MEDICAL TEACHING IN THE ACUTE CARE SETTING

MEDICAL TEACHING IN THE ACUTE CARE SETTING

Michael E. Mahla, MDProfessor of Anesthesiology and Neurosurgery

Assistant Dean for GME

Lecture Goals

Review the opportunities and challenges of teaching in the acute care setting and how these differ from “traditional” clinical medical teaching.

The ACGME Competencies in the acute care setting – which are important

Challenges of production pressureSuggest techniques for optimizing education in the

acute care setting – the Dreyfus model and the BID model

Assessment of the competencies in the acute care setting – integration of the Dreyfus model.

The Six Core Competencies and Acute Care Teaching

Patient Care Skills – Defined by program requirements

Medical Knowledge – Defined by program requirements and Board Examinations

ProfessionalismInterpersonal and Communication SkillsSystems-Based PracticePractice-Based Learning and Improvement

A Scenario49 yo male with history of colon CA, S/P resection and chemotherapy presents to ER with extreme SOB sitting bolt upright. History of increasing UE and facial swelling likely secondary to developing SVC syndrome. Infusaport in place – scheduled to be electively removed in 48 hours.

The patient is very frightened. Room air SpO2 = 85%, improved to 92% on facemask oxygen. All accessory muscles in use, patient cannot speak more than 2-3 words without stopping.

A Scenario

Anesthesiology resident is called to the ED to urgently secure this patient’s airway. Attending accompanies the resident to the ED.

Questions:◦How much should the resident do in this life-

threatening situation?◦How can education occur in this life-threatening

situation?

The Problem

Another Scenario54 yo female is brought to the operating room emergently for craniotomy and removal of intracranial mass. She was seen in clinic the previous day and admitted for surgery. On the morning of the scheduled surgery, she is found unresponsive. Intubation attempt on the floor was unsuccessful, and she is brought emergently to the operating room for treatment of developing herniation syndrome.

QuestionsShould the resident be allowed to manage the airway given previous failed intubation attempt?

What educational opportunities are there in this acute emergency?

Another scenario49yo female with severe rheumatoid arthritis presents for elective anterior cervical corpectomy followed by posterior cervical fusion. The patient has a history of well-controlled hypertension treated with lisinopril. No other significant medical history other than rheumatoid arthritis treated with gold, Imuran, and steroids. The patient is developing increasing difficulty walking.

Preoperative discussion and planning with the attending physician occurred.

Another scenario

How is this scenario different from the previous two?

What options are there for teaching / learning in this case that were not available in the other cases?

Acute Care Teaching

The Challenges◦Content and Direction of teaching often cannot

be determined in advance What do I want to learn today? Learning

What did you learn today? Infrastructure for learning may not be in place if

acute care learning presents challenges the student is not ready to handle.

Learning may be inappropriately repetitive when the learner is repeatedly exposed to scenarios that may be mastered in one or two exposures.

Acute Care Teaching

The Challenges◦ Much of acute care learning has been based solely on

“Learning by Doing.” Pure discovery model of learning – ASSUMPTION:

students will develop appropriate rules and understandings to guide future practice.

Mayer RE. Should there be a three-strikes rule against pure discovery learning? The case for guided methods of instruction. Am Psychol 2004; 59: 14-19. ◦Discovery learning is ineffective and inefficient. ◦Does not guarantee students will come in contact with

needed learning opportunities◦Does not guarantee that students will learn the rules to

appropriately guide future practice.

Acute Care Teaching

The Challenges◦Teaching and patient care must occur

simultaneously. No teaching of this skill.

◦Many excellent clinicians cannot teach when their clinical skills are taxed.

◦Many excellent teachers cannot apply their clinical skills at the same time as teaching.

◦Learning depends on learner not teacher.◦Quality, quantity, and content of learning

variable from learner to learner.

Acute Care Teaching

The Challenges◦Teaching adds stress to an already stressful

situation. Burn-out is common. The challenged learner exaggerated negative

feelings in the teacher The “challenged” teacher is prone to negative

behavior.

Acute Care Teaching

The Benefits◦ IMPACT, IMPACT, IMPACT

The impact of acute care medicine will often fix concepts in the learner’s memory better than in any other learning environment.◦Example: Failed traditional intubation hypoxemia

subsequent application of difficult airway algorithm resulting in safe, successful intubation of the trachea.

◦ Impact is a two-edged sword for multiple reasons, however. Can firmly fixate WRONG concepts and approaches which

just happen to work in one instance. Can completely overwhelm the learning and render

useful integration of the experience impossible.

Acute Care Teaching

The Benefits◦To the teacher, acute care is rarely boring and

presents both patient care challenges and educational challenges simultaneously. Patients presenting with the same problems

commonly behave differently. Learners faced with the same problem rarely learn

the same way.

Where do the scales tip?

Based on what is presented:◦Many challenges◦Few benefits – and some of the benefits are

actually “veiled” challenges.◦Many who are charged with teaching in the

acute care setting: Struggle with production pressure – academic

medical centers clearly must be competitive with private institutions.

Education takes 2nd place – and a distant second at that.

◦Many educators have turned to simulation to address most of these challenges.

Acute Care Teaching

How can we as educators improve the effectiveness of teaching in the acute care setting and overcome many of the challenges presented?

Acute Care Teaching

Acute Care Teaching

Know your learner

Knowing the learner is key to actively taking control of learning in the acute care setting.

May be difficult when there are many housestaff and medical students

Depends on an effective, objective evaluation system that is readily accessible to the faculty.◦May cause bias in the approach to the student.

Know your learner

Dreyfus Model of Skills Acquisition:Novice

◦A novice is all about following rules – specific rules, without context or modification.

◦Don’t need to “think” just “do”. ◦A rule is absolute, and must never be violated.◦Get experience following directions and doing

the new skill. All the learner is responsible for is following directions.

◦Learning environment is safe.◦Learn the rules and correction applied when

rules are not followed.

Know your learner

Evaluation is based entirely on being able to spit out / apply rules-based responses.

Example◦BLS

Know your learner

Advanced Beginner◦ Still rules based, but rules start to have situational

conditions. In one situation you use one rule, in other situations

you use another. The advanced beginner needs to be able to identify the

limited need to selectively apply different rules. This is still rules-based, but has a few decision points. ◦Learner must be able to follow branch points and

appropriate apply different rules.◦This stage of competence could collapse into a larger

Novice category without appropriate mentoring.◦Learner is now responsible for some recognition. Perception is important.

◦Example - ACLS

Know your learner

Competent◦Realization that learner’s skill or domain is

more complex than a series of rules and branches. Learner sees patterns and principles (or aspects)

rather than a discrete set of rules – rules become “rules of thumb”.

Learner is led more by his/her experiences and active decision-making than by strictly following rules. What is developed now are guidelines that help direct competent individuals at a higher level.

Know your learner

Competent◦ Learner is now accountable for decisions as he / she is

not following the strict rules and context of the previous stages. If a decision made doesn’t produce the desired result, the learner takes responsibility.

◦ Critical tipping point for most people – and why most people never really become “competent” in most things they learn. Learner must decide to just “follow the rules” or spend the

time to get fully involved with and take responsibility. This is a KEY Branch point that should guide

all teaching in the acute care setting◦ Evaluation to determine whether someone is

competent must therefore have input from the learner.

Know your learner

Proficient◦ At this point the learner’s understanding of the skill or

domain has become more of an instinct or intuition. Learner will do and try things because it just seems like

the right thing to do (and will most often be right). Perceives systems rather than discrete set of different

parts. Recognizes that there are often multiple competing

solutions to a specific problem and has a “gut feeling” about which is correct.

Quickly knows “what” needs to be done and then formulates how to do it.

Define the Stages of Competency

Difficult◦Much disagreement about what constitutes

necessary skills for each level.Important to develop consensus in your

program.Defining the Stages carefully will allow

each teacher to direct teaching appropriately.

Must be aware of the competency of each learner.

Acute Care Teaching

Using the cases presented earlier, let’s teach the novice, advanced beginner, and competent learner.

The examples involve anesthesiology trainees, but should be readily applicable to other acute care situations – use your imagination to apply these concepts to your situations.

54 yo female is brought to the operating room emergently for craniotomy and removal of intracranial mass. She was seen in clinic the previous day and admitted for surgery. On the morning of the scheduled surgery, she is found unresponsive. Intubation attempt on the floor was unsuccessful, and she is brought emergently to the operating room for treatment of developing herniation syndrome.

The Issues

Patient’s airway must be secured rapidly because of non-responsive state and elevated intracranial pressure.

Decompressive surgery must be accomplished very quickly to avoid transtentorial herniation.

Teaching the Novice

What does the novice “want” to do?◦EVERYTHING!!

What “should” the novice do?◦APPLY THE RULES!

What are the rules? These must be very clear to the novice.◦Securing the airway rapidly avoiding

hypoxemia or hypercapnia is essential in the patient with herniation syndrome.

◦The patient must be prepared as quickly as possible for surgery.

Teaching the Novice

Teaching the advanced beginner

Advanced beginner now has some technical skills and some experience evaluating patients

54 yo female is brought to the operating room emergently for craniotomy and removal of intracranial mass. She was seen in clinic the previous day and admitted for surgery. Pertinent medical history includes significant coronary artery disease treated with 4 drug-eluting stents. The patient takes 1 baby aspirin and Plavix daily. On the morning of the scheduled surgery, she is found unresponsive. Intubation attempt on the floor was unsuccessful, and she is brought emergently to the operating room for treatment of developing herniation syndrome.

Teaching the Advanced Beginner

What does the advanced beginner “want” to do?◦ EVERYTHING!!

What “should” the advanced beginner do?◦ APPLY THE RULES!◦ Use acquired skills. These may include airway management and line

placement assisted as needed. What are the rules? These also must be very clear to the

advanced beginner as well as the situational judgment component.◦ Securing the airway rapidly avoiding hypoxemia or hypercapnia is

essential in the patient with herniation syndrome.◦ Significant coronary artery disease needs to be investigated and

appropriately evaluated / treated prior to surgery.◦ Coagulation status will likely be a problem – needs evaluation and

planning.◦ Rapidly preparing the patient for surgery and starting surgery

overrides other considerations.


The advanced beginner is taught that surgical considerations (e.g. in this case need for speed) may override assessment of the patient’s exercise tolerance, frequency of angina, stability of angina, coagulation status (aspirin and plavix) which would occur prior to elective surgery.


Teaching the Competent

Learner sees patterns and principles (or aspects) rather than a discrete set of rules – rules become “rules of thumb”.

Learner is led more by her/his experience and active decision-making than by strictly following rules.

Learner is now accountable for decisions as she / he is not following the strict rules and context of the previous stages. If a decision made doesn’t produce the desired result, the learner takes responsibility.

Another scenario49yo female with severe rheumatoid arthritis presents for elective anterior cervical corpectomy followed by posterior cervical fusion. The patient has a history of well-controlled hypertension treated with lisinopril. No other significant medical history other than rheumatoid arthritis treated with gold, Imuran, and steroids. The patient is developing increasing difficulty walking.



Resident physician has reviewed pathophysiology of RA and recognizes the instability of the cervical spine.

He also recognizes the significance of spinal cord compression and need to avoid significant hypotension.

He also recognizes the interaction of an ACE-inhibitor with general anesthetics (significant risk of hypotension).

He develops a plan. The teacher:◦ agrees with plan.◦ would manage the patient differently, but the plan is rational

and should be fine.◦ feels plan is not a good one.

Teaching the competent

Resident decides to manage the airway with an awake, sedated intubation and awake positioning to minimize neurologic injury.

He did not recognize the patient’s emotional state and extreme anxiety about waking up paralyzed from this surgery.

The patient cannot tolerate the awake intubation.


If you were correct about his skill level (competent), then the learner should…..


The competent physician learns that evaluation of the patient’s emotional state prior to dangerous surgery may lead to significant alterations of the anesthetic plan. The competent physician feels chastened that this evaluation was not done and resulted in failure of the plan. This experience enables avoidance of the problem again. Experience teaches the competent.



Additional Tools for Teaching in the Acute Care Setting

Roberts NK et al. The Briefing, Intraoperative Teaching, Debriefing Model for Teaching in the Operating Room. J Am Coll Surg 2009; 208: 299-303

Readily applicable to other acute care settings.

Provides a framework for learning somewhat similar to the more traditional methods of learning – but works in the acute care setting.

BID Model

Guided discovery versus pure discovery. Guided discovery:

◦ Expert provides learner with preparatory information BEFORE the experience.

◦ Provides appropriate level of verbal and manual guidance during the acute care experience.

◦ Gives feedback afterward. Mayer RE. Should there be a three-strikes rule against pure

discovery learning? The case for guided methods of instruction. Am Psychol 2004; 59: 14-19. ◦ Mayer demonstrated that guided discovery learning

occurred more quickly (efficient), was more accurate, and was better retained than pure discovery learning.

BID Model

Scallon SE et al. Evaluation of the operating room as a surgical teaching venue. Can J Surg 1992; 35: 173-6.◦60 cases observed in the OR. Clinical teaching

in the OR occurred in fewer than 50% of cases! What teaching did occur tended to cover history,

physical findings, diagnosis, complications. It did not include operative planning discussions or discussions of the teaching physician’s past experiences with patients with similar problems.

BID Model

Roberts NK et al. Toward a precise and practical model of debriefing for surgical education (poster AAMC meeting 2008).◦Typical OR teaching to surgical trainees has

three defining characteristics Focused on getting through the case efficiently

and effectively Didactic teaching was mainly opportunistic –

events trigger teaching “scripts” Learning is likely to be defocused.

BID Model

The BID model requires that the learner be actively involved in creating learning objectives for acute care teaching.

Try it differently49yo female with severe rheumatoid arthritis presents for elective anterior cervical corpectomy followed by posterior cervical fusion. The patient has a history of well-controlled hypertension treated with lisinopril. No other significant medical history other than rheumatoid arthritis treated with gold, Imuran, and steroids. The patient is developing increasing difficulty walking.


BID Model

Learner’s objective: I would like to improve my airway management skills in the patient with an unstable cervical spine.

Teacher’s response: Great. Let’s start with your decision-making about the general approach to the airway. How do you decide what approach to take?

BID Model

Intraoperative teaching then focuses on options for plans B and C when A doesn’t work. In addition teaching may focus on making better choices for plan A.

Summary

Acute care teaching is commonly unfocused and highly dependent on opportunity.

These problems have led to increasing focus on simulation for teaching.

Knowing the learner and taking advantage of specific learning plans relevant to the clinical scenarios of the day (learner initiated) may greatly improve the effectiveness of acute care teaching.

Given the ACGME mandate to evaluate the core competencies AND determine ability to practice independently without supervision, acute care teaching must become more effective and focused.

Simulation can help – but simulation rarely has the same impact as acute care teaching, and our learners usually much prefer acute care teaching.

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MEDICAL TEACHING IN THE ACUTE CARE SETTING