Teaching Residents How to Teach

Starting The Shift: Expectations and Enthusiasm

Recall the anxiety and feeling of being overwhelmed that accompanies most MS4s as they begin a rotation in our complex teaching EDs. Before jumping right into patient care, defuse some of the anxiety and consider setting the “educational stage” for the shift by asking some of the following questions:

Where did you grow up?
Where did you go to undergraduate school?
What is your medical school/specialty choice?
Have you worked in the ED before?
What would you like to learn more about during this shift?
Do you understand that it’s fine to say, “I don’t know”? I’m relying on you to be completely honest in your answers to me today and to tell me if you aren’t sure about something.

This places the learner at greater ease and sets the tone and expectations for your time together.

MS4s have large gaps in their experiential and cognitive database, interspersed with islands of understanding. Many MS4s have never encountered or cared for a patient with the chief complaint, signs, or symptoms now confronting them. Conversely, their general knowledge base may appear artificially strong if they have had a recent in-depth immersion rotation with similar patients (e.g., their familiarity with doing a slit lamp examination immediately following an ophthalmology rotation). The following questions are helpful in developing realistic expectations of your learner:

Have you ever taken care of a patient with this illness before?
Are you comfortable doing this portion of the PE?

If the response to either of these questions is “No” then consider inviting the student to tag along with you as you model the approach to the patient before turning the case over to him or her. This often saves the patient, the student, and you from a large amount of frustration. (CAVEAT: Explain to the learner that the ONLY way to be in trouble is to delay the implementation of care for a sick patient. Ensure that the student understands that you want him or her to alert you at any time they encounter a patient who appears to be significantly ill. In this scenario, walk the student through the case [as opposed to taking over the care completely]). You may wish to set a firm time line for the student, for example, “I want you to do the initial discussion of this patient with me no more than 15 minutes after you enter the room.” This prevents the student from attempting a traditional “complete Hx and PE.”

The majority of MS4s have little experience in critical thinking about their patients. Previous rotations largely reinforce the role of “data gatherer” and “observer,” with the team doing the “data synthesis” components for them. Because their initial training and previous inpatient services reinforced and rewarded thoroughness of data gathering, one can anticipate that this component will be overdone. New learners working in the ED almost always gather unfiltered, extraneous information and are unable to weigh the importance of individual components. The ED rotation is designed to teach them the “broad strokes” of caring for patients with a wide array of undifferentiated conditions. Questions useful in teaching these “broad strokes” include the following.

Is this patient “sick” or “not sick”?
What is the most likely diagnosis?
Do you think this patient will be able to go home, will go home with close follow-up within 1 or 2 days, or requires admission to the hospital?
If you could order only one test for this patient, what would it be?
Tell me three things that could kill/harm this patient if they are not diagnosed today?

Do not underestimate the difficulty that these seemingly simplistic ideas may pose to your novice learner (imagine an 80-year-old patient presenting as “weak and dizzy” or the uncooperative patient with “altered mental status”). Using these questions decreases the likelihood of encountering the robotic MS3 “ward presentation” style of regurgitating unfiltered historical data and demonstrates the unique EM physician approach to patient care. Notice also that just as EM physicians tend to be focused and direct in obtaining a patient’s history, these questions are specific and directive. Your learner will (hopefully, but not always) quickly ascertain that critical thinking and focus are required during the ED rotation. (CAVEAT: Ask that all presentations start with a review of any abnormalities of the vital signs during the first 15 s of discussion.) A recommended learner presentation template is presented in Table 17.2.

Table 17.2 Presentation template for learners in the ED.

Have you ever cared for a patient with this chief complaint before? Y/N

Is this patient (check one):

“sick” (likely to require admission)? ______
“not sick” (likely to go home after testing and treatment)? ______
“unclear” (need the test results and response to treatment before I can tell)?

Are there abnormalities in the vital signs? Y/N

Which one(s) is/are MOST worrisome? ______

Does the patient have any medication allergies? Y/N

What is the most likely cause of this patient’s symptoms?

What are the two or three WORST things that might be causing these symptoms?

What diagnostic or therapeutic interventions would you like to order?

The ED patient population is replete with “difficult” or “challenging” patients for many reasons. Learners have rarely encountered this spectrum of humanity and can easily become frustrated about caring for such patients. Consider advising the learner to ask the following questions to these types of patients.

What do you think is causing you to feel this way?
What are you hoping we can do for you here in the ED today?
(If the patient’s symptoms have been present for more than several days.) What changed to make you decide to come in now as opposed to 12 h or 2–3 days ago?
If I could fix only one of your problems, which one would you want me to fix?
Are you supposed to take any medications each day for any health problem?
Have you started taking any new medicines, changed the dose of any medicines, or stopped taking any medicines in the past 5 days?
Have you ever been in the hospital overnight as a patient?

Electronic medical records have improved our ability to access medical histories for difficult historians, but these questions are useful in preventing potential misunderstandings.

Finalizing a patient encounter affords an excellent opportunity to ensure that a proper plan of care is instituted and that the learner has assimilated (at least short term) the major points (you thought) you taught them. The following are several questions helpful in finalizing.

What does the patient need to understand regarding his or her follow-up?
What did you find most challenging about this patient?
What would you do differently the next time you care for a similar patient?
What is the most important thing to remember when caring for a similar patient in the future?

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