Ask students to make predictions

how_learning_worksA student’s previous knowledge helps them establish new learning. By creating connections to this old material, they are able to build off it and solidify the new content in their minds.

While teaching in the emergency department, this can be done by asking them to use their prior knowledge to make a prediction. They then test this prediction by seeing if it comes true or not. Whether they predicted correctly or not, it can be used as a teaching point later.

  • “Do you think this patient will be admitted or discharged? Why? Let’s see what happens and talk about it later.”
  • “Do you think this troponin on will be positive or negative? Let’s see and talk about use of troponins when it comes back.”

Try it out during a shift and let me know how it worked.

Giving Effective Feedback in the ER

Giving feedback to students in the ER is easy. If they did well, you say “STRONG WORK!” and if they did poorly… “READ MORE.” Of course, this provides nothing the student can use to improve. Drs. Ester Choo and Michelle Lin from San Francisco General Hospital created this video on how to give effective feedback.

Concrete and on-the-spot feedback is important to allow students to understand how they are doing and make changes to their behavior. Be nice, but don’t be afraid to give constructive criticism. Remember our goal is to help create good doctors.

One trick I like to use is to have the student at the beginning of their shift identify one area they want to work on. This may be reading EKG’s, creating appropriate differential diagnoses or presenting in a concise and focused way. If they don’t provide something, then you can suggest something: “Today, why don’t we concentrate on appropriate ordering of testing.”

Having one item to work on makes it easier to observe the student’s performance and offer a plan for them to improve. Offer this feedback, at several times during the shift and announce it as such.

“Let me give you some feedback on how you’re doing so far on your presentation. Your HPI was disjointed, you can really tighten it up by using your differential to come up with the pertinent positives and negatives. Why don’t you you see this lady with chest pain and try that before the next patient you present to me.”

EM4 Rotation Objectives

Here at Rush we have a required clerkship in Emergency Medicine. As faculty here, you are not only doctors but teachers. So we should know what the students are here to learn – what the students are expecting us to teach them.

These objectives were taken from a national consensus created by clerkship directors from across the country. They have also been matched with Rush Medical College’s terminal objectives (things we want our students to be able to do before graduating).

They are grouped into the 6 “competencies” similar to those on which residents are evaluated. These are:

  1. Patient Care
  2. Medical Knowledge
  3. Self-Directed Learning
  4. Interpersonal and Communication Skills
  5. Professionalism
  6. Putting Care into a Practical Context

Below I’ve listed what each of these mean in greater details and some examples of how we can teach these to our students.

Please feel free to comment. Are there better ways to teach these? Do you have any special effective teaching tricks? I’m all ears.

Patient Care

Under direct faculty supervision, students should be given primary responsibility for patient care (of noncritical patients) and begin to act independently during the fourth-year EM rotation. Primary responsibility for patient care will help foster the students’ ability to think critically, assess their knowledge and skills, and allow them to make clinical decisions affecting patient care.

Specific Learning Objectives

  1. Obtain an accurate problem-focused history and physical examination.
  2. Recognize immediate life-threatening conditions.
  3. Patient management skills:
    1. Develop an evaluation and treatment plan;
    2. Monitor the response to therapeutic interventions;
    3. Develop appropriate disposition and follow-up plans.
  4. Health promotion:
    1. Educate patients on safety and provide anticipatory guidance as necessary related to the patient’s chief complaint;
    2. Educate patients to ensure comprehension of discharge plan.

Was their history and physical accurate? Were they able to recognize that the vital signs were grossly abnormal? Can they make and follow-through with a plan? Are they checking on the CT results? Are they finding out why that urine was never done? For patients being discharged, they should be able to educate patients on how to be safe - most easily through the discharge instructions.

Medical Knowledge

Students should develop a differential diagnosis that is prioritized on potential life-threatening conditions and likelihood of disease. Students should demonstrate knowledge (or understanding) of basic diagnostic modalities and interpretation of results. Most importantly, students should cultivate an appreciation of risk stratification and pretest probabilities for selected conditions.

Specific Learning Objectives

  1. Develop a differential diagnosis when evaluating an undifferentiated patient:
    1. Prioritize likelihood of diagnoses based on patient presentation and acuity;
    2. List the worst-case diagnoses.
  2. Create a diagnostic plan based on differential diagnoses.
  3. Develop a management plan for the patient with both an undifferentiated complaint and a specific disease process.

Can the student come up with an appropriate differential diagnosis which includes life threats and probable causes? Does their testing make sense?

Self-Directed Learning and Lifelong Improvement

Practice-based learning can be demonstrated through systematically evaluating patient care and population features; teaching other students and health care professionals; and applying knowledge gained from a systematic evaluation of the medical literature, including study design and statistical methodology.

Specific Learning Objectives

    1. Effectively use available information technology, including medical record retrieval systems and other educational resources, to optimize patient care and improve their knowledge base.

Can the student find the answers to questions they don't know by themselves? Were they able to look up how good is ultrasound for appendicitis?

Interpersonal and Communication Skills

Students are an important element of the health care team, and effective communication with patients and other health care providers is essential for patient care. Students must demonstrate interpersonal and communication skills that result in effective information exchange and interaction with patients, family members, and health care providers.

Specific Learning Objectives

  1. Humanistic qualities
    1. Effectively communicate with patients, family members, and other members of the health care team
    2. Demonstrate a compassionate and nonjudgmental approach when caring for patients.
  2. Presentation skills:
    1. Present cases in a complete, concise, and organized fashion;
    2. Effectively communicate with consultants and admitting services.
  3. Documentation: provide accurate and organized documentation in the medical record when appropriate.

Did they establish a relationship with their patients and their families? Are their presentations clear and concise? Can they coherently call a consult or and admit up to the floor? Are their charts done?

Professionalism

Professionalism should be viewed as an academic virtue, not just an expected set of behaviors. Students should learn to reflect on their professionalism during clinical rotations and learn from faculty role models.

Specific Learning Objectives

  1. Work ethic
    1. Be conscientious, on time, and responsible;
    2. Exhibit honesty and integrity in patient care.
  2. Practice ethical decision-making.
  3. Professional behavior:
    1. Exercise accountability;
    2. Maintain a professional appearance
    3. Be sensitive to cultural issues (age, sex, culture, disability, etc.);
    4. Work in a collegial manner with other members of the health care team.

Were they on time? Honest? Professionally dressed? Basically, did they act like we expect a doctor to act?

Putting Care in a Practical Context

Called Systems-based practice in the resident lingo, this competency extends beyond the individual patient’s bedside to include an understanding of how EM relates to other practitioners, patients, and society at large, while considering the cost of health care and the allocation of health care resources. Understanding the ‘‘system’’ involves learning ways to advocate for patient care and assist patients in dealing with system complexities (such as assuring appropriate follow-up) and how to partner with health care providers to assess, coordinate, and improve patient care.

Specific Learning Objectives

    1. Recognize when patients should be appropriately referred to the emergency department (ED).
    2. Recognize the importance of arranging appropriate follow-up plans for patients being discharged from the ED.
    3. Recognize the role of EM in the community, including access to care and its impact on patient care.
    4. Understand the indications, cost, risks, and evidence behind commonly performed ED diagnostic studies.

I'll admit this one is tougher to measure. Some things I'd look for is inappropriate use of testing or resources? Do they request too many consults? Too many MRI's? Do they make sure the patient has follow-up, especially in those that need to be seen immediately? And that may mean coming back to the ER.

I hope this helps clarify our objectives a little bit. If you have any questions, please feel free to comment.

How to Fill Out Student Evals

Hey folks. I wanted to take a moment to introduce to you how we do our evaluations for medical students. The M4’s have a required rotation in Emergency Medicine. We’re supposed to be filling out a 5-page form on each student, but we know no EM physician is going to EVER fill that out. Instead, I’ve made a very short online form that later gets translated into that bigger form.

Here’s a video of how the system works. Students request an evaluation and you get an email (to your Rush email, if you prefer another email – let me know). Just click the link in the email and fill out the short form (takes about 5 seconds). The student then gets a summary of your “teaching points” but nothing else. So don’t write anything nasty in that box!

Teaching in the ER

Effective teaching in the ED. Teaching is one of the legs in our promotion. The core themes:

Teaching in the ER

The core themes revolve around improving the educator, the learner and the institutional system.

Improve the education

  1. Announce the teaching moment
  2. Turn work into teaching
  3. Think out loud
  4. Teach beyond the shift
  5. Create mini-teaching rounds

Improve the learner

  1. Empower the learner – ask “so what one thing do you want to learn today?”

Improve the institutional system

  1. Teaching shifts

Med Student Shadowing – Think Out Loud


Being a hospital associated with a medical school, we’re bound to have students interested in emergency medicine — even M1’s. Some of them may want to hang out with us in the ER to get a feel of what it’s like.

I know what you’re thinking: They don’t know enough of anything to be helpful. I don’t have time to spend explaining everything to them: like “what does CHF stands for?” and “why did you give them motrin instead of ibuprofen?” I can’t even go to the bathroom without them following me. If I can make a couple of sharp turns and duck into the juice room, maybe I can lose the student. Or maybe I’ll have them look something up in Rosens, that’ll get them out of my hair for an hour or two.

However, there is a way to make shadowing informative for the student, enjoyable for the patient and create minimal time disruption to you.

First, ask the patient if it’s okay to have a student in the room. Introduce the student as an observer, and ask the patient and family if it’s okay if he or she hangs out in the room. More importantly let the patient know you’ll be thinking out loud to help the student understand your thought processes. Tell them you may use medical jargon, and if they (the patient) doesn’t understand they should feel free to ask questions.

Then go through the patient evaluation, but THINK OUT LOUD. Let the student know what you’re thinking and why you’re doing things. “I’m asking these questions to rule out a PE, remember patients who are truck drivers are at increased risk for thromboembolism… what? Oh, that’s a blood clot.” “I’m hearing crackles at this left base, possibly signifying a pneumonia.” “Now we’ll order an EKG to check for cardiac causes.”

Patient’s love this because it gives them a rare peek into how we doctor’s think. It’s a glimpse into something interesting to them. Plus many patients are more than willing to help a student learn. It feels good to be part of the education process. The student also gets a glimpse into how we think, rather than just chasing us around and wondering “why did he ask about cocaine use?” or “what does that swollen leg mean?”