This week’s How I Educate post features Dr. Geoff Comp, the Associate Program Director at Creighton University School of Medicine/Valleywise Health Medical Center in Phoenix, Arizona. Dr. Comp spends all of his shifts with learners, including emergency medicine residents, off-service residents, and medical students. He describes his practice environment as a county hospital with a Level 1 Trauma designation that has both an adult and pediatric emergency room. Below he shares with us his approach to teaching learners on shift.
Name 3 words that describe a teaching shift with you.
Innovative, evidenced-based, fun
What delivery methods do use when teaching on shift?
My favorite method of teaching is hands-on bedside describing and demonstrating different ways to complete a task or procedure with the learner. However, during patient presentations, I use a lot of scratch paper to show flow diagrams illustrating how to develop a differential diagnosis or plan from a chief complaint. I also use previously identified articles to help illustrate a point. Frequently I will pull up the resource on a computer, and then send the learner a copy of what we discussed for them to review after shift.
What is one thing (if nothing else) that you hope to instill in those you teach?
Identify the learning opportunity in every encounter you have on shift. Sometimes learning is focused on a specific patient and their chief complaint, but other times it is related to optimizing skills such as team leadership and interpersonal interaction with other staff in the emergency department. If the learner is provided the tools to identify their own learning points their potential is limitless.
How do you balance your flow with on-shift teaching? Does this come at the expense of your documentation?
This is a super hard one to do. Unfortunately, personal documentation usually takes a backseat during many of my clinical shifts so I can spend more time interacting with patients as well as the learners. However, I try to identify my own methods for workflow optimization and explicitly share that with learners. For example, if I’m working through a particularly complex MDM I will include the resident working on the case with me to discuss my thought process. If I’m having a hard time incorporating the completion of different procedures in a workflow on shift, I will share the thought process of my list of things to do in order stratification with a learner as well.
Do you feel departmental flow and metrics adversely affect teaching? What is your approach to excelling at both?
Occasionally, a busy fast paced ER provides an opportunity to teach more than just medical or scientific topics! You can absolutely teach the learner about your thought process and flow as well as different requirements for when they will be working as an attending. Spend the time talking about why you’re documenting the way that you are, talk about how you keep metrics in mind and share with them details on documentation for billing and critical care time. There is also always an opportunity to create a list of the medical topics that you want to make sure you cover after you get through a bit of the rush or after shift over a quick snack, or at an out-of-hospital meet-up!
It can be difficult to sit back and let senior learners struggle what is your approach to not taking over prematurely?
Time, experience, and your own comfort in critical patient care and resuscitation is the key to effective senior learner guidance. We need to know and understand the skills of our senior learners as well as understand when patient safety may be compromised. The true hallmark of a great teacher is to know and understand at what time in each patient case they need to be able to step in. That space between a learner’s knowledge and when you feel like you need to step in is the space for learner growth and allows for optimum learner engagement. The second important component is being intentional with your learner about when you will be taking over because of concern for patient safety. This should always be paired with an active and intentional debrief of the entire patient encounter as soon as the patient has been stabilized. The second step allows for education and learner optimization without compromising patient safety or losing the teaching opportunity.
Do you start a teaching shift with certain objectives or develop them as a shift unfolds?
The teaching goals are pretty individualized. Some learners really respond well to setting the stage at the beginning of the shift and asking what goals they have for learning. Other learners need a little bit of guidance in identifying a tangible goal for the day. Matching the energy and experience level of the learner is important for a successful shift. However, I have my own personal goals when it comes to teaching as well as basic standards that I try to follow for the day. These include making sure that I am constantly intentional about teaching and giving feedback, identifying small pearls in seemingly “easy” cases to advance the learner, and focusing on understanding and patience when I’m working with struggling learners to help them ultimately succeed.
Do you typically see patients before or after they are presented to you?
The timing of when I physically see patients myself is usually tied somehow to the goals of the learner or to help me identify areas of improvement. For new or junior learners I try to sneak in before they present to me to identify key points of the history and physical so I can help guide them in proper presentation style and technique. With more advanced learners I usually see a patient after they present to me to confirm key parts of the history and circle back with them about different components of the case.
How do you boost morale amongst learners on shift?
A positive attitude is a choice and being an example of positivity is the best way to boost morale. Choosing to identify the components of an event that you can modify will allow for a beneficial outcome. By practicing positivity in the face of a challenging shift, departmental pressure, or a difficult case, you are actively demonstrating techniques to the learner. Be the type of attending that you want to learn from. However, I also work to boost morale by doing both individual and group check-ins, as well as debriefing during periods with high patient loads/acuity or after a critical resuscitation. I also work on giving intentional and direct mini-feedback sessions throughout the shift to provide positive encouragement and identify areas for learning.
How do you provide learners feedback?
Feedback should be time sensitive, directed towards a specific action/event, and well defined, and it should be provided with strategies for improvement. I start all feedback sessions by saying very intentionally “I’d like to give you some feedback.” I also work to make sure that I identify some sort of resource to either review or have the student look up. I then close the loop at a later time by asking them about their own personal exploration of the topic after our previous feedback session.
What tips would you give a resident or student to excel on their shift?
Identify a measurable goal that you want to achieve by the end of your shift. If you start your shift with the intention of saying what you would like to accomplish you will be able to strive for that goal throughout the entire experience. Also, loop in your teachers and mentors with this process. Let the attending that you’re working with for the day know what your goal is so they know how to provide appropriate feedback at the end of the shift and know what to be looking for!
What are your three favorite topics to teach during a shift?
Resuscitated procedures/resuscitation mindset as well as team leadership, wilderness and environmental medicine, and orthopedic injuries.
What is your favorite book or article on teaching?
I really like articles that help explicitly identify different on-shift teaching techniques. It’s hard for me to pick one specific one but a couple that I give to residents with a specific interest in medical education include EM Cases Teaching on Shift and EMRA Resident as an Educator.
Who are three other educators you’d like to answer these questions?
Michael Epter, Sara Krzyzaniak, and Stephani Lareau.
Read other How I Educate posts for more tips on how to approach on-shift teaching.