We (doctors) are notoriously bad teachers, relying on pimping, lectures and just overloading the learners with information. Good teachers actively engage the learner, provide specific and immediate feedback (especially positive feedback), limit the content and are willing to admit ignorance. Adult learners prefer to learn concepts (not facts) and need to apply them quickly for them to sink in. Their main goal is summed up in the phrase “what’s in it for me?”
This one-minute teaching technique tries to take these things into account. Plus it’s really easy and fast to do, even on a busy shift.
0. Business as usual.
Let the resident/student present the patient, they usually will stop after their physical exam and wait for you to give them the assessment and plan.
1. Get a commitment.
Make them commit to either a diagnosis or treatment plan. It’s okay to be wrong, but without putting their money down on something, they really won’t learn as much. For example, ask “what do you think is going on?” “Uh, maybe it’s GERD?” Even if they come up with a good differential and plan, you can still have them commit to some hypothetical situation, “what would you do if this patient was hypotensive? 80? 3 months old?” etc.
2. Ask for supporting evidence.
Find out why they think what they think. Let them follow their reasoning through especially if they’re wrong. “I think it’s GERD because he’s too young to have cardiac chest pain.”
3. Teach general rules.
Give them just ONE clinical pearl, not a whole lecture. They won’t remember a whole lecture and we don’t have time for a whole lecture. “Remember to always consider PE, especially in patients who have cancer, a broken arm and just drove from Miami.”
4. Reinforce what the learner did well.
This is the part that seemed hoakey to all of us, but they kept reinforcing how important it is to give specific and immediate feedback on what the learner did right before you tell ’em what they did wrong. Typically in medicine, no insults/arguments is to be interpreted as a compliment. That or a general “hey, good job.” You need to be more specific, such as “you elicited all the risk factors for PE very well…”
5. Correct Mistakes.
Now you can tell them what to do better next time (in a nice way). “…but you always have to consider PE. If you don’t consider it, you will certainly miss it.”
6. Further Study.
This is where we either point the resident/student to a source for further study (after the shift) or if they ask us something we don’t know, we can tell them we’ll look it up and get back to them. If you ask them to look something up, it helps to ask them later on what they learned.
very cool idea, rahul … this new fangled blogspotthing :)as far as teaching, easiest thing i’ve come up with is immediately after the resident or student haspresented the H&P, i ask them based on the chiefcomplaint and pt. specifics, what are the three worst things this patient could have? since the people we train tend to have the non-EM mentality of most common instead of most concerning cause of symptoms, it helps to redirect the focus of thought.doesn’t necessarily mean we’ll do a work up on each potential differential, but it gets the ball rolling as far as medical decision making, and we can bring in a little evidence based medicine to decide which diagnoses can be discarded by just history and physical. this way, even a non-acute patient with say shortness of breath can be used to have a quick review of wells criteria, pros and cons of d-dimer, and risk stratification instead of the resident just chalking up their symptoms to anxiety, and doesn’t take more than an extra 3 minutes on whichever patient you choose to do it on that shift. basically, steps 1-2 of what you’ve listed below.
That’s perfect. I used to do something similar during residency, and teach the students to do the same thing. After looking at the age, vital signs, gender and chief complaint, they have to come up with five critical diagnoses. What I’m hoping this does for the students is gives them focus when they go into the room. They make sure to ask about PE, TAD, ACS, PTX and esophageal rupture. Their job is to convince themselves that it’s none of those killer differential diagnoses. Ruling it out can usually be done on history and physical. Thanks for the comments.