By Phillip Stephens, DHSc, PA-C
Medical education is a vital component of medicine, and medicine is becoming increasingly complex. As emergency departments become busier, clinical education must often occur at a more rapid pace than ever before to meet the demands of a busy department. This requires an understanding of efficient teaching methods, and Emergency Medical Associates (EMA) is at the forefront of providing this training to a new generation of medical professionals.
In July for example, Southeastern Regional Medical Center, in cooperation with the Campbell University School of Medicine, will begin three residency programs in Lumberton, N.C.: Internal Medicine, Family Medicine and Emergency Medicine. It is one of the latest EMA sites to train emergency medicine residents and already trains medical students, PA students and nursing students from various institutions.
Southeastern is only the sixth emergency medicine residency in North Carolina. The site is unique in that the other five are much larger centers, with four associated directly with university campuses and the other situated in a metropolitan area. But we share with these and other sites across the nation providing emergency medicine training the common challenges of precepting and mentoring students.
A 2012 study published in Education in Medicine Journal found that third-year residents were more comfortable precepting medical students than were second-year residents. In the first six months of PGY2, residents felt precepting interfered with their ability to perform clinical work; PGY3 residents felt better about their ability to teach while maintaining patient flow.
This is the general consensus among a broad spectrum of clinicians from advanced providers (APs) to attending physicians: sometimes students slow them down, but with experience in managing clinical education, a greater level of comfort is attained. There are some accepted models that can facilitate the teaching function and help manage precepting responsibilities.
3 Steps to Beginning a Student Rotation
Three things must occur from the beginning of a rotation for a new student:
- Review your expectations with students from the beginning and let them express their expectations as well as their fears.
- Actively involve students rather than allow them to be passive observers; they will get more from the experience as an active participant.
- Involve other staff. Sharing teaching responsibilities with the entire staff not only levels the teaching load but provides a varied experience for students.
Once students begin seeing patients, it’s helpful to allow a complete formal presentation of a few patients. But once it is clear they possess this traditional skill, switching to a problem-focused presentation streamlines the process and helps them learn to get to the main issue in emergency medicine.
Research has shown that the interaction of presenting a patient to a preceptor can take up to 10 minutes. Six minutes actually consumes the majority of the time presenting the case, with three minutes for questioning and one minute for discussion.
Ideally, students should learn to present a case to include a differential diagnosis, workup and management plan. This may not occur until they gain experience, but continually challenging students to go beyond a history and physical is key to their development. The goal is for students to develop analytical thinking and case management skills.
The One Minute Preceptor Method
Most students will stop the presentation after the history and physical portion. This is where a model like this may be helpful.
- Get a Commitment: Ask questions that commit the student to analyzing a portion of the care. These shouldn’t be questions to gain more data but rather to gain insight into the student’s reasoning skills. “What do you think is going on with this patient?” “What labs should we order?” “Why? How will they be helpful?” “What parts of the physical exam should we focus on?” Questions are designed to challenge students to push beyond their comfort level. They should not simply reflect the preceptor’s thought process but rather explore the learner’s thought process.
- Probe for Supporting Evidence: Once students are committed to some aspect of the exam or care decision process, it’s important to explore the rationale for the decisions to which they are committing. Questions like, “What evidence supports your diagnosis?” “What else could this be?” “Why do you think the patient needs to be admitted?” or “Why would you pick that medication?” This helps develop logical reasoning with supporting evidence.
- Reinforce What Was Done Well: Simply saying the student did well is not specific enough for the learner to understand what aspect was done well. Thought processes valued by the preceptor should be emphasized specifically. “Your presentation was well organized” or “You considered the right range of possibilities,” or “You supported the diagnosis quite well.”
- Provide Guidance Regarding Errors and Omissions: Just as you first provide feedback on what was done well, then point out things that could be improved. “You need to note the patient has abnormal vital signs,” “I agree a pulmonary function test is useful but not indicated in the patient’s acute phase.” This part is about balancing positive and negative feedback.
- Teach a Principle: Brief presentations provide the opportunity to teach a single point that can be applied to other patients. Sharing a validated scoring tool like a Wells’ Score or having the student research a specific aspect of the case are examples of helping the student generalize the information, as is advice on the fundamentals of approaching ED patients, such as “Don’t forget to acknowledge and address the patient’s fears.”
- Conclusion: Wrap it up; summarize the case and provide the next expected steps for the student. These steps should take only a minute or so. Don’t expect students to control the time. The preceptor must focus the discussion and at this point explain the next steps. These steps may be to have the student perform the exam while the preceptor watches or have the student watch the preceptor. It may be to have the student participate in obtaining a blood gas. But make a clear conclusion and expectations regarding the next actions.
Although it seems like a lot of steps, this process can be performed quickly by keeping those steps in mind: emphasize a key aspect of the case for students to commit their focus, probe for evidence that supports the committed decisions, inform students what was done well and what they need to improve upon, and then teach a specific principle before wrapping it up by outlining further expectations.
Precepting Can Be a SNAP(PS)
An alternative approach is the SNAPPS method.
S: Summarize the Case
N: Narrow the Differential
A: Analyze the Differential
P: Probe the Preceptor
P: Plan the Management
S: Select an Issue for Self-Directed Learning
According to the Emergency Medicine Residents Association, Bruce Janiak, MD, at the University of Cincinnati in 1970 was the first emergency medicine resident. At the time, there was almost no actual emergency medicine faculty, and experts in other specialties taught the residents emergency medicine principles and techniques. By 1975, there were 31 residencies in the United States, mainly in the Midwest, but it was not until 1979 that the American Board of Medical Specialties approved the American Board of Emergency Medicine.
Those early residents were pioneers. Their futures were uncertain in this new specialty, which is still relatively new. But they persevered.
Current emergency providers are vital to training the next generation of emergency professionals. And EMA is in the forefront of the field as we join in focusing on the best methods to train those who after all will be the ones to surpass us and take the practice of emergency medicine to new heights.
Phillip Stephens, DHSc, PA-C, is the associate practitioner site director for Emergency Medical Associates at Southeastern Regional Medical Center, Lumberton, N.C. He is adjunct faculty at A.T. Still University in Mesa, Ariz., where he teaches Research Methodology and has practiced as an emergency medicine physician assistant for 25 years.
