Don’t Be a Gym Teacher: The Value of Teaching Medical Students in the ED

by Bob Stuntz in ,

Did you listen to Joseph Cruz's guest posts on his top 10 momentum breakers?  If not, shame on you. Go listen to Part 1 and Part 2.  Go ahead, we'll wait...

Did you hear how he discussed medical students in the context of breaking momentum?  Joseph of course discusses some strategies in there to get medical students to work with you and be engaged.  Well, a few listeners stood up for our med students.  One of them was one of my current chief residents, and soon to be ultrasound fellows, Mark Gonzales, DO, MPH.  So Mark decided to write the following piece.  I agree wholeheartedly with Mark, and love working with medical students.  And, I think it is crucial to learn how to be a good teacher as a resident, even if you're not planning on being an academic physician (look out for some upcoming related content on iTeachEM...).  Read on to learn how you can do better by your students.  

- Bob Stuntz, MD

Those that can’t do, teach, and those that can’t teach…teach gym.”

– Jack Black, School of Rock

Comical, and hopefully inaccurate, this line from the movie School of Rock points directly at one of the saddest stereotypes about education in general:  that people become teachers because they’re unable to do the work in their chosen field.  Whether there’s any truth to this or not, this statement has no role when it comes to teaching emergency medicine.  In our world, a quality teacher simply cannot be an inept clinician.  And this responsibility goes for us as residents as much as it does for our attendings.  Medical students require quality teaching from us much like we require adequate guidance from our attendings.

I heard someone once say, “I can only be expected to be as good as my attending.”  There’s at least a partial truth to this.  In turn, the same goes for the guy in the short white coat that showed up to work your shift with you.  He is somewhat of a reflection of you by the end of the day, depending on how valuable you were to him.  If you complain that he just follows you around or neglect him because he’s not going into EM or abandon him because his 7-minute presentation about a sprained ankle frustrated you, you’re not doing him any favors.

To me, it is a privilege just to be around medical students, let alone be a part of their education.  And in EM, we almost exclusively have 4th year medical students – ones who have been through at least a year of clinical rotations, which makes teaching them that much easier.  By the time they’ve gotten to you, they’ve picked a specialty that they’re hopefully excited about, they’re anxiously navigating the match process, they’re traveling to interviews, they can make more sense of the patients they see than they could a year ago, and they generally have a pretty good understanding of their role in the clinical setting.   Do you remember your 4th year of med school?

Whether they’re going into EM or not, they have a lot to gain from you, and probably more than you realize.  Our specialty applies to every other specialty and all doctors need knowledge of what to do in an emergency if they’re the only one around.  Sure, a budding pathologist may not be all that interested in her EM rotation at first but you’ll never find someone more excited to make sense out of a CBC differential.  So meet her halfway and do whatever you can to involve her interests with as many patients as possible, so called “learner-centered education1.”  When she’s reviewing slides in the lab one day and you helped her understand how debilitating a sickle cell crisis can be or what it’s like to tell someone you found an apple core lesion on their CT scan, she’ll gain an appreciation for the big picture.  It’s easier to draw interest out of them than you may think.

We’re also the only specialty with a board certified attending sitting next to us during every shift.  Teaching opportunities are abounding in a busy ED and the answers from an expert are always at the ready whether you know what to tell them or not.  

Have you ever worked a shift with a medical student when there aren’t enough “real” emergencies?  Play the “what if” game.  “What if” this weakness patient was 7 months old and liked to suck on bottles of honey?  What would you consider if this first time mother who brought her crying, snotty-nosed kid in at 3am brought in a child who was inconsolable but otherwise well?  You can do this same sort of thing with sick versus not sick.  For example, you can do a FAST exam on a minor/stable trauma patient and show them what to look for if the patient was hypotensive.  Or take that same patient and explain a clinical decision tool like NEXUS or Canadian C-spine.  Or even just use this to introduce them to the NNT.

Some other ideas and considerations:

  • You can always go into the room with them and let them run the show, stepping in only if they really need you.
  • There’s always a pile of EKGs lying around somewhere.  Same goes with the PACS list for reviewing CXRs and head CTs.
  • Want to cover the nuts and bolts of a given topic?  ALiEM has you covered with Michelle Lin’s Paucis Verbis Cards, which you can easily load on your smartphone for free.
  • Take them on a “flow tour” through the ED – from triage through checkout.  They’ll gain an appreciation for patient flow and develop a basic concept of the bigger picture.
  • Show them different parts of your shop – give a detailed tour through the trauma bay or the airway cart or the suture cart.  You might even discover something there yourself.
  • Go into an empty exam room and just start giving them a case where they have to figure out how to use a piece of equipment (transcutaneous pacing is a good one).
  • Suggest a blog or podcast.  This list is a good start, but of course don’t forget to mention EMRes.
  • EM is a case-based specialty.  They should know and read this book.
  • Set them up for presenting to the attending the way you know the attending will want.  You’ll both look good and you’ll get along better for it.
  • Set them up for their intern year.  Have them do discharge instructions, have them figure out what specific x-ray views they want, see how they do with picking up two patients at a time if you feel like they’re ready for it.
  • Are they a little long-winded with presentations?  Break the case down for them into illness scripts so they have an idea of what’s important (i.e., 37yoF, recent 10 hour road trip, smoker, takes OCPs, here with chest pain and tachycardia).
  • Is feedback awkward for you?  Just do the sandwich thing – a positive, a point for improvement, then another positive (i.e., “Your documentation is thorough and your presentations are concise and right on point.  You could probably improve by following up on patients a little more timely and letting me know results before I see them, which will make you that much more impressive.  This shouldn’t be difficult given your level of enthusiasm and how patient-centered you seem to be.)

Fortunately medical students can be valuable to you as well.  This is an opportunity for you to recognize your own gaps and broaden your own knowledge base.  You’ll start asking yourself questions and leading yourself to more answers.  This only makes you a better clinician.  Try not to just view them as an impediment to your efficiency or your free pass out of rectal exams for the day.  Utilize the capabilities they have to make you more efficient.  You can always see a couple patients while they’re seeing one and get a good start on your note while they present to you.  Or you can pop into the room where they’re seeing a patient and have them do a bedside presentation after you finish up in another room.  Again, these are 4th year students – give them a little more room to do things and a little push of their comfort level so they’re more ready for life as an intern in a few months.  

Finally, some people like giving them rules.  I have only two rules for medical students: 1) never hesitate to find me if something seems wrong (abnormal vitals, looks sick, acute changes, concerning mechanism of injury, etc.) and 2) let me know if you want to see another patient.  That way they’re more comfortable saying they’re uncomfortable and I can make sure they’re not walking into a bad situation.  Set them up for success and recognize their value.  View it as a symbiotic relationship between the two of you.  Don’t be the proverbial gym teacher.

  1. Guth, Todd A.  Resident as Educator:  A guidebook written by residents for residents.  EMRA.  2013.
  2. Joshi, Nikita.  What makes a good clinical educator?  Academic Life in Emergency Medicine (ALiEM).  1 May 2014.

Mark Gonzales, DO, MPH is a chief resident in Emergency Medicine at WellSpan York Hospital.  He is soon to start his Ultrasound fellowship with us as well.  His interests include student education and critical care.  Incidentally, he looks like Jim Furyk.