Article review: Teaching when time is limited

A 2008 British Medical Journal article focused on practical tips and approaches to teaching in busy environments. This is especially relevant to those of us in Emergency Medicine. We are balancing trying to take care of patients, teach eager learners, and troubleshoot logistical hurdles while trying to find 30 seconds to eat dinner or have a bathroom break! I wonder how many emergency physicians have hydronephrosis at any given time on a shift... Someone should do a study.

Basically, bedside teaching can be extremely high-yield to the learner and can be done concisely. The question is how and when. The general framework is comprised of 3 steps:

Identify the learner needs.
Teach rapidly.
Provide feedback.

Identify the learner needs. When lecturing in a large-group setting, you need to know your audience. Similarly with bedside teaching, you need to know the learner's knowledge base. At the beginning of my shift, my trick is to ask the learner what (s)he wants to learn or work that day. I then have an invested learner and know what areas to focus on.

Teach rapidly. There are several models for teaching rapidly, but the one I find most useful in the ED is the "one-minute preceptor" model. This works especially well after the learner presents a new patient to you:

1. Ask the learner what (s)he thinks is going on with the patient. Avoid presenting your own assessment too early.
2. Ask the learner why (s)he thinks that and solicit for alternative explanations.
3. Teach a short general principle. (eg. 10% of patients with kidney stones don't have microscopic hematuria.)
4. Provide positive feedback on something done correctly.
5. Provide 1 concrete constructive tip for improvement. (eg. Next time, remember to perform an abdominal exam in patients with flank pain to check for a pulsatile mass.)

Other models are presented, such as the Aunt Minnie model, SNAPPS model, "activated" demonstrations, and case presentations at the bedside. I find the one-minute preceptor works best for me.

Provide feedback. This is crucial in teaching. It can be subtle to the learner, so I preface with "Just a little feedback...". For example: "Just a little feedback, your presentation on this renal colic patient was really well done and, although unlikely, I'd just consider AAA in your exam and differential diagnosis in the future."

Reference:
Irby DM, Wilkerson LA. Teaching when time is limited. BMJ 2008; 336(7640): 384-7.