The medical student’s opinion of you and how you handle patients will enhance their rapport with emergency physicians when they become physicians. If they are treated with respect, given responsibility, and taught while on service, their opinion of our specialty may be more favorable. One of the most compelling reasons to teach medical students may be that you or your family will one day need the services of one of these medical students who become specialists. Should you not help them acquire the desire, skills, and knowledge to be the best doctors they can be?

From the emergency medicine (EM) standpoint, it should be made clear to medical students that no matter what specialty they enter, they will interact with emergency physicians on behalf of their patients and probably their friends or family members. Therefore, they need to know process issues, such as the fact that patients are seen based on their acuity. All patients who come to the emergency department (ED) will be seen, no matter the hour, insurance status, or degree of illness, but some will have to wait. Students should learn that because of patient volume and the inability to close our doors when the ED is full, we have a limited amount of time to spend with each patient. We are sometimes forced to make decisions about care without the luxury of knowing a thorough patient history or having all requested test results in hand. Regardless, students should understand that every patient will be well cared for in the ED.

Unique Educational Experiences During an Emergency Medicine Rotation

Patients usually come to an ED because of a new illness or condition or an exacerbation of a chronic illness; therefore, students will learn the approach to a patient with an undifferentiated complaint (Table 14.2). On many services, the admitted patient has already been diagnosed and treatment has been started by the admitting physician or a physician in a clinic or ED. The student in the ED will learn to develop a list of differential diagnoses. Although students are expected to develop differentials on every service, the ED sees patients spanning all services, so the differential cannot be limited to a specific specialty’s area of expertise.

Table 14.2 Unique educational experiences in EM.

On the wards, students are often expected to gather an all-encompassing history, conduct a physical examination, and then describe the treatment for all the identified problems. In the ED, students are expected to perform a focused complaint-oriented history and physical examination to identify a complaint-specific differential diagnosis and management plan. Because the evaluation and subsequent presentation occur rapidly (often in <30 min), students have minimal time to consult a textbook or obtain directions from a resident physician.

On the wards, most patients have been stabilized, and for those who are not, the students are never really independently in charge of the care. But in the ED, we often allow students to provide supervised care to potentially sick patients, not only just from the standpoint of the vital signs but also in terms of time-sensitive issues such as myocardial infarctions and strokes. The patient may arrive unstable without a diagnosis or become unstable in the course of care. As an ED physician is in close proximity, we often allow students to continue to provide the primary care for such patients.

In other services, the student can expect to see patients and complaints specific to that service. For example, on an orthopedics rotation, students see fractures and musculoskeletal injuries, and on a cardiology rotation, they see diseases germane to the heart. From the medical student’s point of view, they can concentrate on a relatively smaller realm of information. In the ED, on one shift, the student may see a patient with chest pain, then a patient with a fracture, and then a newborn with fever. This aspect of not knowing what you will see next is part of the thrill of being an EM physician, but it is unnerving to many students.

During their third year, students are expected to perform procedures to which they might have had only limited exposure. We might assume that the student learned suturing on surgery and obstetrics rotations, but in reality, he or she was given only the opportunity to learn. Many students avoid procedures even when given the perfect opportunity to learn and practice them. In the ED, we assign them the task, not ask if they would like to try.

On the wards, students usually work with the same physicians for 4, 6, or 8 weeks. They learn the quirks of their supervisors and nuances of what to say or do on rounds to stay out of trouble. In the ED, they have limited continuity with a single attending/resident, and each attending/resident has different expectations of the student regarding the care of a specific disease.

Clerkships are often a mandatory rotation, so many students are not there by choice. Some of them take this time to improve their knowledge base, see things they will never get a chance to see again based on their specialty choice, or learn how to take care of medical and surgical emergencies. Taking the time to know the student’s specialty choice and helping them see the most relevant patients and diseases that they will one day care for may be the starting point for a long-lasting rapport.

Qualities of an Effective Teacher

As this topic is covered in many other sections of this chapter, I offer only a few relevant points here (Table 14.3). Students respond better if you treat them with respect. Acknowledge their presence. Know their name and what specialty they have chosen. Engage them in conversation about something other than the patient.

Table 14.3 Qualities of an effective teacher.

Maintain professional behavior. Using derogatory language with a patient, a nurse, or other service providers is inappropriate and will diminish the student’s regard for you and your specialty. Disrespectful treatment of staff or patients will do the same. One of the hurdles of EM is overcoming the often incorrect perceptions that other services have of us. Treating other service providers with disrespect in front of students or other staff damages our credibility and makes overcoming this hurdle even more daunting. Model the behavior you want them to emulate. Actions speak louder than words. Contradicting your words with opposing actions makes you an unreliable hypocrite and therefore unworthy of trust.

Show clinical competence in your field. Many students have already been taught a certain approach to a disease, and when we alter that approach, confusion can result regarding whom to follow. Take the time to show the student the literature that supports your practice, explain why your approach varies from what he or she was taught or what the consultant expected, and acknowledge that there is often more than one way to treat a disease.

Teach with enthusiasm because it is infectious. Anger, cynicism, rudeness, and disrespectful behavior breed the same in your student, and that disrespectful behavior might be directed at you one day. Your teaching ability has a positive and significant effect on the student’s learning [1].

Be open and approachable. Do not be condescending or overbearing. If students do not feel comfortable asking a question or being wrong with a plan or differential, they will avoid you or become reluctant to move forward in their knowledge and skills. This stunts your ability to teach and their desire to learn.

Adult Learner Themes

A good teacher should remember several things about adult learners. They are independent thinkers who have already developed their opinions, ways of learning, and ideas about effective teaching. Teaching students should include the educational themes discussed in this section (Table 14.4).

Table 14.4 Adult learner themes.

Adult learners come from varied backgrounds. They have had different personal and medical experiences. Depending on when they enter your rotation, they have completed different third- and fourth-year rotations. Depending on their desired field of medicine, they have put more effort into learning the topics and skills they think will benefit them most.

Determine the student’s level of ability and knowledge base before you start to teach. Each student has a different level of knowledge and experience. Ask probing questions, in an unassuming manner, to see where their knowledge base ends so that you know where to start teaching. Otherwise, you might deliver a great talk on kidney stones to someone who just finished urology. It may still be a great presentation but it may not be needed or appreciated by the student. Knowing their abilities allows you to give students a little more (or less) independence in their clinical decision making. Finding gaps in their knowledge base allows you to identify areas for self-directed learning, such as having them look up Well’s criteria in the diagnosis of pulmonary embolism.

Developing a student’s intrinsic motivation to learn is better than imposing an extrinsic motivation. Motivating a student by showing that an improved knowledge base makes you quicker (because you do not have to look it up), allows you to ask the right questions (because you know what points are important in the history), and maintains the respect of the patient (because you did not have to consult with another physician) helps them know what skills they should aspire to master to become a talented physician. This motivation will apply throughout their entire career. In contrast, external motivation, such as telling students they need to learn something because it will be on the upcoming test, can be short lived. Once the test is over, do they really need to still know it?

Aim for a higher level of cognition than just the accumulation of facts. Knowing to use β-blockers as the first-line therapeutic agent for aortic dissection is an example of fact accumulation. Knowing that the reason to use a β-blocker first is to decrease the shearing force and not just the blood pressure allows students to apply that thought process to other diseases. Then they know why nitroprusside, an effective blood pressure control drug, is not used first or alone.

Information should be filtered into a structured format for use in future clinical scenarios; this can be done by teaching a concise but generalizable rule [2]. The statement that young adults with back pain do not usually need radiographic evaluation is true. Knowing that red flags indicating the need for radiographic evaluation include cancer, fever, trauma, previous surgery, neurologic deficits, and intravenous drug abuse allows the student to apply that knowledge to a wider range of patients.

Let them know when teaching will occur. Many students do not recognize it unless it is labeled or PowerPoint slides are on a screen. Start teaching points with transitions such as “A quick teaching point from this case is …” or “Let’s see what we learned from that encounter …”

Comprehending difficult topics and acquiring complex skills take time and repetitive exposure to retain knowledge and understand how it applies. Therefore, for multifaceted cases, such as the treatment of a patient with acute coronary syndrome (ACS), recognize that the student requires repetition of the whole process to reinforce learning. A student cannot grasp the care for ACS, from aspirin to heparin to Plavix to glycoprotein IIb/IIIa inhibitors as well as β-blockers, during the first encounter with a patient with this condition. Understanding will be gained over repeated exposure to patients with ACS as the student learns another portion of the treatment algorithm each time and the already learned portions are reinforced.

It is acceptable not to know something, but it is not acceptable to be content to not know it. Admit when you do not know something and make a collaborative effort to find the answer. In medical education, we often punish those who do not know something. The punishment can be direct, through condescending commentary, or it may be indirect, by causing embarrassment by moving a discussion away from a student who does not know an answer to another person who knows the answer. Fear of not knowing makes students avoid the challenge of a new disease encounter. They stick to what they know, so they will look intelligent and skilled in your eyes.

Welcome questions. Reframe them if necessary to help the student understand the concept they are addressing. Allow students to get to the proper conclusion using their own thought process and pattern as long as it is logical and arrives at the appropriate end point. There are many different ways to look at a picture, and each of us assimilates it in a different way. As long as we are assimilating the same picture, different routes give you another way to assess the next clinical picture. This process takes time and you must listen.

When adult learners disagree, or do not immediately agree, it is often because what the teacher has just said does not match what they have been told, seen, or experienced. Sometimes students who are labeled as difficult are really very smart and learn differently. Learn their take on the matter and then look into the discrepancy.

Educational Curricular Components

Any clerkship should structure the educational experience around a set curriculum based on obtainable and defined learning objectives (Table 14.5) [3]. The clerkship should provide a learning environment to increase the student’s knowledge as well as an opportunity to gain clinical experience and skills [4]. For EM, published curricula for third- and fourth-year rotations as well as an educator’s handbook are available [5–8]. A primer is available to medical students to help prepare them for their time in the ED [9].

Table 14.5 Educational curricular components of teaching.

The students and the educators should know the expectations of the rotation, especially during clinical time. The clerkship director should align his or her expectations with those of the medical school and the Liaison Committee on Medical Education (LCME). Educators should align their expectations with those of the clerkship directors or discuss the differences. Expecting students to adhere to two sets of expectations for their clinical shifts puts them into a double bind.

Part of the curriculum is in lecture format, often delivered as PowerPoint presentations. Devote ample time to your preparation for lectures to medical students. If you deliver incorrect information, students are put in the position of disagreeing with you or, worse yet, applying false information to patient care. If the error is left unchecked long enough, it will take precious energy, time, and friction with other health care professionals to reverse it. Do you not believe me? Think about the issue of giving narcotics to a patient with a surgical abdomen and how long it has taken to even start to reverse that medical myth.

The EM curriculum undoubtedly has a procedural component. Be certain to know what knowledge level your students should have and have actually achieved. Students often say they have never been shown how to do something, such as how to suture, even if they just attended a surgery rotation. It saves them the embarrassment of having to say that they hid from that exposure. Remind them that they should learn as much as they can on each rotation, not just check a box and complete the least that is required of them. Students also like to say they can do something, but do you make them show you? Even something as simple as administering oxygen to a patient gives you a chance to teach.

Although we often want to move directly to the differential and evaluation plan, do not expect that students are competent in their history taking and physical examination skills. They learned these skills in the first 2 years of medical school, when they did not really use them often and nobody had taken the time to watch and reteach them. Therefore, we should demonstrate and evaluate both history taking and physical examination skills.

Feedback is crucial to effective teaching and is reviewed in greater detail in Chapter 7. If you do not provide feedback, you are, in essence, reinforcing the student’s behavior. Therefore, give specific feedback in real time. Depersonalize the issue; state only facts and explain why the behavior or deficit will cause a problem. Specifically identify areas of strengths that you want the student to continue and areas of weaknesses that he or she can work on. These are easy to identify when you allow students to work on a presentation, a list of differential diagnoses, and an evaluation plan. Students quickly learn that if they stall for a mere few seconds, most faculty will step in and take over the differential and evaluation/treatment plans.

Promote students’ self-evaluation by encouraging them to reflect on how they performed during the shift. Students are often harder on themselves than you will ever be. If they identify a problem that you agree with, their self-awareness followed by your acknowledgment and plan for correction will lead to a stronger desire for change and monitoring of the behavior [10]. If a knowledge deficit is identified, the student will have the desire to fill the void and not just answer the isolated question.

Evaluation of the student will be part of your educational responsibilities and is required in all clerkships. It is imperative that teachers take the time to learn the objective criteria for the different areas of evaluation and abide by them. Not evaluating a student robs the student and the clerkship director of the chance to learn from, or act on, your impressions. Giving inflated grades so that you do not have to defend your scoring only allows incompetent students to become incompetent doctors. Always remember that bias creeps into our evaluations as well. Being cute, nice, polite, respectful, attentive, funny, affable, or gregarious does not make students competent. It just makes them more desirable to have around. Do not let that stop you from objectively evaluating their skills.

Clinical Teaching

Providing a structure for the administrative aspects of a rotation allows students to adapt quickly to the new environment with less anxiety and stress (Table 14.6) [11, 12]. This allows them to learn more and ask more clinically oriented questions. Guide students in their selection of patients to help them stay within the limits of their ability. Allow them sufficient, not excessive, time to complete a directed history and physical examination. Give them time to review the records and develop their presentation. When the clinical situation does not afford the student this time, explain that you are going to guide the case quickly because of the status of the department or the patient.

Table 14.6 Pearls for effective clinical teaching.

Understand that the presentation of the case is the primary focus of the student–faculty interaction. This is the student’s time to shine, and his or her level of anticipation/anxiety will match the faculty’s expectation and confidence. Because presentations in the ED are concise and directed, inform the student of what you expect from him or her during the presentation. The best solution would be for all faculty members to agree on a single format and then present this format to students during orientation to the rotation. When the student presents a case to you, allow him or her to finish without interruption.

If you have no expectations of the students, they will meet them easily and often do no more. Therefore, expect students to develop a list of differential diagnoses. This list should include common diseases as well as those that cannot be missed without significant morbidity or a chance of mortality to the patient. Expect them to use the history and physical to remove, retain, and order various diagnoses on the differential. Ask them to defend this final list, as it will give you an insight into their thought process as well as identify their level of knowledge on the subject. This allows you to know what to teach and what to encourage them to read.

Expect students to generate an evaluation plan for the patient, which includes why they are recommending a specific test (laboratory test, radiograph, physical examination) and what they will do with the results. Stepping over them and telling them what to order may allow you to move the patient along faster, but it does not allow you to assess their knowledge base or correct any misconceptions, such as ruling out infection because of a normal white blood cell count.

Think out loud. We make connections and decisions considering multiple items of history, physical, knowledge, and process, but we just state the conclusion and expect that students follow the process.

Debrief a student at the end of a clinical interaction so that you can address his or her performance and agree on his or her knowledge level, clinical competence, and interpretation of the history, physical, and clinical data [13]. Further feedback will follow after more clinical encounters, but directed discussion at the end of a single encounter allows reinforcement of clinical findings, rules, and thought processes. The clinical experience gives the student a framework to guide further reading and learning. The student will more quickly remember information associated with a clinical scenario than that from unattached reading.

Be prepared to teach when the moment arises. Teaching in the clinical arena is a fluid process. Remain committed to teaching, even if it is only in 30-s blocks of time at the end of a case. Take advantage of “teachable moments” and specifically inform learners that you are teaching them something. Faculty who practice only one standard way of teaching will limit their opportunities to teach. Instead, learn multiple ways of teaching at the bedside (discussed in Chapter 5), including the microskills model (Chapter 24), the 1-min observation, learner-centered precepting, and modeling problem solving [14].

Having a variety of teaching skills and the desire to teach enables the faculty member to identify many teaching opportunities and adapt the teaching to the clinical environment. Some days allow longer and more in-depth discussions. Some busy shifts and more difficult patients lend themselves to modeling the thought process and patient interaction skills. Remember that you do not have to teach after each patient encounter or during each student interaction; your time, ability, and mood may not allow for it. In addition, the student’s level of knowledge and ability may not require additional teaching, but just feedback on a job well done.

Allow others to teach. If they did a good job congratulate them and move on. Reiterating a clearly presented argument wastes time and undermines the ability of the original teacher. If you reward teachers’ ability, they will do more of it. If you take over, they will stop. If you show confidence in them, students will respect them. The student will then have two trusted teachers and two sources of information. It is not about you; it is about giving the student as many educational resources as possible.

Techniques for Overwhelmed Students

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