Obstacles Inherent in The Emergency Department

Educators in the ED often cite lack of time as the major obstacle to teaching during a shift. While balancing patient care and teaching is always a challenge, nowhere is this truer than in the ED, with its large volume of patients and high workload. Physicians are under constant pressure to see patients rapidly, manage them efficiently, and maintain a high level of vigilance to identify the few who have truly emergent needs. The acuity of patients is a major factor in time limitation; just a few critically ill patients may absorb the instructor’s full attention, often for long stretches of time [1].

At the same time, EDs are being held to more stringent standards of patient satisfaction, meaning that facilitating patient flow and communicating with patients and their families also remain high priorities during a shift. Additional tasks such as overseeing flow of the entire department, directing online medical control, receiving calls from primary care physicians and consultants, and arranging interhospital transfers may contribute to the workload. Emphasis on quality of documentation, out of concern for both billing and litigation, shunts the remaining time and energy toward careful charting.

Overall, the demands of patient care leave little time for teaching activities and feedback [2]. Unlike other departments in the hospital, the ED cannot set aside a structured teaching time as a routine part of the workday in the form of morning report, lunchtime conferences, or extended rounds. Teaching must occur spontaneously and is always subject to interruptions by phone calls, incoming trauma patients, or questions from nurses and other staff members [3]. Students and trainees are frequently interrupted during their presentations [4]. Even without direct interruptions, distraction comes in the form of the ever-present background noise of phones, overhead pages, and the voices of staff, patients, and their families. Contributing to the challenges of the teaching environment is the limited physical space. Depending on the layout of the department, simply finding an open area to gather for teaching can be difficult in a crowded ED in which hallways are lined with occupied patient gurneys and back-and-forth pedestrian traffic. Discussion about individual cases can be limited further by the lack of privacy.

The makeup of the learner population creates one of the most challenging aspects of teaching in the ED. Learners range from third-year medical students to senior ED residents to rotators from across medical and surgical disciplines, all with widely divergent skill sets and learning needs [5]. Knowing how to make teaching appropriate for students being exposed to the ED for the first time, for ED residents trying to hone advanced management skills, and for off-service rotators seeing cases out of their comfort zone requires a sensitivity and subtlety that may seem impossible to achieve within the confines of an 8- or 10-h shift. Exacerbating this problem is the limited face-to-face time between individual instructors and learners in the ED. In addition, unlike many services in which a learner is paired with a single instructor for an extended period, instructors and learners in the ED may have little consistent or longitudinal contact.

Instructor-Based Obstacles

The barriers to teaching inherent in the ED may exacerbate the personal challenges faced by any medical educator who aims to teach on a daily basis. The ED environment requires a spontaneous and flexible style of teaching that does not come naturally to many people. Training programs do not commonly provide formal education on effective teaching strategies, and young graduates who have recently become faculty may find balancing patient care with the desire to teach extremely challenging. They also find balancing learner autonomy and supervision challenging and fraught with medicolegal risk, particularly if they have not received explicit guidance or training in this skill. Even experienced physicians may feel uncertain about how best to relate important clinical points, provide constructive feedback, and determine goals for trainees [6]. Instructors may interpret the weariness of tired trainees as a lack of interest in learning, or they may feel intimidated by the niche areas of knowledge owned by off-service rotators. Because teaching is rarely rewarded in concrete ways, instructors may succumb to more explicit pressures to excel in documentation, ED flow, or patient satisfaction, setting aside teaching as a “last priority” that rarely gets attention.

Learner-Based Obstacles

Teachers may have trouble “getting through” to their learners, not because the teachers are ineffective, but because the learners themselves encounter obstacles in taking advantage of the educational opportunities of the ED. There are many reasons for resistance to learning. Fatigue may be a factor, especially in non-ED rotators who do not anticipate how demanding an ED schedule can be. Learners may feel, justifiably or not, that some patients are reluctant to be cared for by anyone other than a fully trained physician. In addition, students and trainees may feel overwhelmed by the wide range of clinical entities presenting to the ED and the breadth of clinical tasks they are expected to perform. Some trainees may work in specialty clinic or ambulatory care settings where patients present with a much narrower range of diseases, are generally stable, and are seen and worked up one or two at a time serially. Others may believe that their most important duty is to complete the workup of every patient they admit, in order to assist their colleagues on the inpatient wards. The variation in clinical practice styles and expectations from physicians may be confusing to learners. The learner may also be facing challenges in his or her personal life that affect performance and receptiveness. Furthermore, generational influences might affect the educational interaction between instructors and trainees [7]. All these factors may result in learners resisting change and missing out on the main educational purpose of the ED rotation by seeking to recreate their comfort zone, selecting patients with disease entities that are familiar, delaying picking up new patients, or being dismissive of information they perceive as irrelevant to their ultimate career. Even students and trainees who are particularly motivated do not always know how or when to solicit feedback about their performance [8].

A particular type of learner-based challenge is encountered with the international emergency medicine (EM) student or trainee, who, although being highly motivated, experiences difficulty learning in the ED. Difficulty can arise from cultural differences, lack of familiarity with EM as a specialty, or very different expectations for the format and environment in which teaching should occur. Challenges specific to interactions between educators and learners from different countries are summarized in Table 2.1. These students may require additional orientation and explicit instruction on the roles and expectations in the ED. Awareness of and sensitivity to differences in international EM are fundamental to a successful experience. The program director of an international teaching experience should serve as a resource for insights into cultural expectations.

Table 2.1 Challenges to the bedside teaching of international EM students.

Solutions

For the aspiring educator, the obstacles discussed thus far may seem overwhelming, particularly because many of them, such as the volume of patients and the number of responsibilities of the teaching physician, are likely to amplify over time. On the bright side, the ED offers many unique opportunities for teaching, including a wide variety of clinical entities, the breadth and depth of clinical skills that can be practiced, and the constant close contact between instructors and learners. To take advantage of these strengths, the successful teaching physician can employ the teaching strategies listed in Table 2.2, each of which is discussed in detail below.

Table 2.2 Strategies for overcoming teaching obstacles in the ED.

Use a Wide Variety of Teaching Techniques

The most realistic approach to teaching in the ED is integrating it with preexisting patient care activities. This requires instructors to be flexible in using a variety of teaching techniques [1, 9, 10]. Preparation and delivery of brief (1- or 2-min) lecture points can be integrated into any of the dozens of clinical actions performed routinely in the ED (e.g., sign-out rounds, patient presentations, interpretation of radiographs or laboratory results, or procedures), ensuring that some level of teaching occurs continuously throughout the shift. Teaching involves the transfer of knowledge and can also occur in the form of feedback. By observing a student or trainee in action, instructors can offer powerful reinforcements of things done well and constructive comments on areas needing improvement [11]. This feedback does not need to come at the end of a shift, when sign-out rounds may be busy. Feedback to trainees can come right after a presentation, a particular case, or a procedure (for an expanded discussion refer to Chapter 7).

Interactive discussion is a simple, effective, and often overlooked teaching technique that can be used to encourage learners to express what they think and why, to consider alternate possibilities, and to bring up their own areas of uncertainty. Questions such as “Why do you think that?” “What else could be going on with this patient?” or “What questions do you have?” prompt learners to work through the problem and come up with their own solutions. This discussion requires the instructor to pause and refrain from interrupting for as little as a few seconds. Furthermore, it can help instructors get to know individual learners and identify their specific educational goals.

A picture can be worth a thousand words. Whether from a book or viewed on the Internet, pictures can enhance teaching points and maximize the time for teaching. Videos of procedures and clinical conditions can be used to illustrate teaching points or offered to trainees to view independently before reconvening with the teaching clinician. Many Web-based resources are available publicly and through affiliated teaching institutions.

Remember that Teaching is a Shared Responsibility Among All Members of the Clinical Staff

All members of the clinical team should be active partners in the teaching process, including the learner. Particularly, during a busy shift, instructors can acknowledge their own limitations and ask learners to take a greater role in the educational process. Peer teaching can be a powerful learning experience and is one that is particularly valued by millennials (Generation Y) [7]. Senior trainees can assume responsibility for teaching interns and medical students; trainees at any level can point out interesting cases to others or find articles and other resources to share with their colleagues. Rotators are a potentially rich resource and should be encouraged to share knowledge from the perspective of their specialty training. Nurses can be engaged by inviting them to participate in discussions after trauma or medical resuscitations, asking them to teach skills such as intravenous line placement and urinary bladder catheterization, and offering to include them in teaching discussions. Finally, the learner should be expected to take an active role in the educational experience by creating their own goals, soliciting feedback, and using printed and Web-based resources to learn more about new topics. While it is important to determine individual learning goals, it is likewise important for the educator to explicitly set educational and professional expectations. Learners should be told what is expected in terms of their role in patient care and learning outside the clinical setting, such as reading on their own to answer clinical questions.

Be Well Prepared for Any Teaching Opportunities that Arise During a Shift

Particularly if there is no structured time during a shift to teach, instructors in the ED should be prepared to take advantage of all available opportunities to teach. Despite the “never-know-what-is-coming-next” quality of the ED, certain situations occur reliably and lend themselves well to teaching. Sign-out rounds, when all staff members are gathered in one place, allow brief discussion of common clinical entities presenting to the ED and are a good opportunity for focused teaching points. High-profile cases such as trauma or resuscitations, which tend to naturally pique the interest of students and trainees, may be followed by a “debriefing” to review core management issues. An unusual presentation or physical finding may be relayed to all learners, even those not directly involved with that patient’s care.

Downtime is rare in the ED, but it occasionally occurs when the department is well staffed or patient volume is low. Having a stock activity for unexpected free time will avoid having to teach extemporaneously; a mock code, a short lecture, or an easily accessible file of electrocardiograms or radiographs can make even 5 or 10 min a high-yield experience. It is also helpful to have a plan for independent learning in case individual learners have time between patients or while awaiting test results; they can be directed to access a teaching file or find their own resources to review a topic and share it with others by the end of the shift [10, 12]. The use of educational prescription cards (Figure 2.1) can remind students and instructors about clinical questions that arise and make sure they are addressed in a timely manner [13].

Figure 2.1 Sample educational prescription. Adapted with permission from Education Prescription. Centre for Evidence-Based Medicine, Toronto. Available at www.cebm.utoronto.ca/doc/edupres.doc. Accessed on March 17, 2012.

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