Adult Learners	Application to ED teaching
Have prior learning and experience	Even the most junior doctors (e.g. interns) bring experiences with them to the ED. They may have specific experience relevant to the condition that they are treating (e.g. they saw similar patients in their undergraduate course) or it may be life experience (e.g. they had relatives with that experience). Open questioning techniques (requiring a more detailed answer from the learner as opposed to a closed question requiring a yes/no answer) can be used to promote reflection on past experiences and practices. A case study with short answer questions to facilitate this reflection could be used in a small group tutorial situation. Small group discussions can also provide opportunities for learners to draw on their own experiences and to learn from each other as well as the facilitator.

Adult Learners

Application to ED teaching

Have prior learning and experience

Even the most junior doctors (e.g. interns) bring experiences with them to the ED. They may have specific experience relevant to the condition that they are treating (e.g. they saw similar patients in their undergraduate course) or it may be life experience (e.g. they had relatives with that experience).

Open questioning techniques (requiring a more detailed answer from the learner as opposed to a closed question requiring a yes/no answer) can be used to promote reflection on past experiences and practices. A case study with short answer questions to facilitate this reflection could be used in a small group tutorial situation.

Small group discussions can also provide opportunities for learners to draw on their own experiences and to learn from each other as well as the facilitator.

Are self directed learners

At the commencement of a rotation in the ED, junior staff should be asked as part of their orientation, what it is they specifically want to get out of this rotation. This allows the identification of personal learning goals. This is relevant to new senior staff as well.

Orientation is also very important for establishing expectations of both learner and facilitator, and ground rules for how education will be carried out within the ED rotation.

Learners should also be offered a choice of learning activities. This will allow learners to choose activities which will address their individual learning objectives and which will address their specific learning requirements and styles. For example, one intern may want to watch a lumbar puncture before performing one under supervision, another may want to practise a lumbar puncture on a manikin first before performing one.

Learn most effectively when they perceive a need for learning

The ED educator needs to help learners recognise the relevance of a learning experience. This will significantly impact on their motivation to learn. Sharing of experiences eg a case example from real life, can help to establish relevancy for a learner.

Additional methods may include; documentation of ED presentations, participation in unit audit meetings or presentations of cases

Prefer problem-centred approaches ED presentations require sophisticated problem-solving techniques. The undifferentiated patient is the norm. Modelling of clinical reasoning from experienced practitioners can assist the novice to understand problem-solving approaches. Evidence suggests that the experienced practitioner does this subconsciously, however verbalisation is necessary to promote collaborative problem-solving by the less experienced. Unit case-based discussions also encourage shared problem solving. Practice self evaluation

Adults require an opportunity for “reflection-on-action”¹ or self-evaluation. Self-evaluation opportunities can be incorporated formally by:

• Use of case studies in a tutorial setting

• End of shift review of cases

• Trolley-side reflection opportunities using open questions

Require feedback Opportunities for feedback on performance should be incorporated into the ED term both formally (as part of a requirement of training eg mid and end of term feedback) and informally from supervisors or peers. Written and verbal feedback can be used. Value experiential (“hands on”) learning opportunities There are numerous opportunities for hands on experience within the ED. Educators need to involve learners in case based discussions and problem solving activities. However, procedural skills may need to be practised away from patients until competence is determined. Then practice under supervision will be appropriate.

1 Schön, D. (1983) The Reflective Practitioner. How professionals think in action, London: Temple Smith.

Learner-centred education

Many traditional medical education experiences are teacher-centred. The teacher is the expert and determines what, how, when and where much is learnt. The teacher is the active participant and the learner is the passive recipient.¹⁶ However, a more effective approach to education is the learner-centred approach. Learner-centred education refers to educational events that place the learner in the pivotal position, responsible for determining learning objectives, actively engaging in learning opportunities and participating in evaluation.¹⁷ This is more in line with adult learning principles.

So how does the ED physician become a learner-centred educationalist? The following suggestions are provided to assist:

• Orientation – to the unit, to the department, to the rotation. Junior medical staff require an orientation for a number of practical workplace reasons, such as awareness of policies and procedures, occupational health and safety, rostering, pay, etc. However, this is an important opportunity from an educational perspective. The orientation can allow exploration of the junior doctor’s learning goals and objectives, past experiences, confidence with procedural tasks and expectations of their ED rotation. The orientation allows the educational supervisor the opportunity to establish ground rules in terms of educational interactions, when feedback will be given and how education with patients will occur. The ED supervisor can acknowledge barriers to learning which are more specific to the ED environment and discuss how these will be overcome.

• Ask the resident to select a patient to present rather than dictating which patient or topic will be discussed.

• Ask residents about past experiences to assist in determining their confidence in managing certain conditions independently. Obviously, supervision will be required until this is determined first hand, but demonstrating insertion of an intravenous cannula (i.v.) to an intern who has previously inserted numerous i.vs may not be the most appropriate and you will not know unless you ask!

• Present junior medical staff with suggested topics for in-service education and ask them to prioritize.

• Ask junior medical staff to present a case to their peers. Let them determine the format they want to use and resources they require.

Junior medical staff are not a homogeneous group. They differ in how they learn, what they need to learn, and why they want to learn. By involving learners in the planning, implementation and evaluation of their learning experiences, both relevance and motivation to learn will be facilitated.

What makes a good ED teacher?

The challenges facing the emergency physician educator, including environmental, patient characteristics, administrative and production imperatives and resource availability, cannot be overstated. However, despite this, there is a consistent commitment to education by emergency physicians. What then makes a good ED teacher? Bandiera and colleagues used a qualitative research design to investigate experienced ED teachers and establish the behaviours that made them good teachers.²

Twelve strategies were identified:

1 Tailor teaching to the learner – taking time to get to know the learner was seen to increase the efficacy of the teaching and learning interaction.

2 Optimize the teacher–learner interaction – this refers to making the teaching more directed and efficient by listening to the learner and using what you know about them.

3 Tailor teaching to the situation – this relies on being adaptable to the situation and changing strategies accordingly, for example by adjusting teaching amounts, types and timing to the time of day, workload and case mix.

4 Actively involve the learner – involve the junior doctor in problem-solving, give them responsibility and some autonomy.

5 Actively seek opportunities to teach – sometimes it is necessary to seek out learners. The junior doctor may be busy with an administrative task when an interesting teaching case arrives. The teacher needs to recognize the potential for learning and bring this to the junior doctor’s attention.

6 Agree on expectations – this can be done at the orientation, when learning objectives and ground rules for interactions are established.

7 Demonstrate a good teacher attitude – this is about being an approachable supervisor/teacher.

8 Make additional teaching resources – this may involve collecting sample cardiographs, X-rays or blood gases for a resource file. It may be writing up some interesting case-generated problems for future review or development of evidence-based clinical guidelines.

9 Use teaching methods beyond patient care. With the advent of interest in clinical skills training and simulation there are opportunities to take the teaching away from the bedside on occasion. Use of standardized patients and role-plays may also be appropriate.

10 Be a role model. This is about demonstrating and practising the principles that you are trying to teach.

11 Provide and encourage feedback – adult learners require feedback for motivation and for learning.

12 Improve the environment – the competing demands within an ED environment make this difficult, but the effective teacher identifies ways in which to enhance the learning environment, for example by creating space and time in a crowded ED.

These findings are supported further in the literature with what learners want. Additional suggestions include:

• using teachable moments well

• taking the time to teach

• challenging the learner

• treating the junior doctor as a colleague.¹⁸

The factors reported by ED teachers and ED learners reflect what is required according to adult learning theory and reinforce the applicability within the ED environment.

Types of teaching in the ED

There are a number of teaching and learning strategies available for use within the ED environment. These can include spot electronic searches on active clinical problems, formal quarantined tutorials, case discussions, demonstrations of procedures or techniques, audit meetings, self-directed learning opportunities such as reading medical literature, online learning programmes, and so on. This section deals with three strategies: ‘trolley-side’ teaching, teaching procedural skills which most ED physicians are familiar with and perform regularly, and simulation, which is developing an emergent role within teaching and learning in the ED.

‘Trolley-side’ teaching

Interactions with patients at the bedside are a crucial component for learning in medicine, the traditional apprenticeship model relying on this methodology. Bedside teaching can provide an opportunity for the experienced clinician to explain clinical reasoning and role model appropriate communication, including listening, patient questioning and respect, supervising the more junior clinicians as they practise these skills, assessing the junior clinicians’ interaction with the patient and providing feedback to them.¹⁹ However, with the numerous environmental constraints within the ED there is a need to look at bedside teaching and determine how best to conduct this activity. In addition, the care of the patient remains paramount and ensuring that this is maintained and that the junior doctor–patient relationship is not undermined is an additional challenge.

The benefits of orientation have previously been mentioned in terms of adult learning principles and learner-centred instruction. However, they are crucial to establishing the expectations from both the learner and the teacher’s perspectives in regards to bedside teaching. Establishing up front how bedside teaching will be conducted, while remaining patient-centred, will enable the learner’s needs to be met. Briefing the patients beforehand and getting them involved in the teaching process enhances patient comfort and participation and may provide enjoyment. Expectations of patient-based teaching may include:

1 Number of bedside teaching opportunities per shift. The supervisor may want to ensure one bedside teaching interaction per shift, identified by either the supervisor or the learner. Alternatively, the supervisor may prefer to be less prescriptive and more opportunistic, identifying bedside opportunities as they arrive, accepting that some shifts may have none and others numerous.

2 Type of bedside teaching. This involves discussing the types of teaching and learning the supervisor is prepared to undertake, for example a procedural skill or history taking or interaction with relatives.

3 What will happen by the trolley-side? It is important to discuss what will and won’t happen by the trolley-side. For example, the history and physical examination will be done at the bedside, but discussion of clinical reasoning may occur away from the patient. This is important to consider, especially if the junior doctor is to have an ongoing professional relationship with the patient. Feedback as to the resident’s performance should also be conducted away from the patient. The supervisor should establish whether or not the resident will be asked questions at the bedside so that this is understood prior to the interaction at the bedside.

4 Outline specific teaching approaches. There are a number of models of bedside teaching that can be used. Lake and Ryan ²⁰ describe the use of set, dialogue and closure. This technique involves an introduction, outlining the objectives of the session (set), a discussion in which questioning techniques are used to elicit information from the learner and to discuss reasoning/rationales (dialogue), and a summation in which the main learning points are discussed and further learning required (closure). An alternative to this is the SNAPPS model described by Wolpaw et al.,²¹ in which the learner:

• Summarizes the case history and their findings

• Narrows the differential diagnosis usually to two or three possibilities

• Analyses the different diagnoses by comparing and contrasting them

• Probes the supervisor/teacher for opinions or any information on which they require clarification

• Plans the patient’s management

• Selects an issue for self-directed learning later on.

This model was piloted and tested within the outpatient setting. However, it has relevance and application for a number of clinical settings. It would require the experienced clinician to explain and possibly model the process in the first instance.

Procedural skill teaching

Management of patients in the ED often involves the practitioner performing procedural skills. Some of these are to assist in formulating diagnoses in the undifferentiated patient, for example performance of bedside ultrasound, others are for treatment of patient conditions, for example application of a plaster to a fracture. Ideally, in this day and age, procedural skills should be practised in a clinical skills setting prior to implementation on a ‘real’ patient.²² However, observation by a junior doctor of an experienced clinician performing a task is also valuable and can sometimes be overlooked in the busy ED department. Sometimes it is done before you realize you could have shown a junior doctor.

The educational theories relevant to teaching clinical skills are drawn from psychomotor theories. There are seven basic principles of the psychomotor domain,²³ including:

1 conceptualization – where the learner needs to understand the background knowledge element of the skill, that is the cognitive components – this involves a knowledge of why the skill should be done, when to do it, precautions and contraindications, etc.

2 visualization – where the learner needs to see the skill demonstrated to get a clear picture of what the skill looks like

3 verbalization – where the learner needs to hear the steps of the skill verbalized

4 practice – where the learner gets the chance to practise the skill

5 correction and reinforcement – where feedback is given to reinforce performance

6 skill mastery – where the learner can perform the skill independently in the learning environment

7 skill autonomy – where the learner can perform the skill independently in a variety of real life situations.

Similarly, Gagne ²⁴ describes three phases in instructional design relevant to teaching a technical skill, including a cognitive phase where the learner is developing cues from the facilitator, an associative phase where the learner is integrating the component parts and an autonomous phase where the skill has become automatic for the learner.

The issue of the relationship of the learner to the experienced clinician is further investigated within the cognitive apprenticeship model.^25,²⁶ The emphasis in this model is on the requirement that the thinking of the expert be made visible and brought to the surface for the learner. Underpinning this model is the ability of the teacher to assess/recognize the level of the learner.

Another debate in the literature is around the issue of whole skill training versus part skill training. Evidence would suggest that the part skill training method be used for the more complex skills while whole skill training be used for the relatively straightforward skills. This requires the facilitator to analyse the skills to be taught and determine the level of complexity of that specific skill. Additionally, what is the whole skill? It can be argued that procedural skills do not occur in isolation. Rather, communication skills are required along with the technical expertise, and should be taught together rather than in isolation to reflect the requirement in reality.^27,²⁸

So what do these theories mean for the ED physician wanting to assist a learner in developing a procedural skill? The important requirements are:

• Background knowledge is required – why, what, how.

• Demonstration by, or observation of an experienced clinician is an important component of learning a psychomotor skill.

• Verbalization of steps – this requires breaking the skill down into steps.

• Feedback on performance by the expert.

• Opportunities for repeated practice under supervision, to allow for feedback and self-reflection.

• Teaching the skill in context not in isolation.

A dedicated skills area within the ED is most beneficial, as this can be used in quarantined or quieter times for supervised or independent practice (once the learner is deemed relatively competent in the skill, to avoid practising incorrect technique). Highlighting the need for practice and observation for all the experienced clinicians assists in identifying these opportunities for the learner within the ED environment.

Simulation

Simulation is an emergent teaching methodology within the ED environment. In its broadest sense it refers to any situation in which the real situation is emulated. It may involve actors playing the role of patients, who are often described as standardized patients, or manikins with computer-generated physiological responses.^29,³⁰

The underpinning educational theory behind simulation comes from a number of theories, including adult learning. However, experiential learning theory is probably of most relevance. Experiential learning theory as espoused by Kolb ³¹ describes experiential learning activities as opportunities for learners to acquire and apply knowledge, skills and attitudes in an immediate and relevant setting. A four-point continuous learning cycle is described:

1 concrete experience

2 observation and reflection

3 forming abstract concepts

4 testing in new situations.

Simulation in healthcare education is clearly an example of experiential learning. It provides the learners with a relevant and realistic patient problem to manage. Following this experience, the learners are able to observe their performance and reflect, whilst exploring with a facilitator hypotheses and new concepts. They can then test this experience by repeat simulations.

There are a number of ways in which ED physicians can incorporate simulation opportunities into their teaching in ED. It may be that paper-based simulations are used to explore clinical reasoning. This involves developing case scenarios and structured questions. Role-playing, using peers or expert clinicians, can be used to practise difficult communication skills such as breaking bad news. Simple part-task trainers can be incorporated into a more complex scenario involving the practice of the skill whilst interacting with a patient. Kneebone and colleagues ²⁸ describe integrating a urinary catheter manikin with an actor to ensure that the technical and communication skills are taught concurrently.

Where higher level manikins are available, whole patient scenarios can be conducted. Teams of junior medical staff can practise rarer critical situations and explore not only technical skills but non-technical skills such as teamwork. Use of audio-visual aids to capture performance is important for providing feedback after such activities. It also allows an opportunity for reflection and peer feedback.

Not all EDs have the luxury of the highly technical simulation ‘gadgetry’, but this should not put them off using simulation as a teaching methodology. Determining the content areas appropriate for using simulation and how this fits into the overall curriculum will be important to ensure that resources are used rationally.³²

Feedback to learners

Feedback is a crucial requirement for learning, and the importance of positive feedback for learning has been well established.³³ Feedback should provide the learner with information that offers ‘insight into what he or she did as well as the consequences of his or her actions’.³⁴ It should allow the learner to know what went well and what could be improved or changed next time. Feedback is part of the formative assessment process that occurs throughout the learning period, rather than as a summative assessment that is to determine a grade or make a final judgment.

Effective feedback has a number of characteristics.^35,³⁶ It should be given in a suitable environment to allow privacy and maintain confidentiality for the learner. There should be adequate time to allow the learner and the facilitator to explore the observed behaviour or skill. There should be clear goals established at the beginning of the learning so that feedback can be related to these goals. The feedback should come from direct observation of the learner’s performance where possible.

Providing learners with feedback is a specific skill in itself and requires practise to develop. A model to assist the emergency physician to give feedback is suggested from Pendleton’s ³⁷ work as:

• Ask the learner how he or she felt.

• Ask the learner what went well and why.

• As the facilitator/teacher to say what went well and why.

• Ask the learner what could have been done better and why.

• Ask the facilitator/teacher to say what could have been done better and why.

• Ask the facilitator/teacher to summarize the strengths and up to three things to concentrate on.

Feedback, when delivered effectively, is a strong motivator to the adult learner and encourages ongoing performance review and reflection by the learner.

Conclusion

Juggling the demands of a being a busy emergency physician requires balancing clinical, administrative and teaching duties. Time is often limited and yet the rewards of being involved in teaching are obvious. Apart from personal satisfaction gained from interacting with junior colleagues, the ability to keep up to date and the opportunity to reflect on one’s own performance are enhanced. Reviewing performance as a teacher and practising education techniques to improve the effectiveness of the facilitation motivate the teacher to continue to teach and improve the satisfaction from teaching. Structuring learning experiences, considering learner needs and providing effective feedback are essential for learners in the ED environment.

Likely developments over the next 5–10 years

• Increasing numbers of medical students and junior medical staff seeking learning in the ED may lead to the need for specific emergency physician educators to orientate and supervise them in the ED.

• Expansion of scenario-based simulation and skills centres may lead to more opportunities for ED team-based interdisciplinary education.

• Increasing patient participation in decision making will necessitate more detailed consent when procedures are performed by the inexperienced.

Controversies

1 Teaching procedural skills should no longer be ‘see one, do one, teach one’ on surprised patients, although some find it difficult to break out of this mould.

2 Communication skills should be practised during a procedure, with a building of skills involving conceptualization of the skill, visualization, verbalization, practice, correction and reinforcement, with eventual skill mastery and skill autonomy.

3 Should patients be informed of the level of experience of those providing care or performing a procedure?

References

1 Lake FR. Teaching on the run tips: doctors as teachers. Medical Journal of Australia. 2004;180(8):415-416.

2 Bandiera G, Lee S, Tiberius R. Creating effective learning in today’s emergency departments: how accomplished teachers get it done. Annals of Emergency Medicine. 2005;45:253-261.

3 Santen S, Hemphill R, McDonald F, et al. Patients’ willingness to allow residents to learn to practice medical procedures. Academic Medicine. 2004;79:144-147.

4 Simons R, Imboden E, Mattel J. Patient attitudes toward medical student participation in a general internal medicine clinic. Journal of General Internal Medicine. 1995;10(5):251-254.

5 Simon S, Peters A, Christiansen C. Effect of medical student teaching on patient satisfaction in a managed care setting. Journal of General Internal Medicine. 2000;15(7):457-461.

6 Berger TJ, Ander DS, Terrell ML, et al. The impact of the demand for clinical productivity on student teaching in academic emergency departments. Academic Emergency Medicine. 2004;11:1364-1367.

7 Denninghoff KR, Moye PK. Teaching students during an emergency walk-in clinic rotation does not delay care. Academic Medicine. 1998;73:1311.

8 Atzema C, Bandiera G, Schull MJ. Emergency department crowding: the effect on resident education. Annals of Emergency Medicine. 2005;45:276-281.

9 Dent AW, Crotty B, Cuddihy H, et al. Learning opportunities for Australian prevocational hospital doctors: exposure, perceived quality and desired methods of learning. Medical Journal of Australia. 2006;184:436-440.

10 Knowles M. The adult learner: a neglected species. Houston: Gulf Publishing, 1973.

11 Cantillon P, Hutchinson L, Wood D. ABC of learning and teaching in medicine. London: British Medical Journal Publishing, 2003.

12 Knowles M. The modern practice of adult education: from pedagogy to andragogy, 2nd edn. New York: Cambridge Books, 1980.

13 Kaufman D, Mann K. Teaching and learning in medical education: How theory can inform practice. Edinburgh: Association for the Study of Medical Education, 2007.

14 Peyton J. Teaching and learning in medical practice. Great Britain: Manticore Europe, 1998.

15 Brookfield S. Understanding and facilitating adult learning. Buckingham: Open University Press, 1986.

16 Gunderman R, Williamson K, Frank M, et al. Learner-centered education. Radiology. 2003;227:15-17.

17 Weimer M. Learner centred teaching. New York: Jossey-Bass, 2002.

18 Thurger L, Bandiera G, Lee S. What do emergency medicine learners want from their teachers? A multicentre focus group analysis. Academic Emergency Medicine. 2005;12:856-861.

19 Celenza A, Rogers I. Qualitative evaluation of a formal bedside clinical teaching programme in an emergency department. Emergency Medicine Journal. 2007;23:769-773.

20 Lake F, Ryan G. Teaching on the run tips 4: Teaching with patients. Medical Journal of Australia. 2004;181:158-159.

21 Wolpaw T, Wolpaw D, Papp K. SNAPPS: a learner centred model for outpatient education. Academic Medicine. 2003;78:893-898.

22 De Young S. Teaching psychomotor skills. In: Teaching strategies for nurse educators. United Kingdom: Prentice Hall Health; 2003:201-215.

23 George J, Doto F. A simple five-step method for teaching clinical skills. Family Medicine. 2001;33:577-578.

24 Gagne R. The conditions of learning, 4th edn. New York: Holt, Rinehart & Winston, 1985.

25 Collins A, Brown J, Newman S. Cognitive apprenticeship: teaching the crafts of reading, writing and mathematics. In: Resnick L, editor. Learning and instruction: essays in honor of Robert Glaser. New Jersey: Lawrence Erlbaum; 1989:453-494.

26 Woolley N, Jarvis Y. Situated cognition and cognitive apprenticeship: a model for teaching and learning clinical skills in a technologically rich and authentic learning environment. Nurse Education Today. 2007;27:73-79.

27 Kneebone R, Kidd J, Nestel D, et al. An innovative model for teaching and learning clinical procedures. Medical Education. 2002;36:628-634.

28 Kneebone R, Nestel D, Yadollahi F, et al. Assessing procedural skills in context: exploring the feasibility of an integrated procedural performance instrument (IPPI). Medical Education. 2006;40:1105-1114.

29 Ker J, Bradley P. Simulation in medical education. Edinburgh: Association for the Study of Medical Education, 2007.

30 Good M. Patient simulation for training basic and advanced clinical skills. Medical Education. 2003;37(suppl):14-21.

31 Kolb D. Experiential learning. Englewood Cliffs. NJ: Prentice Hall, 1984.

32 Binstadt E, Walls R, White B, et al. A comprehensive medical simulation education curriculum for emergency residents. Annals of Emergency Medicine. 2007;49:495-504.

33 Kilminster S, Jolly B, van der Vleuten C. A framework for effective training for supervisors. Medical Teacher. 2002;24:385-389.

34 Ende J. Feedback in clinical medical education. American Medical Association. 1983;250:777-781.

35 Schwenk T, Whitman N. The physician as teacher. Baltimore: Williams & Wilkins, 1987.

36 Vickery A, Lake F. Teaching on the run tips 10: Giving feedback. Medical Journal of Australia. 2005;183:267-268.

37 Pendleton D, Schofield T, Tate P, et al. The consultation: an approach to teaching and learning. Oxford: Oxford University Press, 1984.

24.4 Undergraduate teaching in emergency medicine

Geoffrey Couser

ESSENTIALS

1 Medical student teaching should be considered core business of an emergency department.

2 The specialty of emergency medicine has a unique body of knowledge that can contribute much to an undergraduate curriculum.

3 To be effective, emergency physician educators need to adopt a strategic and comprehensive approach to curriculum development, delivery and assessment.

4 It is essential that goals and objectives of student education in emergency medicine be clearly defined so that a consistent and integrated curriculum is delivered.

5 The specialty will play an increasingly important role in medical student education in the next 10 years as numbers of students rapidly increase and models of healthcare continue to change.

Introduction

Emergency medicine now plays a central role in medical curricula in undergraduate and postgraduate medical schools in Australia and New Zealand. This is not unexpected, as the principles and practice of the specialty have much in common with contemporary medical education: it is problem-focused, interdisciplinary, and integrates many aspects of community-based and hospital-based clinical practice. Clinical practice easily integrates and builds upon the basic medical sciences traditionally taught early in the medical course. Much growth in academic emergency medicine has occurred in the last 10 years, with the establishment of academic departments and dedicated university positions. However, the majority of medical student teaching is performed by emergency physicians in clinical practice in public, and an increasing number of private, emergency departments (EDs).This chapter will address the issues surrounding medical student teaching at the departmental and the broader faculty level.

Overview of undergraduate medical education in Australia

It is important for emergency physicians interested in teaching medical students to be aware of recent trends and developments in medical education in Australasia. The last 15 years have seen the establishment of graduate schools of medicine and a massive reform of the traditional undergraduate curricula. The CanMEDS 2000 Project and the World Health Organization, among others, have listed the key outcomes expected of a doctor.¹ These outcomes have been adopted by many schools worldwide as a basis for reform and reorganization, and are listed in Table 24.4.1. In more detail, the Australian Medical Council has listed 40 attributes of medical graduates to guide faculties with curriculum design and subsequent accreditation.² Many schools have organized their curricula into themes, or domains, so that these outcomes can be vertically integrated, tracked and assessed throughout the course. Some schools have adopted problem-based learning as a tool to achieve these educational outcomes, with others using case-based and outcomes-based learning to place content in a clinical context.

Table 24.4.1 Essential roles and key competencies of specialist physicians – The CanMEDS criteria ¹

Medical expert

Communicator

Collaborator

Manager

Health advocate

Scholar

Professional

These changes have not been without controversy, with some critics concerned that this has been at the expense of basic science teaching and the teaching of sound clinical practice.³ Curriculum reform has occurred in parallel with significant changes in the health system, with a growth in information technology, changing patient expectations and a massive increase in medical knowledge. Models of healthcare delivery are changing, with increased pressures on public hospitals such as access block, declining numbers of inpatient beds and the increasing complexity of medical conditions. The shift to the home and community management of many conditions has altered the patient mix available for student teaching. University salaries have not kept pace with the growth in public and private medical salaries, which has contributed to a decline in numbers of academic faculty and core medical school functions shifting to specialists within the public hospital system. Despite this, there has been an increasing number of medical students and medical schools, with over 3000 graduates per year predicted to require intern posts by the middle of the next decade.⁴ It is in this changing environment that emergency medicine has established itself as a key part of any modern medical curriculum. With a growing number of medical students, emergency physicians and patients, the specialty is poised to play an even greater role in the training of future doctors. Both the need and the opportunity exist for such expansion.

The importance of medical student teaching

This is an important point to consider, as many feel that the provision of clinical care is the core business of an ED and hence may not be willing to allocate resources for teaching students. Similarly, university medical schools may not be aware of the growth of emergency medicine as a specialty and hence may not be aware of what it can offer students. However, once established, a strong academic presence can contribute to departmental morale and performance. Table 24.4.2 lists the benefits of emergency medicine teaching to students, EDs and medical schools. These points may be used to argue for an increased presence and accompanying resources within a curriculum.⁵ Resources and a formal place in the curriculum often come only after years of hard work in establishing the bona fides of emergency medicine. This may require much time and effort from a dedicated individual.

Table 24.4.2 Benefits of medical student teaching in emergency departments

Benefits to students

• Usually an enjoyable term with unparalleled pathology and clinical experience

• Integrates theoretical knowledge with the workplace

• Learns acute care resuscitation skills

• The opportunity to see patients before anyone else in the system

• Emergency medicine is the embodiment of an equitable and accessible healthcare system

Benefits to the emergency department and hospital

• Students gain a positive view of the specialty and this may influence subsequent career choice

• May improve subsequent intern performance

• Improves the overall professionalism and reputation of the department

• Teaching is a core business of a hospital and should be embraced

• May assist with recruitment and retention of staff with an interest in teaching

• Students can assist with procedures and may improve patient flow in some circumstances

Benefits to the medical school

• Allows access to a large number of patients with a broad range of clinical conditions otherwise not available for teaching

• Allows access to a large pool of medical and nursing staff otherwise not available for teaching

• Emergency medicine can teach knowledge and skills not readily taught by other disciplines, such as resuscitation, health systems and time management

Curriculum development

Medical student teaching in EDs has, until recent years, been largely a passive and opportunistic affair. Inpatient units would send groups of hapless students ‘down to “cas”’ to see if there was ‘anything interesting going on’. As such, exposure to emergency medicine was ad hoc, unstructured and highly selective, in that clinical exposure was based around what the students themselves thought was interesting and useful. With the growth of the specialty in recent years departments have been able to take a more active role in education, control student entry to the department, ensure appropriate orientation and attempt to take advantage of the rich and broad clinical experience on offer. As faculties have become aware of the learning opportunities on offer in EDs, as well as the teaching abilities of staff, emergency physicians have been able to negotiate a greater role in university affairs and integrate emergency medicine into the broader undergraduate curriculum. With this comes a responsibility for emergency physicians to understand the function of universities, and the requirements which come with running an academic term. Table 24.4.3 provides suggestions for developing a university teaching presence.

Table 24.4.3 Minimum requirements for developing student placements in emergency departments

• Nominate one person to be the term coordinator and liaison with the university

• Understand the rules and regulations which govern student placements in your hospital and at the affiliated university

• Develop a clear orientation package for students and make it clear that students will not be allowed into the department until they have received orientation

• Develop a clear curriculum statement providing a broad overview of goals and objectives for the term (see Table 24.4.4)

• Define specific learning objectives for students, e.g. ‘At the end of this placement you will be able to describe the assessment of the patient presenting with chest pain’

• Consider how students will be assessed and clearly describe this prior to the commencement of the term

• Consider who will supervise the students – for this reason it is essential to engage with all levels of staff within the department and to provide them with support, training and guidance

It is essential that once a department has decided that medical student teaching should be a part of its function then a curriculum needs to be considered. Both the Australasian College for Emergency Medicine and the American College of Emergency Physicians have produced documents with varying degrees of detail concerning this,^6,⁷ and a growing number of papers are being published providing guidance to curriculum developers.⁸^–¹⁰ Most core curriculum statements contain elements which reflect the clinical practice of emergency medicine, and an example of such a list is provided in Table 24.4.4. This provides a framework around which specific topics can then be taught. The teaching programme will need to be modified and adapted accordingly depending upon the expertise of and time available to specialists within the department.

Table 24.4.4 Suggested core curriculum topics in emergency medicine

An often overlooked but essential component to consider is that of the ‘hidden curriculum’. This is less well understood, but relates to what students learn by being exposed to the practice of medicine. It can cover aspects such as professionalism, ethics and physician behaviour. As the vanguard of a fair and equitable health system, emergency medicine can teach important attitudes to the next generation of doctors.

Different ways to teach emergency medicine

Once teaching content is decided upon, then it is worth spending time considering which format is the best way to deliver the material. Until recently, undergraduate emergency medicine has largely been taught in the workplace and no other teaching options have existed. However, with the growth of the specialty and the increased need for teachers, the specialty has been able to attract resources and play a greater role in all years of the medical course in some universities. Therefore, depending upon available time and resources, different formats of teaching should be considered for different situations. For example, resuscitation skills may be best taught using simulation and practice, once basic concepts have been covered by lectures or online modules.

In all formats, teachers should consider the basic principles of adult learning and teach accordingly. When delivering material, teachers should remember that adults learn best when the topic is meaningful, linked to experience and pitched at the correct level, and the students are motivated, have clear goals, are actively involved, receive regular feedback and have time for reflection.¹¹ Utilizing a range of methods means that material can be delivered in a meaningful way and optimal learning conditions can be achieved. It is essential that the physician taking responsibility for undergraduate teaching within a department takes a leadership role and provides ongoing training and support for both junior and senior colleagues in effective teaching methods.

Whichever teaching method is chosen, evaluation of the process by the participants is an essential part of the quality improvement cycle. This may be in the form of a brief questionnaire or standardized form, such as a part of a student evaluation of teaching and learning (SETL) programme. Evaluation helps ensure teaching is meeting students’ learning needs, identifies areas where teaching can be improved, and provides feedback and encouragement for teachers.¹² Documenting evaluations can form part of a teaching portfolio, which can be used in academic job applications as tangible evidence of a clinician’s commitment to and proficiency in teaching. Importantly, from a student’s perspective, being asked to evaluate a teaching session and then seeing the comments acted upon provides a strong sense that their participation is valued and as a result may improve the learning process overall.

Some basic pedagogical theory should be considered when choosing and applying methods of teaching: many educators refer to Miller’s triangle of clinical competence ¹³ and the concept of a spiral curriculum¹⁴ when designing curricula. Figure 24.4.1 is a schematic representation of how emergency medicine as a subject could ideally progress through a 5-year course utilizing these theories of curriculum design. Most departments will only be in a position to offer clinical exposure in the final years of the course, but much progress has been made across the region in penetrating all years. The following delivery methods could be used in this framework to deliver a comprehensive and effective emergency medicine curriculum.

Fig. 24.4.1 A suggested overview of the progression of emergency medicine in an integrated 5-year curriculum.

Lecture based

Lectures can be delivered at any stage of the medical course, but to maximize their effectiveness they need to be developed in an integrated fashion and linked to other components of the course. Emergency medicine can be used effectively as a vehicle to illustrate basic science concepts to junior medical students.¹⁵ Case-based learning is a popular method to use in this setting, as learning objectives and concepts can be illustrated in a ‘real-world’ setting. For example, rather than delivering a lecture on ischaemic heart disease, an emergency medicine lecture would be entitled ‘I’ve got pain in my chest’ and the lecturer would engage with students to create a genuine feel for this common emergency presentation. The content would need to be modified depending upon the seniority of students, for example junior medical students would use the case as a reference point to illustrate anatomy and physiology, whilst more senior students may use the same scenario to learn about clinical decision making and evidence-based medicine.

Lectures need not be didactic and overloaded with content – they can be an efficient means of transmitting information to large groups. In general, lectures should add value. There is little point simply repeating content from a text, as students can gather information themselves in their own time. In this sense, prospective lecturers should remind themselves of the qualities of an effective educator: expertise in the subject area, enthusiasm for the topic and the task, and capacity to engage the learners.¹⁶ By utilizing these qualities, educators can turn a lecture into a valuable learning experience.

Tutorials and small-group learning

Tutorials are small group sessions, with opportunities for interaction and reflection. This model of teaching is well-suited to emergency medicine, as individual cases and experiences can be presented and discussed in a comfortable environment. The learners can lead the discussion and take the topics into new and previously unconsidered areas. Nevertheless, providing a structure to the tutorial will help ensure that the time is spent wisely and learning opportunities are maximized. These are usually easily implemented in a department, as they can be integrated with other departmental activities and can run independently of any broader curriculum. This is often the only way that the specialty can deliver its core curriculum in a school without a formal emergency medicine presence.

Web-based

This is growing in popularity as schools rely more on information technology to deliver content, but few emergency physicians have had the time or the access to moderate and upload content and hence maximize the opportunities this mode of teaching can present. At a basic level, bulletin boards, web logs (blogs) and email are useful ways to maintain regular communication with students and to distribute journal articles and policies, and orientation manuals can be posted online.¹⁷

However, with faster internet conditions and a new generation of students increasingly familiar with technology, new opportunities are appearing: virtual worlds and the operation of a ‘Second Life’ ED (http://secondlife.com) may become useful tools for education.

Work-based

This is the original method of medical student education: at the bedside of the patient. Medicine has been taught this way for thousands of years, and reinforces the point that medical students are essentially apprentices in a trade. Emergency medicine excels in this area because of the broad range of experiences on offer in a department. Challenges exist, as not all students will be exposed to the same conditions during a rotation. Achieving a uniform experience for students is difficult,¹⁸ and so workbooks have been developed to guide students through their rotation, alerting them to the broad range of undifferentiated conditions which regularly present. Utilizing junior staff can be helpful in the education of medical students: pairing a student with a resident or registrar allows the students to see how a doctor works, and it involves junior doctors in teaching at an early stage of their careers. It helps with rostering, in that students can be allocated to medical staff with a pre-existing timetable. Medical schools offer clinical academic titles to doctors involved in teaching, and all staff should be encouraged to apply for such titles.

Teaching by the bedside is an important activity and opportunities abound for clinical teaching. Clinicians being aware of a broader curriculum can be of assistance, as it can be difficult to think on the spot when confronted with a ‘teachable moment.’ Some guidelines exist to maximize the value of bedside teaching and the well-developed principles of ‘set, dialogue and closure’¹⁹ are explained and listed with an example in Table 24.4.5.

Table 24.4.5 Planning a teaching episode

Concept	Components	Example in practice
Set	Roles – trainers, learners, patients Objectives – what are they going to learn? Linkages – to other learning events Environment – seating, lighting, distractions

Gather the students in a quieter part of the department where distractions will be minimal, and make it clear what the session is about: ‘I’d like to talk about ways we assess headaches in the emergency department’ Dialogue

Questions – use often

Understanding

Eyes – two-way contact

Stimulation – make it interesting

Timing – finish on time

Check what the students know about the topic, and ask an open question to start, e.g. ‘What are the worrying signs of a headache?’ Encourage discussion, use first names in the discussion Closure

Review – ask for questions, check understanding

Eyes – contact with learner

Summary

Termination

Summarize the discussion, check that the students have understood it, terminate with a comment (e.g. ‘Thunderclap headaches are a feature of subarachnoid haemorrhage, and later we’ll talk about the role of a lumbar puncture’)

You have just assessed a young male with a severe headache. You realize that this is an ideal teaching opportunity for the medical students present.

Simulation

Simulation is a growing field which has been embraced by emergency physicians and the Australasian College for Emergency Medicine. A large knowledge base has been developed, and as such it will not be discussed at length here. However, the main barrier to utilizing simulation for undergraduate teaching is cost and the available time of emergency physicians. Fortunately, universities are starting to recognize the value of this method of teaching and opportunities are being created.

Clinical skills teaching

Emergency medicine has long had a reputation amongst students for ‘being the place where you get to do useful things’. Whilst proponents of the specialty in universities are keen to promote the other features of emergency medicine in an educational setting, this statement is still undoubtedly true. Many skills can be taught in the ED or a skills laboratory, and emergency physicians are ideally placed to teach them. Whether it is junior medical students examining patients for the first time or learning practical skills such as venesection and suturing, emergency physicians have a lot to offer in this regard. Like most teaching, there are useful techniques that can be employed to improve learning.²⁰

Assessment principles

Assessment should be considered as a tool which drives learning, and should be developed in parallel with the curriculum rather than considered at the end. It is essential that the appropriate form of assessment be matched to the subject matter. Assessment tools selected should be valid, reliable and practical, and have an appropriate impact on student learning.²¹ For instance, when assessing competency in advanced cardiac life support, it would be more valid to use a practical-based assessment process such as an observed objective structured clinical examination (OSCE) rather than a written examination. Figure 24.4.2 provides a graphical representation of matching assessment processes to skills and knowledge. A large number of assessment methods exist and educators should possess at least a basic understanding of their use and application. It is essential to understand that all universities have rules which govern the assessment of students, and failure to strictly adhere to these rules exposes a department to academic appeals and complaints of unfairness and bias.

Fig. 24.4.2 The learning assessment pyramid.²¹ OSCE, objective structured clinical examination.

Likely developments over the next 5–10 years

Emergency medicine will continue to play a significant role in medical student education and is poised to make greater contributions in coming years. This will occur both by design and necessity: as described, the increase in student numbers is coinciding with the growth and maturation of the specialty in Australia and New Zealand. Emergency medicine will continue to expand throughout medical curricula rather than being the practice-based pre-intern term it currently occupies in the latter years of most medical courses. A recent shift in focus in the tertiary sector towards teaching ability rather than purely a research output will create opportunities for emergency medicine to gain a stronger foothold in universities. Teaching programmes will expand to deliver material, not just unique to emergency medicine, but the specialty will be opportunistic and be called upon to teach where significant gaps exist at an undergraduate level. In many universities there is no academic presence in surgical subspecialties such as ear, nose and throat, ophthalmology, and orthopaedics. It will be left to emergency physicians to teach students the basics of these specialties, just as we currently manage many common acute conditions in these areas without specialist input.

It is now time for the specialty to move beyond just the provision of training in acute medicine as envisaged by the landmark Macy report in 1994.²² The specialty will develop its own body of knowledge and curriculum in important but under-represented areas of medical education such as clinical decision-making, medical error and health systems design and management. Emergency physicians need to take a leading role in the development and delivery of curricula in these areas. There is much to suggest that the increased sub-specialization of medicine has led to fragmentation of the health system, with the subsequent inability of society to achieve coherent and sustainable outcomes in health policy. Emergency medicine as a specialty has the opportunity to take a leading role in training doctors and other health professionals capable of understanding the key challenges facing the health system in the 21st century.

Controversies

1 There is much debate about the effectiveness of current methods of medical student training, but emergency medicine as an academic specialty is adaptable and capable of working within any number of curricular styles.

2 EDs will struggle to handle increased numbers of students without additional dedicated support from universities and may need to consider withholding access until appropriate sustainable resources can be provided.

3 Emergency physicians still have much to do in creating a coordinated undergraduate curriculum that is vertically integrated with prevocational and specialist training in the specialty.

4 It is inevitable that more academic departments of emergency medicine will be created but first the specialty must clearly define its core curriculum and its role in the health education system

5 Changes in the health workforce with a re-definition of the role of the doctor and an evolution of the other health professions will necessitate that the specialty apply its knowledge base to broader health science training, including that of evolving positions such as physician assistants.

References

1 The Royal College of Physicians and Surgeons of Canada. Can MEDS 2000 Project skills for the new millennium. Ontario: Report of the societal needs working group, 1996.

2 Australian Medical Council. Goals and objectives of basic medical education. http://www.amc.org.au/GoalsBasicMed.asp. (accessed 13 August 2007)

3 Van der Weyden M. Medical education and hard science. Medical Journal Association. 2003;180(12):601.

4 Crotty B, Brown T. An urgent challenge: new training opportunities for junior medical officers. Medical Journal Association. 2007;186(7):S25-S27.

5 Russi CS, Hamilton GC. A case for emergency medicine in the undergraduate medical school curriculum. Academic Emergency Medicine. 2005;12(10):994-998.

6 Australasian College for Emergency Medicine. Policy on the emergency medicine component of the undergraduate medical curriculum. http://www.acem.org.au. (accessed 13 August 2007)

7 ACEP Academic Affairs Committee. Guidelines for Undergraduate education in emergency medicine. http://www.acep.org/webportal/PracticeResources/issues/acad/prepemundergradguideeduc.htm. (accessed 9 August 2007)

8 Task Force on National Fourth Year Medical Student Emergency Medicine Curriculum Guide. Report of the Task Force on National Fourth Year Medical Student Emergency Medicine Curriculum Guide. Annals of Emergency Medicine. 2006;47:E1-E7.

9 Pacella CB. Advanced opportunities for student education in emergency medicine. Academic Emergency Medicine. 2004;11(10):9-12.

10 Coates WC, Gendy MS, Gill AM. Emergency medicine subinternship: Can we provide a standard clinical experience? Academic Emergency Medicine. 2003;10:1138-1141.

11 Lake F, Ryan G. Teaching on the run tips 2: educational guides for teaching in a clinical setting. Medical Journal Association. 2004;180(10):527-528.

12 Morrison J. ABC of learning and teaching in medicine: evaluation. British Medical Journal. 2003;326:385-387.

13 Miller GE. The assessment of clinical skills/competence/performance. Academic Medical Journal. 1990;65:563-567.

14 Harden RM, Stamper N. What is a spiral curriculum? Medical Teacher. 1999;21:141-143.

15 Walls J, Couser GA, Gennat H, et al. Clinical cases in emergency medicine: a physiological approach. Sydney: McGraw-Hill, 2006.

16 Arnold R. The theory and principles of psychodynamic pedagogy. Forum of Education. 49(2), 1994.

17 McKimm J, Jollie C, Cantillon P. ABC of learning and teaching: web based learning. British Medical Journal. 2003;326:870-873.

18 Coates WC, Gendy MS, Gill AM. Emergency medicine subinternship: can we provide a standard clinical experience? Academic Emergency Medicine. 2003;10:1138-1141.

19 Lake F, Ryan G. Teaching on the run tips 3: planning a teaching episode. Medical Journal Association. 2004;180(12):643-644.

20 Lake F, Hamdorf J. Teaching on the run tips 5: Teaching a skill. Medical Journal Association. 2004;181(6):327-328.

21 Shumway JM, Harden RM. AMEE Guide No. 25: The assessment of learning outcomes for the competent and reflective physician. Medical Teacher. 2003;6(25):569-584.

22 Josiah MacyJr. The role of emergency medicine in the future of American medical care. Annals of Emergency Medicine. 1995;25:230-233. Foundation

24.5 Postgraduate emergency medicine teaching and simulation

Victoria Brazil

ESSENTIALS

1 Postgraduate emergency medicine teaching traditionally has followed an apprenticeship model.

2 This model is being challenged by workforce trends and innovations in medical education.

3 Learning technology, including medical simulation, has the potential to make training more effective and efficient, but currently lacks rigorous evaluation.

Introduction

Emergency departments (EDs) provide many learning opportunities for postgraduate doctors. The varied clinical case mix, procedural nature of practice and flexibility of work attract doctors to vocational training. Postgraduate emergency medicine teaching has traditionally followed an apprenticeship model, with the underlying assumption that patient care experience and opportunistic bedside teaching from clinical experts provided the knowledge, skills and attitudes requisite for emergency medicine practice. This model is currently being challenged by contemporary workforce issues, changed service provision models, improved technology and advances in medical education.

Current training pathways in postgraduate emergency medicine

In those countries where emergency medicine has been recognized as a specialty, with a model and scope of practice, formalization of postgraduate training has followed. In Australasia, Canada, South Africa and the UK, specialist colleges have been responsible for accreditation and standards for emergency medicine training.¹^–³ The American Board of Emergency Medicine (ABEM)⁴ in the USA fulfils a similar role. In other jurisdictions, tertiary institutions (Malaysia) or professional societies (many European countries) provide the educational framework for vocational training.

These formal training programmes provide a structured educational experience for vocational trainees. The length of training varies from 3 to 7 years, generally uses graduated patient care responsibility as the primary learning experience, and requires a range of rotations through emergency medicine and other clinical experience such as anaesthesia, intensive care, psychiatry and paediatrics.⁵ Most programmes involve both in-training assessment and formal examinations during the period of training. Many programmes also require logbooks or portfolios of clinical experience.

The regulatory frameworks continue to evolve. The UK has recently reconfigured postgraduate training in the ‘Modernising Medical Careers’ initiative,^6,⁷ resulting in the NHS taking on roles previously held by specialist colleges. In Australia there are calls for shorter ‘non-specialist’ training programmes for career emergency doctors, particularly to address rural and regional workforce challenges.⁸ In developing countries, there is variable progress toward formal postgraduate training.

The inconsistency in programme requirements, together with traditional protectionist policies in some countries, has meant that there exists minimal mutual recognition of emergency medicine qualifications internationally.

Challenges for contemporary emergency medicine education

There are growing pressures on postgraduate medical education in emergency medicine (Table 24.5.1). The impact of these trends can be observed in emergency medicine curricula, teaching and learning processes, learning technology, assessment and accreditation, and faculty development.

Table 24.5.1 Pressures leading to change in delivery of postgraduate education in emergency medicine

• An international medical workforce shortage,⁹ increasing pressure to produce qualified practitioners in a shorter time, and with a more ‘work ready’ focus

• Changing workforce roles, with challenges to traditional emergency physician scope of practice from nurse practitioners, physician assistants and other extended role practitioners

• Increased service provision expectations of clinicians, as a result of rising healthcare costs throughout the developed world, decreasing the time available for teaching and learning in the clinical arena

• The patient safety agenda and societal expectations mean that ‘learning by doing’ and practising skills on patients is less acceptable

• The expectations of GenerationY, in which trainees expect flexibility in training delivery and a practice model that provides work–life balance

• Learners’ changing expectations of teaching processes, as a result of exposure to innovations in undergraduate medical education

Curricular trends

There has been a global trend in postgraduate medical education toward ‘outcomes based’ curricular models. This has resulted in a shift from curricula defining a knowledge base to be acquired, to ‘outcome’ concepts of roles and competencies for specialist physicians.

The CanMEDS model, developed in Canada and adopted by the Australasian College for Emergency Medicine (ACEM), requires training be oriented toward preparing emergency physicians (and other specialist trainees) for their roles as medical expert, communicator, collaborator, manager, health advocate, scholar and professional.¹⁰

The Accreditation Council for Graduate Medical Education (ACGME) in the USA defines six core competencies required of specialist trainees: medical knowledge, patient care, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. These general competencies have been translated into specific emergency medicine curricular objectives.¹¹

Integral to this curricular trend has been increased recognition of communication and professional domains of practice. Concepts of teamwork, leadership, patient safety, quality improvement, and communication with patients and peers have been specified in recent curricula.¹² New domains of learning, such as medical informatics and evidence based medicine, have become explicit curricular content.

Innovation in teaching and learning

Bedside teaching, or ‘teaching on the floor’, remains the foundation of most ED trainees’ educational experience. It provides the opportunity to reflect upon clinical and professional aspects of emergency medicine practice in an integrated manner. It should be facilitated by a graduated increase in patient care responsibility throughout the training programme. However, the quality of this experience is dependent on the availability and skill of clinical supervisors, and on time constraints in busy EDs. In this environment, clinical teaching can remain ‘education by random opportunity’, and learners may not be exposed to rare but important conditions or procedures.

Didactic elements of specialist training vary in format but most programmes or institutions provide a structured element of training that consists of trainee- and supervisor-delivered presentations, procedural skill sessions, journal clubs and lectures by visitors or outside specialists. Following the trend towards competency-based curricular models, there is a general trend toward these teaching activities becoming more standardized and structured.

Reflective practice is an important learning skill for postgraduate trainees. Clinical audit ¹³ and portfolios¹⁴ can facilitate this, and most training programmes also encourage participation in critical incident review, trauma review meetings and morbidity and mortality rounds.

Recent innovations in training incorporate interprofessional and team-based learning, following recognition of the team approach required for effective clinical practice. This includes multidisciplinary formal educational sessions and team-based simulation experiences.¹⁵ Such activities are focused on communication and professional domains of competence, and provide trainees with a broader perspective on systems-based practice in emergency medicine.

Learning technology

Technology provides many potential applications for teaching and learning in emergency medicine, but frequently is adopted without critical review of educational value.

Content-based technological adjuncts such as textbooks on CD ROMs have made published references more available and more easily updated. Electronic formats also allow replication of high quality images and videos. These adjuncts do not fundamentally change the way trainees learn.

Web-based content for emergency medicine has exploded over recent years. A Google search for ‘emergency medicine’ reveals more than 64 million web pages. As a result, the emergency medicine trainee requires effective information retrieval and quality analysis skills. Recent literature suggests that public access search engines such as Google Scholar have now replaced traditional Medline database searches as the preferred method of information retrieval by trainees.¹⁶

Procedural skill training has been enhanced by the use of manikins, part trainers, and virtual reality systems,¹⁷ reducing the use of animal labs and cadavers. There is evidence that this approach is more effective than traditional procedural skills training on patients.¹⁸ Video-based instruction of procedures allows demonstration of procedural performance under ideal conditions, with rehearsed teaching scripts. Many of these are now available on personal digital assistants for ‘just-in-time learning’ for trainees. More comprehensive e-learning packages for procedural skills training use a problem-based approach, informed by known complications and high risk situations, and often complemented by hands-on sessions.¹⁹

Clinical decision support software provides educational opportunities in conjunction with solutions to clinical problems. Many of these programmes have extensive resource materials embedded that can be utilized in clinical practice or for primarily educational purposes.

The internet has also provided opportunities for the formation of virtual learning communities in emergency medicine. Informal discussion boards and weblogs foster collaborative networking and debate. Formal training activities can also be conducted via asynchronous learning networks,²⁰ and specialized software platforms can enhance interactivity and promote user-generated content for more active e-learning experiences.²¹

Videoconferencing and tele-education have sought to answer the challenges of distance in emergency medicine education.²² This technology has been successfully employed in the continuing medical education (CME) arena,²³ but improvements in technology and bandwidth potentially provide greater access to interactive educational activities at all levels of emergency medicine training. It may help to relieve the teaching workload in smaller or more remote EDs.

Simulation-based learning for emergency medicine

Medical simulation encompasses any kind of simulated patient interaction, manikin or virtual-reality-based procedural skill performance, or simulated complex emergency medicine scenario. It involves technology as simple as standardized human patients with a role play script, and as complex as high fidelity simulators designed to provide realistic tactile, auditory and visual stimuli. The varied dimensions of simulation and its wide application to professional practice offer potential solutions to many healthcare educational challenges.²⁴

The critical issue for simulation-based learning is an understanding of the educational objectives. These may range from knowledge acquisition, procedural skill proficiency, applied physiology and pharmacology, to complex teamwork skills and behaviours inherent in crisis resource management. The educational objective should then determine the nature of the equipment used, scenario design, the level of fidelity required, and the approach to debriefing.

Simulators, equipment and fidelity

Manikin technology continues to improve. The most technologically complex full body simulators currently cost more than $A400 000. They operate via detailed physiological modelling software, and can manifest pulses, breathing, blinking and vocalization, together with an ability to alter lung mechanics and compliance, and cardiovascular parameters. Less complex simulators can manifest many of these same features without the strict adherence to physiological modelling, but with the benefit of lower cost and increased portability.

Manufacturers have classified manikins as high or low fidelity based on their technological complexity. However, the fidelity of the simulation experience as perceived by the learner is far more complex. The authenticity of the scenario presented, including clinical, professional and communication challenges, the realism of the team composition and the physical environment all appear to be more important to both the learners’ perception of fidelity and the learning outcomes achieved.^25,²⁶

Combining simple ‘part trainers’ with standardized patients has been successfully used to integrate a procedural skill with communication performance, for instance an actor wearing a synthetic skin pad with a laceration and responding to a junior doctor suturing the wound.

Teamwork and communication skills training using medical simulation

Crisis resource management (CRM) training in emergency medicine using human patient simulation ²⁷ draws on parallels between acute patient care and the aviation and military industries, where it has been recognized that human factors are crucial to team performance.

A typical scenario might involve a team of medical and nursing participants managing a man with chest pain, who is accompanied by his wife in the ED, and who then develops a life-threatening arrhythmia. Participants need to identify and manage clinical issues, while engaging in the communication, teamwork and leadership activities inherent in real clinical practice. The scenario is then followed by video-assisted, expert debrief to reflect upon individual and team performance. This experiential learning approach enables cross-domain training in which cognitive, procedural and affective domains of practice are authentically integrated. The interprofessional nature of the learning experience provides a unique opportunity for increased understanding of the role of other healthcare disciplines.

Educational benefits

Simulation enables ‘efficient’ learning through standardized exposure to clinical challenges which may be infrequent in clinical practice. It allows practice and failure in a safe environment, without risk to patients.

Advanced manikin and audiovisual technology, together with logistic expertise, mean that these learning experiences can be provided in the practitioner’s own ED. The use of the authentic work environment allows very high levels of fidelity to be achieved, as the team uses its own equipment and clinical processes. The other key advantage of this approach is that the usual work team can engage in learning together, without the cost and logistical barriers of travelling to a synthetic environment. Provision of the simulation-based experience and group debriefing via videoconferencing and remote control of equipment is at the boundary of present technological capacity.

In addition to their role in learning, human patient simulators can be used for competency assessment, which is made reliable by standardized challenges. However, it is important that assessment activities are clearly distinguished from those whose objective is learning, as key differences in simulation performance are observed.

This reproducibility also provides opportunities to study the effect of fatigue or expertise level on emergency physician or trainee performance, and for testing new medical equipment or clinical systems.

Limitations

There are limitations to simulation-based training. There are significant costs in equipment and trained personnel to run programs. Critical care situations, especially cardiac and airway emergencies, can be simulated with a high degree of fidelity, but many other emergency medicine clinical challenges are not suitable. Negative training is a recognized risk. Allowing the participants to not wear gloves or lead aprons, or simulating overly positive clinical responses to medical interventions, can allow poor behaviour patterns to develop, or train learners to have unrealistic expectations in the real clinical environment.

Training for providers

Educators using simulation-based modalities require proficiency in technological issues, experiential learning principles and small group process. Training for providers of simulation-based emergency medicine education is varied. Short courses exist at many simulation centres, and most providers run their own ‘in-house’ quality assurance process to ensure a standardized approach to scenario design, delivery and group debriefing. However, there is a lack of agreed standards in this area.

Evidence for simulation-based learning

Evidence for clinical practice improvement is currently lacking, despite intuitive appeal.²⁸ There are methodological challenges in the reliable measurement of teamwork and communication performance, and attribution issues involved in any demonstration of patient outcome improvement. Professional associations in the field are working towards international consensus on learning objectives, methodology and evaluation.

Assessment and performance appraisal

Trainee assessment formats in formal postgraduate emergency medicine training programmes are diverse. These formats have usually been determined by national training and accreditation bodies (see Chapter 27.5). There is considerable variation in the domains of performance formally assessed, the definition of ‘professional competence’ required and in the standardization of assessment processes undertaken.

In-training assessment by clinical supervisors is a core element in most programmes, but this may be provided by one designated supervisor of training or many clinical supervisors in a group-based assessment. Literature suggests that in-training assessment is a valid tool (i.e. measures the right thing),²⁹ but the potentially subjective nature of supervisor assessments continues to raise questions as to reliability.

Most programmes also have formal examination components, generally developed and administered externally by the national training body. A variety of formats exist, including multiple-choice questions, written tests, structured interviews and clinical examination vivas.

Workplace-based assessment is becoming more prevalent, with use of tools such as clinical simulations, portfolios, standardized patients and multisource ‘360 degree feedback’ assessment that involves assessment by patients, peers, nursing staff and others.³⁰ Patient care quality outcomes have been suggested as an assessment tool.³¹ These formats encourage the trend toward specific assessment of communication and professional competence, which mirror the shift in curricular content.

Faculty development in emergency medicine

Many emergency physicians are enthusiastic clinical teachers. However, there is now recognition that these clinician educators require specific preparation for their teaching role. Specific training for educators in emergency medicine is variable, including Masters level courses, short workshops,³² and institution-based group professional development activities. These courses typically cover topics such as curriculum development, teaching and learning processes, and assessment and feedback skills.

Programmes are more formally developed in the USA, where a number of teaching fellowships exist in emergency medicine and the Society for Academic Emergency Medicine (SAEM) has published a Faculty Development Handbook.³³ These initiatives have been reinforced by the emergence of ‘clinician educator tracks’ in academic institutions to provide an academic career structure for clinical teachers.

Non-vocational teaching in emergency medicine

Pre-vocational education

In Australasia, the UK and other countries where prevocational doctors exist, the emergency medicine term has been recognized for learning acute care skills, management of the undifferentiated patient, and professional skills such as teamwork and communication. These competencies and domains of learning have been formalized recently in consensus statements such as the Australian Junior Doctor Curriculum Framework.³⁴

Continuing medical education

There is a societal expectation in developed countries that physicians maintain their skills and competence to manage patients in their speciality. This concept has led to certification processes that require participation in learning activities after specialist qualification has been achieved. The extent and complexity of these systems vary, but mostly require periodic assimilation of a portfolio of attendance at conferences and workshops, together with demonstration of participation in teaching, quality assurance activities, research or other special interests. Some jurisdictions require update examinations.

The provision of CME is a significantly more deregulated market than vocational training. Government health departments, hospitals, private companies and tertiary institutions are all active in providing CME activities.

The effectiveness of current CME offerings, as measured by changes in physician behaviour, appears lacking,³⁵ raising questions about the design and educational value of many of these courses. However, it is recognized that many CME activities also provide a political and social function.

Controversies and future directions

1 Workforce issues will create pressure to shorten and standardize vocational training, including that in emergency medicine, around the world. The Australian and UK governments in particular have been proactive in reviewing postgraduate training models to address workforce challenges. This may result in a significantly more deregulated training environment in which tertiary institutions and private providers play a greater role.

2 Adoption of advances in educational methodology should continue to make teaching and learning processes more efficient, effective and outcome orientated. However, this process depends upon financial support, models for which vary between countries.

3 Societal expectations will likely require increased transparency and reliability in assessment methods.

4 Technology and web-based modalities have an enormous potential to facilitate collaboration, distance learning, and to compensate for the inefficiencies inherent in clinical exposure, but require critical analysis of educational benefit.

References

1 Steiner IP. Emergency medicine practice and training in Canada. Canadian Medical Association Journal. 2003;168(12):1549-1550.

2 Australasian College for Emergency Medicine. http://www.acem.org.au. Online. (accessed 5 August 2007)

3 College of Emergency Medicine South Africa (CMSA). http://www.collegemedsa.ac.za/view_college.asp?. Online. Type=Link and CollegeID=55 (accessed August 2007)

4 American Board of Emergency Medicine. http://www.abem.org/public/. Online. (accessed 5 August 2007)

5 Taylor DM, Jelinek GA. A comparison of Australasian and United States emergency medicine training programs. Academic Emergency Medicine. 1999;6(4):324-330.

6 How is medical training changing? Modernising medical careers. Online. Available: http://www.mmc.nhs.uk/download/What%20is%20changing%20at%20MMC.pdf (accessed 9 August 2007)