Friday, August 12, 2011

How to Teach

In our orientation to becoming senior residents, we were talking about how to teach. It's common for a lot of residents to feel like teaching is a burden -- teaching less experienced residents and medical students is essentially an additional job and our primary job is pretty much all-consuming. Therefore, I wanted to share a couple of tricks, especially for new interns, about what I've learned about teaching in the last year (especially teaching medical students)

1. Probably the biggest point about teaching is that you DON'T need to be an expert to teach. Lots of interns still feel very inexperienced and diffident. It's normal to feel threatened by teaching. It's normal to feel scared about what will happen if a medical student asks you a question and you don't know how to answer. There's two prongs to addressing these fears:
A) As an intern, you have really learned a lot in the last year/year and a half of training that you have compared to a medical student. Think back to when you were a third year, just starting rotations. Everything was new. Even if you don't know a lot about a topic, what you have to say is valuable to a medical student
B) It's totally okay to be honest about your limitations. If a medical student asks me a question I don't know the answer to, I usually encourage them to look it up and let me know. Everyone learns by looking things up and that's a really healthy habit to get into. I don't think of it as me being an inferior teacher by resorting to having the med student look it up (or looking it up with them), I think of it as me teaching them how to learn.

2. Time. Time is the perennial enemy of the resident. The secret is that teaching doesn't need to take a lot of time -- if you're clever about it, you can even net time from teaching.
A) Make your limitations clear. If I don't have a lot of time to teach, I make it really clear how much time I do have by saying things like: "let's talk about asthma for five minutes" or "here's the five things that are really important to know about Kawasaki disease." This makes the discussion feel complete, rather than rushed. If there are questions I can't answer due to time, I treat that limitation the same way I treat my knowledge limitations -- encouraging the student to seek some answers on their own and regroup with me later.
B) Remember how much you learn by doing. People feel guilty making medical students do work. That's a really, really silly attitude. Most medical students realize that the currency in which they get paid is teaching and the currency with which they pay is by doing work. Even with that transaction aside, medical students are not just there to learn the academic side of medicine; they are there to learn the practical side of medicine. Have a ton of orders to write that's keeping you from teaching? Awesome! Medical students need to learn how to write orders. They also need to learn how to examine patients, talk to nurses, write prescriptions, call outside labs to check on results, call consults and the million other day to day things that make intern's lives hectic. I'll be honest -- it usually does take me more time to teach the medical student how to do these things than to do everything myself, but it doesn't take THAT much more time and I don't feel guilty for ignoring my student.

3. "But I don't know WHAT to teach!" or "I don't know HOW to teach!" It's unfortunate, but we're never really taught how to teach well. Not as medical students and not as residents. But it's not that different from anything else you teach yourself how to do: you learn it by doing it over and over, watching what mistakes you make and trying new things until you get it right. For me, a lot of how I learned to ad lib teach was by creating a couple short teaching talks that I could give and giving those over and over until I felt confident. I learned how the would go, solicited feedback on them from the med students and perfected them. If I'm stressed out or intimidated, I still go back to them. It works best if they're things that are common, so that they're likely to be relevant to one of your patients, likely to be something you know well and likely to be something the student will use again.
For peds, I think the newborn exam is perfect. It's fast, easy to teach, easy to teach while you're getting work done (like admitting a newborn), something all pediatric residents know well and something that's usually totally new to students.

4. Teaching repays you. Besides being fun, making you feel like you've contributed to the next generation of doctors and helping you recruit med student minions to help get your work done, I think the biggest benefit of teaching is how much you learn by doing it. Medical students ask questions I never would have thought of and by having them look it up for me (or looking it up with them), I've learned things I never would have on my own. But even more importantly, by spending my time thinking about how to boil down topics to a few essential points to make them quick and easy to teach, it really helps me remember things.

Wednesday, August 10, 2011

More Stuff I Learned

The emergency department (and life in general) has kept me really busy lately, but here's some stuff I learned recently:
1. Syphilis can be painful, despite medical school teaching that it isn't (luckily, I didn't learn this from personal experience!) Chancroid and lymphogranuloma venerum are the two leading differentials for painful genital ulcers, but both are unusual in the United States.
2. Appendicitis has a largely heritable component. Courtney asked me in conversation why some people get appendicitis and others don't. Lit review shows that about 50% of the variability is explained by genetic factors. Who knew?
3. Although MRSA is not a major player in causing otitis, it should be covered when treating mastoiditis

In other news, I found out that I'd been knitting in the round WRONG for the last 10 years. Apparently, you hold the needles close to you and the cables away from you!

Monday, August 8, 2011

How to talk to teens

I had a really frustrating experience in the ED the other day.

I needed a urine specimen from a teenager. Everything had been ordered and I was busy dealing with an actual emergency (it does happen sometimes!) when the nurse came up to me and told me that the patient was refusing to provide a urine specimen and she needed me to talk to the patient.

So I went in to the room and said "I heard you had some questions about the urine specimen. What questions can I answer for you?" The teenager refused to even make eye contact with me. The mother said "She doesn't want to pee in a cup."

"Okay..." I responded, a little confused for how the mom became the spokesperson for this decision. I addressed the teenager again "can you tell me why not?"

She shrugged, but neither her nor her mother proffered an answer. I was a little frustrated, but it also seemed like no one had tried the common sense response so far, so I decided to go for it. "I think that you probably think that it's gross to pee in a cup. To be honest, I know it's weird and it feels strange. Unfortunately, I need for you to do it so that I can make sure you're healthy, so not providing a urine specimen isn't a choice right now. The choices are that you can pee in a bed pan, you can pee directly into a cup or you can pee in a hat (a thing you place on the toilet to catch urine.) If you don't like any of those options, we can use a bladder catheter, which is a tube that we put into your bladder through your urethra. Those are the only choices I can offer you right now. Do you have any questions?"

She now made eye contact. I held my gaze steady. I was pretty willing to be the adult in this circumstance. She shook her head. "OK. Do you have a preference?" She shook her head again. "OK, I'll have the nurse come in and show you the hat and the bed pan and you can choose."

She peed in a bed pan.

The demographic in the emergency department is always a little different. A lot of times we have parents who just don't know how to tell kids that certain things aren't options. Certainly, not all parents are this way (and in the particular case that this is based on the parent was a great parent, who was just at the end of her rope for reasons that weren't relevant to the story.) I was pretty impressed by how easily I reached consensus on what was going to happen. Sometimes, it just takes firmness and explaining what is and is not up for discussion.