Teaching Trainees at Different Levels in the ED

In Education & Quality Improvement by Nadim Lalani

Like many institutions, we have a mix of EM resident learners rotating through our departments. Expectations and competencies of junior learner differ greatly from that of a senior learner. For Example:

  • PGY 1 – Focus on clinical skills e.g. Xray reading and procedures
  • PGY2-4 – Focus on more challenging patient encounters e.g. medical and procedural management of the septic patient
  • PGY 5 –  Focus on managerial roles e.g. taking referrals from family doctors

At our recent Faculty Development Workshop my brilliant colleague – Dr Rob Woods gave an engaging presentation on teaching senior learners in the ED. He subsequently facilitated an impromptu crowd-sourcing of the participants. The result was the derivation of an easy-to-apply rubric for expectations for trainees at different levels in the ED. We hope you find it useful.

Expectations for Trainees at Different Levels working in the ED

Table of equivalent trainee levels from different residency programs

BASIC CLINICAL TRAINEEJUNIOR RESDIENTSENIOR RESIDENT
EXPECTATIONSExposure to the breadth of EM patients & complaints, procedural experienceSee as many critically ill patients as possible, with support & supervision, on-shift follow-up and disposition of own patientsCarry trauma pager, manage critically ill patients, handle surges in patient volume, review lab reports + call patients, take handover
PATIENT PRESENTATIONSComplete history & physical exam, explanation of clenical reasoning, rationale for DDx and diagnostic and treatment planAbbreviated H&P, key pertinente negatives essential, management plan to disposition at first encounterAbbreviated H&P with likely diagnosis and management plan
CLINICAL REASONINGDDx for COMMON chief complaintsDDx for MOST chief complaintsDDx for ALL chief complaints
REVIEWING PATIENTSAfter every patient, unless very straightforward, confirm H&P at bedside for MOST patientsAfter a few patients, unless complex/uncertain, confirm H&P at bedside for SELECT casesAt the point of disposition, batched (3-5 at a time), unless complex/uncertain, confirm H&P for SELECT cases
GOAL NUMBER OF PATIENTS PER SHIFT8/shift (1 patient/hour)12/shift (1.5 patients/hour)16/shift (2 patients/hour)
LEVEL OF SUPERVISION FOR CRITICALLY ILL PATIENTS & PROCEDURESClose supervision or assist/observe if little prior exposureVariable depending on level of comfort/experience of residentMinimal supervision unless resident uncomfortable
CONSULTATIONSListen in on consultation requests by attending, request consultation with supervisor presentRequest consultations after reviewing case with supervisor, supervisor may or may not be presentManage outside consultations to the ER, call consultatns without prior review with supervisor if comfortable
SUPERVISING ADDITIONAL TRAINEES (students, PGY1s)Sporadic teaching of cases or procedures or interpretive skills, depending on comfort level of traineeTag team supervision between resident and attending OR resident supervises trainee with reduced patient loadSupervise trainee with a full patient load on some shifts, at the discretion of the resident OR tag team supervision
TIPS FOR SUPERVISORSExplore clinical reasoning, give feedback on both effective and ineffective clinical reasoning strategiesExplore clinical reasoning in select cases, share experience around professional issues (sleep, exercise, nutrition, time management, finances)Push limits of knowledge: change details of cases to ensure depth of knowledge on every topic, teach around transition to practice skills (billing, professional expectations, CME)

Adapted from Rob Woods, University of Saskatchewan, 2013

This post was copyedited by Dat Nguyen-Dinh (@dat_nd) and reviewed by Rob Carey (@_RobCarey)

Nadim Lalani

Nadim is an emergency physician at the South Health Campus in Calgary, Alberta. He is passionate about online learning and recently made a transition into human performance coaching. He is currently working on introducing the coaching model into medical education.