This week’s How I Educate post features Dr. Michael Galuska, the Program Director at Conemaugh Memorial Medical Center. Dr. Galuska spends all of his shifts with learners which include emergency medicine residents and medical students. He describes his practice environment as a rural community-based residency program. Below he shares with us his approach to teaching learners on shift.
Name 3 words that describe a teaching shift with you.
Sarcasm, Autonomy, and Coffee.
What is one thing (if nothing else) that you hope to instill in those you teach?
How learning truly is a lifelong skill that you should continue to develop. I look things up on shift myself all the time. I’m always trying to learn from cases, love discussing difficult or obscure cases, and I hope that my passion for ongoing learning in medicine still shows. On a more practical note, the other thing I like to try to instill is truly thinking about what you are ordering on a patient, which is easy to forget when bundle ordering on an EMR. I think it’s natural when we get busy to just skip actually formulating a good differential diagnosis and just “order chest pain labs” rather than really scrutinize a patient’s risk stratification, whether they even need a troponin or a d-dimer for instance. And for goodness’ sake, every chief complaint does not require a lactate.
How do you balance your flow with on-shift teaching? Does this come at the expense of your documentation?
I typically finish most of my documentation after my shift so I can focus my shift on supervising and teaching students and residents.
What is your method for reviewing learners’ notes and how do you provide feedback on documentation?
I’ll read through some notes during the shift and give on the fly documentation tips, but I sign notes and do most of my own documentation post-shift. I’ll mention documentation in end-of-shift evaluations or text a resident after a shift if I notice something major I had to change, but that’s pretty rare, and I don’t bother residents with minor changes. I also lecture on good documentation and EM billing and coding to all the residents yearly.
It can be difficult to sit back and let senior learners struggle what is your approach to not taking over prematurely?
Unless a patient is critically ill and time is of the essence, I think it’s important to sit back and give all residents the appropriate amount of autonomy based on their skill level, not just senior residents. It’s easy to jump in and just tell a resident what to do, it takes considerable restraint to have them work through a problem or figure out a solution on their own, but when they do they learn far more from it.
Do you start a teaching shift with certain objectives or develop them as a shift unfolds?
As a night shift worker, I can comfortably say that I start my shift with the singular goal of just surviving through the night, and then I just develop any other goals as the shift unfolds.
Do you typically see patients before or after they are presented to you?
After, unless the patient is critically ill or arresting, then I’ll go in the room with the resident.
How do you boost morale amongst learners on shift?
I have a coffee bar in my office and will make a variety of mid-shift coffees for anyone that wants one. My blueberry donut-flavored coffee is currently the fan favorite.
How do you provide learners feedback?
Verbal feedback in the moment of a teaching point is far more valuable to the learner I think. We do end-of-shift written feedback on residents as well, but I don’t know that it carries the same weight from a learner’s perspective.
What tips would you give a resident or student to excel on their shift?
For students, I think the biggest thing is really switching out of “reporter” mode into a “manager” role. So many students when they start 4th year are excellent at taking histories but haven’t been challenged to independently formulate differentials and plans. Also, many initially need to focus on really following up on their patient’s studies and reexamining their patients throughout their shift. We really try to instill these expectations early on in a rotation. From a resident standpoint, I think one of the hardest things to do is learn how to become more productive and learn a good rhythm with picking up and discharging patients and managing their list. One tip I like is to tell residents to pick a number of patients they feel like they can safely take care of at once. That may be 3 for a new PGY1 or 6 for a more senior resident, the overall number doesn’t matter. Each time you pick up a patient that gets you to your “max” number, you look at your list to see who can be discharged or admitted before picking up another. If you have numerous patients to disposition at once, you see another patient between each disposition, rather than spending 30 minutes clearing your list all at once. This prevents residents from seeing a ton of patients all at once, then getting stuck when all their dispositions come up at one time which can make it difficult to continue to be productive seeing patients by mid-shift. It’s not always possible to do this, but conceptually this is a good way of managing your cognitive load without getting overwhelmed and will make you more productive by avoiding that time 3-4 hours into a shift where your list gets to the point where you have to just stop seeing patients altogether while you purge all your dispositions, then find yourself with no active patients an hour later.
What are your three favorite topics to teach during a shift?
Approach to 1st trimester vaginal bleeding, Venous Thromboembolism, Ultrasound and procedures.