Don’t Be a Gym Teacher: The Value of Teaching Medical Students in the ED

Did you listen to Joseph Cruz’s guest posts on his top 10 momentum breakers?  If not, shame on you. Go listen to Part 1 and Part 2.  Go ahead, we’ll wait…

Did you hear how he discussed medical students in the context of breaking momentum?  Joseph of course discusses some strategies in there to get medical students to work with you and be engaged.  Well, a few listeners stood up for our med students.  One of them was one of my current chief residents, and soon to be ultrasound fellows, Mark Gonzales, DO, MPH.  So Mark decided to write the following piece.  I agree wholeheartedly with Mark, and love working with medical students.  And, I think it is crucial to learn how to be a good teacher as a resident, even if you’re not planning on being an academic physician (look out for some upcoming related content on iTeachEM…).  Read on to learn how you can do better by your students.  

- Bob Stuntz, MD

Those that can’t do, teach, and those that can’t teach…teach gym.”

– Jack Black, School of Rock

Comical, and hopefully inaccurate, this line from the movie School of Rock points directly at one of the saddest stereotypes about education in general:  that people become teachers because they’re unable to do the work in their chosen field.  Whether there’s any truth to this or not, this statement has no role when it comes to teaching emergency medicine.  In our world, a quality teacher simply cannot be an inept clinician.  And this responsibility goes for us as residents as much as it does for our attendings.  Medical students require quality teaching from us much like we require adequate guidance from our attendings.

I heard someone once say, “I can only be expected to be as good as my attending.”  There’s at least a partial truth to this.  In turn, the same goes for the guy in the short white coat that showed up to work your shift with you.  He is somewhat of a reflection of you by the end of the day, depending on how valuable you were to him.  If you complain that he just follows you around or neglect him because he’s not going into EM or abandon him because his 7-minute presentation about a sprained ankle frustrated you, you’re not doing him any favors.

To me, it is a privilege just to be around medical students, let alone be a part of their education.  And in EM, we almost exclusively have 4th year medical students – ones who have been through at least a year of clinical rotations, which makes teaching them that much easier.  By the time they’ve gotten to you, they’ve picked a specialty that they’re hopefully excited about, they’re anxiously navigating the match process, they’re traveling to interviews, they can make more sense of the patients they see than they could a year ago, and they generally have a pretty good understanding of their role in the clinical setting.   Do you remember your 4th year of med school?

Whether they’re going into EM or not, they have a lot to gain from you, and probably more than you realize.  Our specialty applies to every other specialty and all doctors need knowledge of what to do in an emergency if they’re the only one around.  Sure, a budding pathologist may not be all that interested in her EM rotation at first but you’ll never find someone more excited to make sense out of a CBC differential.  So meet her halfway and do whatever you can to involve her interests with as many patients as possible, so called “learner-centered education1.”  When she’s reviewing slides in the lab one day and you helped her understand how debilitating a sickle cell crisis can be or what it’s like to tell someone you found an apple core lesion on their CT scan, she’ll gain an appreciation for the big picture.  It’s easier to draw interest out of them than you may think.

We’re also the only specialty with a board certified attending sitting next to us during every shift.  Teaching opportunities are abounding in a busy ED and the answers from an expert are always at the ready whether you know what to tell them or not.  

Have you ever worked a shift with a medical student when there aren’t enough “real” emergencies?  Play the “what if” game.  “What if” this weakness patient was 7 months old and liked to suck on bottles of honey?  What would you consider if this first time mother who brought her crying, snotty-nosed kid in at 3am brought in a child who was inconsolable but otherwise well?  You can do this same sort of thing with sick versus not sick.  For example, you can do a FAST exam on a minor/stable trauma patient and show them what to look for if the patient was hypotensive.  Or take that same patient and explain a clinical decision tool like NEXUS or Canadian C-spine.  Or even just use this to introduce them to the NNT.

Some other ideas and considerations:

  • You can always go into the room with them and let them run the show, stepping in only if they really need you.
  • There’s always a pile of EKGs lying around somewhere.  Same goes with the PACS list for reviewing CXRs and head CTs.
  • Want to cover the nuts and bolts of a given topic?  ALiEM has you covered with Michelle Lin’s Paucis Verbis Cards, which you can easily load on your smartphone for free.
  • Take them on a “flow tour” through the ED – from triage through checkout.  They’ll gain an appreciation for patient flow and develop a basic concept of the bigger picture.
  • Show them different parts of your shop – give a detailed tour through the trauma bay or the airway cart or the suture cart.  You might even discover something there yourself.
  • Go into an empty exam room and just start giving them a case where they have to figure out how to use a piece of equipment (transcutaneous pacing is a good one).
  • Suggest a blog or podcast.  This list is a good start, but of course don’t forget to mention EMRes.
  • EM is a case-based specialty.  They should know and read this book.
  • Set them up for presenting to the attending the way you know the attending will want.  You’ll both look good and you’ll get along better for it.
  • Set them up for their intern year.  Have them do discharge instructions, have them figure out what specific x-ray views they want, see how they do with picking up two patients at a time if you feel like they’re ready for it.
  • Are they a little long-winded with presentations?  Break the case down for them into illness scripts so they have an idea of what’s important (i.e., 37yoF, recent 10 hour road trip, smoker, takes OCPs, here with chest pain and tachycardia).
  • Is feedback awkward for you?  Just do the sandwich thing – a positive, a point for improvement, then another positive (i.e., “Your documentation is thorough and your presentations are concise and right on point.  You could probably improve by following up on patients a little more timely and letting me know results before I see them, which will make you that much more impressive.  This shouldn’t be difficult given your level of enthusiasm and how patient-centered you seem to be.)

Fortunately medical students can be valuable to you as well.  This is an opportunity for you to recognize your own gaps and broaden your own knowledge base.  You’ll start asking yourself questions and leading yourself to more answers.  This only makes you a better clinician.  Try not to just view them as an impediment to your efficiency or your free pass out of rectal exams for the day.  Utilize the capabilities they have to make you more efficient.  You can always see a couple patients while they’re seeing one and get a good start on your note while they present to you.  Or you can pop into the room where they’re seeing a patient and have them do a bedside presentation after you finish up in another room.  Again, these are 4th year students – give them a little more room to do things and a little push of their comfort level so they’re more ready for life as an intern in a few months.  

Finally, some people like giving them rules.  I have only two rules for medical students: 1) never hesitate to find me if something seems wrong (abnormal vitals, looks sick, acute changes, concerning mechanism of injury, etc.) and 2) let me know if you want to see another patient.  That way they’re more comfortable saying they’re uncomfortable and I can make sure they’re not walking into a bad situation.  Set them up for success and recognize their value.  View it as a symbiotic relationship between the two of you.  Don’t be the proverbial gym teacher.

  1. Guth, Todd A.  Resident as Educator:  A guidebook written by residents for residents.  EMRA.  2013.
  2. Joshi, Nikita.  What makes a good clinical educator?  Academic Life in Emergency Medicine (ALiEM).  1 May 2014.  http://www.aliem.com/makes-good-clinical-educator/



Episode 29: US in Dyspnea Part 2

She’s short of breath.  Has a history of CHF, COPD, cancer, and has had a cough today…

Sound familiar?  Undifferentiated dyspnea can be a challenge.  But you know me, I’m a sucker for anything 1,540 m/s, and US is usually the answer.  Fortunately, EM Chief Resident, FOAM US superstar, and resident US guru Jacob Avila (@UltrasoundMD) agrees, and he wanted to teach you all how to use US to solve this concerning clinical conundrum.  The possibilities are endless, but Dr. Avila shows you how to simplify your clinical decision making and make the right call. 

In the conclusion, Dr. Avila takes you through pneumonia, pleural effusion, and PE/DVT.  He also offers the all important word of warning: remember to incorporate US correctly.  Know your indications, how do perform and interpret the exams correctly, and put them in the right clinical context.  

Make sure to check out Jacob and his great blog, 5 Minute Sono.  While you’re at it, Jacob works a bunch with Ben Smith, who has a great US blog himself - give him a look as well.  Also, check out the EM Res Podcast Google Community.  Check out our example videos and Dr. Avila’s amazing summary of references!  Then enjoy the podcast!

And of course, if you haven’t already, go back and listen to Part 1!

This episode and part one will be eligible for Asynchronous Learning - Will be posting the quiz in the next few days.  After answering the short questions in the quizzes, you can print out a certificate that says you spent time listening to the podcast and doing the quiz.  My hope is, that with approval from your individual US EM Residency program directors, you can count this toward individual interactive instruction time (also known as asynchronous learning) if you are in a US EM residency program.  As stated, make sure your program director approves of this before you go chalking this up as asynchronous time.    

Episod 28: US in Dyspnea – Part 1

She’s short of breath.  Has a history of CHF, COPD, cancer, and has had a cough today…

Sound familiar?  Undifferentiated dyspnea can be a challenge.  But you know me, I’m a sucker for anything 1,540 m/s, and US is usually the answer.  Fortunately, EM Chief Resident, FOAM US superstar, and resident US guru Jacob Avila (@UltrasoundMD) agrees, and he wanted to teach you all how to use US to solve this concerning clinical conundrum.  The possibilities are endless, but Dr. Avila shows you how to simplify your clinical decision making and make the right call. 

How good is physical exam in this very scenario?  Can you tell the difference between CHF and COPD with US?  What about pneumothorax?  And how to you figure out if that effusion is causing tamponade?  Dr. Avila has got it all covered in Part 1.  And in part 2, coming next week, there will be even more goodness - PE, DVT, pneumonia - we’ve got it all.  

Make sure to check out Jacob and his great blog, 5 Minute Sono.  While you’re at it, Jacob works a bunch with Ben Smith, who has a great US blog himself - give him a look as well.  Also, check out the EM Res Podcast Google Community.  Check out our example videos and Dr. Avila’s References below, and then enjoy the podcast!

This episode and part two will be eligible for Asynchronous Learning - look for the quiz after part 2.  After answering the short questions in the quizzes, you can print out a certificate that says you spent time listening to the podcast and doing the quiz.  My hope is, that with approval from your individual US EM Residency program directors, you can count this toward individual interactive instruction time (also known as asynchronous learning) if you are in a US EM residency program.  As stated, make sure your program director approves of this before you go chalking this up as asynchronous time.    






Check out Dr. Avila’s amazing summary of references!

Episode 27: Momentum Breakers, Part 2

In Epsiode 27, EM Resident contributor Dr. Joseph Cruz of edocc.com rounds out his top 5 ED shift momentum breakers for the EM resident.  We have talked about the importance of mental simulation and preparation for your shifts before.  It is just as important to think about what is going to slow you down or stop you in your tracks on your next shift.  

If you are interested in helping contribute to the EM Res Podcast, let me know.  I am always happy to have resident contributors as well.  Make sure to check out Joseph’s blog, The ED on Cruise Control.  Follow him on Twitter @CruzaderJC.  Our next few episodes will be coming from another guest resident contributor, Jacob Avila (@UltrasoundMD), who will be talking about the use of US in undifferentiated dyspnea.  

Also, make sure to check out the EM Res Podcast Google community, and head on over to Emergency Board Review if you are interested in helping out with a completely free resource for EM board review!  

Episode 26: Momentum Breakers, Part 1

In Epsiode 26, we have a new EM Resident contributor to the EM Res Podcast.  In Part one of a two part episode, Dr. Joseph Cruz of edocc.com discusses 5 of his 10 ED shift momentum breakers.

We have talked about the importance of mental simulation and preparation for your shifts before.  It is just as important to think about what is going to slow you down or stop you in your tracks on your next shift.  

If you are interested in helping contribute to the EM Res Podcast, let me know.  I am always happy to have resident contributors as well.  Make sure to check our Jospeh’s blog, The ED on Cruise Control at www.edcc.com.  Follow him on Twitter @CruzaderJC

Also, make sure to check out the EM Res Podcast Google community, and head on over to www.emergencyboardreview.com if you are interested in helping out with a completely free resource for EM board review!  

Podcast Episode 25: Pediatric Appendicitis

In what two age groups is perforated appendicitis most common?  If you said the very young and the very old, you would be correct.  As we all know, the workup and diagnosis of appendicitis in kids can be extremely difficult.  There are communication barriers, distractors, and mimickers.  So how do we tease out the right history and get to the correct conclusion?

In this episode, we discuss many of the more difficult and important aspects of the workup for a child with possible appendicitis.  Can physical exam change your pretest probability?  Can you do labs without imaging, or is it an all or nothing workup?  what about documentation and follow up?  How do you handle the indeterminate ultrasound?  Do you use oral contrast if CT is needed, or IV only?  

In this conference, we have a panel of five of our best and brightest attendings discussing these issues and more.  You’ll hear from:

  • Dan Kaminstein, MD: You’ve heard him before, international medicine and ultrasound expert
  • Tom Kehrl, MD: From the Airway tips and tricks episode, and our EUS fellowship director
  • Andy Kepner, MD: Emergency Physician with a surgical background and director of our sim center
  • Erik Kochert, MD: Also a frequenter of the EM Res podcast, APD and Research director
  • Jess Riley, MD: Emergency physician with both academic and community experience
  • Bob Stuntz, MD: You know me

This episode does run longer than the typical episode, but it is chock full of good pearls.  Let us know what you think in the comments below, or head over to the Google Community to discuss this episode.

References:  

  1. Bundy DG1, Byerley JS, Liles EA, Perrin EM, Katznelson J, Rice HE.  Does this child have appendicitis?  JAMA. 2007 Jul 25;298(4):438-51.
  2. Ebell MH1, Shinholser J2.  What Are the Most Clinically Useful Cutoffs for the Alvarado and Pediatric Appendicitis Scores? A Systematic Review.  Ann Emerg Med. 2014 Apr 11.
  3. Ohle R1, O’Reilly F, O’Brien KK, Fahey T, Dimitrov BD.  The Alvarado score for predicting acute appendicitis: a systematic review.  BMC Med. 2011 Dec 28;9:139.
  4. Meltzer AC1, Baumann BM, Chen EH, Shofer FS, Mills AM.  Poor sensitivity of a modified Alvarado score in adults with suspected appendicitis.  Ann Emerg Med. 2013 Aug;62(2):126-31.
  5. Ross MJ1, Liu H, Netherton SJ, Eccles R, Chen PW, Boag G, Morrison E, Thompson GC.  Outcomes of children with suspected appendicitis and incompletely visualized appendix on ultrasound.  Acad Emerg Med. 2014 May;21(5):538-42.
  6. Estey A1, Poonai N, Lim R.  Appendix not seen: the predictive value of secondary inflammatory sonographic signs.  Pediatr Emerg Care. 2013 Apr;29(4):435-9.
  7. Bachur RG1, Dayan PS, Bajaj L, Macias CG, Mittal MK, Stevenson MD, Dudley NC, Sinclair K, Bennett J, Monuteaux MC, Kharbanda AB; Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics.  The effect of abdominal pain duration on the accuracy of diagnostic imaging for pediatric appendicitis.  Ann Emerg Med. 2012 Nov;60(5):582-590.
  8. Leeuwenburgh MM1, Stockmann HB, Bouma WH, Houdijk AP, Verhagen MF, Vrouenraets B, Cobben LP, Bossuyt PM, Stoker J, Boermeester MA; OPTIMAP Study Group.  A simple clinical decision rule to rule out appendicitis in patients with nondiagnostic ultrasound results. Acad Emerg Med. 2014 May;21(5):488-96.
  9. Elikashvili I1, Tay ET, Tsung JW.  The effect of point-of-care ultrasonography on emergency department length of stay and computed tomography utilization in children with suspected appendicitis.  Acad Emerg Med. 2014 Feb;21(2):163-70.
  10. Yu CW1, Juan LI, Wu MH, Shen CJ, Wu JY, Lee CC.  Systematic review and meta-analysis of the diagnostic accuracy of procalcitonin, C-reactive protein and white blood cell count for suspected acute appendicitis.  Br J Surg. 2013 Feb;100(3):322-9.
  11. Kwan KY1, Nager AL.  Diagnosing pediatric appendicitis: usefulness of laboratory markers.  Am J Emerg Med. 2010 Nov;28(9):1009-15.

Either click here to listen to the podcast, or check out the episode embedded below:


Asynchronous learning quiz: Coming Soon!