228 Teaching Critical Care

Teaching success should be measured in terms of student performance, not the activities of the teacher. Delivering a carefully organized PowerPoint presentation, supervising problem-based workshops, or providing bedside clinical tutorials does not mean one has taught. Unless the learner has acquired new cognitive or psychomotor skills, teaching has not occurred.¹ An effective teacher takes responsibility for ensuring that students learn. If the teacher’s perception is that providing a lecture or any instructional methodology fulfills this obligation, then the teacher is serving as “the” educational resource. The focus of this model is on what the teacher did and not on what the learner learned.

Stritter described a different model, one focused on the student.¹ In this model, the teacher assumes responsibility for the learner’s success and creates an environment conducive to learning by managing the educational resources. The teacher as a “manager” creates specific educational objectives, motivates students, utilizes various educational strategies, evaluates learning, and provides effective feedback to ensure the learner achieves all the educational objectives.¹

The goal of this chapter is to provide a detailed description of each of these steps, from creating educational objectives to providing feedback, so the teacher can apply the concepts, whether organizing and presenting a 1-hour lecture, a 1-day workshop, a 1-month elective, or a 1-year curriculum.

Creating Educational Objectives

Educational objectives outline the skills and behaviors the student, resident, or fellow will be able to demonstrate after the teacher has completed a lecture, daily bedside instruction, 1-month elective, or fellowship training. Objectives should be developed for every instructional activity because they are a road map. They guide the teacher in developing an appropriate curriculum, they set unambiguous expectations for the learner, and they serve as a reference for evaluation and feedback.^2,³

Developing educational objectives involves three steps.^2,³ First, using action verbs (e.g., defines, explains, demonstrates, identifies, summarizes, evaluates), the instructor describes a specific behavior the learner must perform to show achievement of the objective. An objective such as “teaches concepts of airway management” is not adequate because it defines what the teacher is doing and does not clearly describe what the learner should be demonstrating. Therefore, it neither serves as a road map for the teacher or the student, nor does it identify a clear behavior the teacher can evaluate.

Second, the teacher should describe the conditions under which the behaviors are to occur. For example “given a scenario using human simulation, the student will evaluate the airway and demonstrate effective bag-mask ventilation” or “given a patient with sleep apnea, the fellow will outline a plan for management of the difficult airway.” Finally, the criteria for acceptable performance should accompany the objective—that is, “bag-mask ventilation will be followed by successful laryngotracheal intubation within 30 seconds.”

Bloom and Krathwohl developed a classification of educational objectives to assess three domains: cognitive, affective, and psychomotor.^4,⁵ Objectives related to acquisition of knowledge are described in the cognitive domain, objectives related to the demonstration of attitudes and values are described in the affective domain, and objectives related to the acquisition of skills are described in the psychomotor domain.^4,⁵

When teaching students a specific clinical skill—for example, how to manage a patient with hypotension—the teacher must establish that the learner has first mastered the lower cognitive domains, knowledge, and comprehension. Learners will not be able to initiate an appropriate treatment for hypotension or evaluate effectiveness of treatment unless they can first list the causes of hypotension and describe the effect of preload on stroke volume. The teacher must be able to identify where learners are in the cognitive domain and help them reach the higher domains such as synthesis and judgment. To accomplish this, the teacher needs to develop educational objectives asking the student to predict the consequence of an intervention or evaluate the effectiveness of treatment. Table 228-1 lists the levels of Bloom’s cognitive domain with the examples of action verbs and provides examples of questions that could be asked during lecture or teaching rounds to force the learner to higher levels.

TABLE 228-1 Bloom’s Taxonomy for Cognitive Domain

Levels of Thinking —Thought Process	Verbs	Example
Knowledge—remembering by recall or recognition: requires memory only	Define, list, recall. Who? What? Where? When?	What are the determinants of stroke volume?
Comprehension—grasping the literal message; requires rephrasing or rewording	Describe, compare, paraphrase, contrast, in your own words.	Describe how a change in end-diastolic volume affects cardiac output.
Application—requires use or application of knowledge to reach an answer or solve a problem	Write, demonstrate, show an example, apply, classify.	Show how a fluid bolus can change systolic blood pressure.
Analysis—separate a complex whole into parts; identify motives or causes; determine the evidence	Why? Identify, outline, break down, separate.	Identify the factors that may contribute to abdominal surgery.
Synthesis—produce original communication, solve a problem (more than one possible answer)	Write, design, predict, summarize, rewrite, develop, organize, rearrange.	Given a patient with chest pain, bibasilar rales, jugular venous distention, and mottled extremities, develop a hypothesis for a decrease in systolic blood pressure.
Evaluation—make judgments, offer opinions; summarize physical findings to support successful therapy	Judge, describe, appraise, justify, evaluate findings to support therapy.	Justify the decision to treat the patient in the previous example with fluids and inotropes.

Educational objectives specifically related to critical care medicine training programs should be developed in accordance with the expectations outlined in the Accreditation Council for Graduate Medical Education (ACGME) program.⁶ In addition to listing the specific cognitive and motor skills that must be taught, the ACGME has also developed general core competencies that focus on patient care and not just knowledge acquisition.⁶ The six competencies include medical knowledge, patient care, interpersonal and communication skills, professionalism, practice-based learning, and systems-based practice.⁷ Examples of educational objectives for each competency are shown in Table 228-2.

TABLE 228-2 Educational Objectives for the ACGME General Competencies

Patient care: Fellow provides patient care that is compassionate, appropriate, and effective for the promotion of health, prevention of illness, treatment of disease, and at the end of life.

• Ability to identify and prioritize patient care plans

• Gathers accurate, essential information from all sources, including medical interviews, physical examinations, medical records, and diagnostic/therapeutic procedures

• Skillfully performs procedures

• Assumes leadership role in orchestrating patient care

Interpersonal and communication skills: Fellow demonstrates interpersonal and communication skills that enable him or her to establish and maintain professional relationships with patients, families, and other members of healthcare teams.

• Provides effective and professional consultation to other physicians and healthcare professionals and sustains therapeutic and ethically sound professional relationships with patients, their families, colleagues, and students. Uses effective listening, nonverbal questioning, and narrative skills to communicate with patients and families

Professionalism: Fellow demonstrates behaviors that reflect a commitment to continuous professional development, ethical practice, an understanding and sensitivity to diversity, and a responsible attitude toward patients, profession, and society.

• Demonstrates respect, compassion, integrity, and altruism in relationships with patients, families, and colleagues

• Adheres to principles of confidentiality, scientific/academic integrity, and informed consent

Practice-based learning and improvement: Fellow will be able to use scientific evidence and methods to investigate, evaluate, and improve patient care practices.

• Develops and maintains a willingness to learn from errors and use errors to improve the system or processes of care; incorporates feedback into improvement activities

• Uses information technology or other available methodologies to access and manage information, support patient care decisions, and enhance both patient and physician education

Systems-based practice: Fellow demonstrates both an understanding of the contexts and systems in which health care is provided and the ability to apply this knowledge to improve and optimize health care.

• Utilizes the resources, providers, and systems necessary to provide optimal care (e.g., social services, PharmDs, nutrition service, case managers, resource intensivists, physical therapists)

• Collaborates with other members of the healthcare team in code situations and triages patients to appropriate level of care

Motivating Students to Learn

The next step in teaching as a manager is to motivate the students to want to learn. To accomplish this they must first value what is being taught. For them to value a specific goal, they need to understand why it is necessary to incorporate the material into their clinical practice.^8,⁹ The affective domain addresses educational objectives that relate to valuing and applying the material. The lowest level of the affective domain is receiving, in which the students attend lectures. Higher levels in the affective domain are concerned with getting the learner to incorporate material into daily patient care.⁵ These higher levels are accomplished by creating an environment that is conducive to learning. Table 228-3 lists specific activities the teacher can use to achieve higher levels in the affective domain. For example, the instructor should explain why certain educational goals have been chosen, why they are important, and what the consequences of failing to incorporate them are. Most importantly, the teacher needs to be aware of any inadvertent behaviors that may inhibit learning—providing negative feedback in front of others or demonstrating negative body language, for example. Because the teacher’s goal is to facilitate rather than inhibit learning, the teacher must recognize and change any behaviors that are barriers to learning.

TABLE 228-3 Teaching for Affective Learning

A particularly effective tool to get students not only to learn but also to apply their cognitive skills to patient care is to put them in “simulated crisis situations” and allow them to make clinical mistakes and then attempt to manage the consequences. For example, as part of the airway management course for critical care medicine fellows, they are given an opportunity to manage a simulated patient with respiratory distress. If they sedate and paralyze the mannequin before obtaining all equipment for intubations, fail to verify intravenous access for fluid resuscitation, and do not evaluate the airway for potential difficulty, they will then have to manage a hypotensive patient with inability to intubate. Making this mistake in a simulated environment and experiencing the potential complications in real time has proven successful in getting fellows to learn and incorporate their cognitive and motor skills into their patient care. Simulation technology is described later under learning experiences.

Learning Experiences

There are numerous instructional methodologies a teacher can use to achieve educational objectives. Because adult learners prefer active learning, a curriculum that requires them to process information, participate in problem solving, and defend clinical judgment increases their enthusiasm for learning.⁹

Unfortunately, traditional methods of instruction such as lectures provide little opportunity for interaction, but because they are an efficient means of conveying a significant amount of information, they are frequently used. Despite being an efficient method for the teacher, they are not as effective as other strategies in helping the learner acquire clinical skills.¹⁰ In addition, much of what is taught is not retained, especially as the quantity of new material in the lecture increases.¹¹ Finally, because didactic sessions are not interactive, the teacher does not have an opportunity to assess whether the learner understands the content and its applicability.

Small group sessions that incorporate problem-based learning and interactive workshops are more effective because they engage the students, force them to defend their decisions, and explain how they evaluate outcomes.¹⁰ Steps involved in developing a problem-based curriculum are to encourage the group to clarify any concept that is not understood, define the problem, analyze the problem, and outline a management plan.¹²

Newer instructional methodologies involve technology. Since 1992, students have had the ability to access the Internet, hyperlink to additional resources, and search for reference material with potential cost savings both in terms of dollars and time compared with traditional instruction.^13,¹⁴ Whereas surveys demonstrate that learners are satisfied with Internet-based instruction, there are no studies to show Internet-based learning is more effective than other educational methods for increasing cognitive function or efficiency of learning.¹⁵

Lectures, small group discussions, problem-based learning, and Internet-based instruction are all effective in helping the learner acquire knowledge. However, none of these methods teaches students or residents how to apply these skills to real-life situations. It is essential that a curriculum includes instruction that gives students an opportunity to learn how to manage unstable patients before they are expected to manage them in the clinical environment.

Each year 44,000 to 98,000 patients die because of medical errors.¹⁶ It is possible that giving students an opportunity to manage complex problems and anticipate consequences of their interventions in an environment where their mistakes do not result in untoward outcomes, where feedback is immediate, and where students can repeat their performance until they acquire these skills might improve patient safety.

Such instructional opportunities exist and have been available for years in the form of simulation. Simulation is defined as any training device that duplicates artificially the conditions that are likely to be encountered in an operation and may include low tech, partial task trainers, simulated patients, computer-based simulation, and whole-body realistic patient simulation. Since the 1960s, simulators have been used to teach crisis management to personnel in military, aviation, space flight, and nuclear power plant operations.¹⁷ Work in cognitive psychology and education theory suggests that more effective learning occurs when the educational experience provides interactive clues similar to situations in which the learning is applied.¹⁸ In other words, teaching management of unstable patients in a simulated environment, providing instruction, and evaluating learning is more effective than didactic sessions.

What initially began as computerized software with a separate torso apparatus has evolved into complex whole-body computerized mannequins with a functional mouth and airway, allowing bag-mask ventilation and intubation.^19,²⁰ The chest wall expands and relaxes; there are heart and breath sounds and real-time display of physiologic variables including electrocardiogram, noninvasive blood pressure, temperature, and pulse oximetry. The human simulator has individual operator controls for upper airway obstruction, tongue edema, trismus, and reduced cervical range of motion. These computerized human simulators require trainees to integrate cognitive and psychomotor learning along with multisensory contextual cues to aid in recall and application in clinical settings.^21,²² This type of simulation has been successfully incorporated into curricula to teach management of obstetrical emergencies, management of difficult airway in the operating room, crisis management in the operating room,^20,²³ and management of unstable patients for critical care medicine trainees. Examples of learning objectives for third-year medical students, fourth-year medical students, and critical care medicine fellows using the simulator are listed in Tables 228-4 to 228-6. Note, all objectives are written in terms of behaviors the student must perform, thus giving the teacher clear guidelines for evaluation.

TABLE 228-4 Learning Objectives for Third-Year Critical Care Medicine Course

Respiratory Distress

• Evaluate a simulated patient in respiratory distress (tachypneic and hypoxemic).

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