This week's How I Educate post features Dr. Graham Snyder, the Associate Program Director at the University of North Carolina and Director of Education for WakeMed Health and Hospitals. Dr. Snyder spends approximately 90% of his shifts with learners which include emergency medicine residents, off-service residents, and medical students. He describes his practice environment as a Level 1 trauma center that sees 125,000 patients annually. Below he shares with us his approach to teaching learners on shift.
Name 3 words that describe a teaching shift with you.
Practically Academic, Comradery, Rejuvenating
What delivery methods do use when teaching on shift?
YouTube, just-in-time sim task-training, observation and feedback of the resident teaching the student.
What learning theory best describes your approach to teaching?
Cognitive learning
What is one thing (if nothing else) that you hope to instill in those you teach?
Love and an appreciation of the honor of caring for patients in their time of need.
How do you balance your flow with on-shift teaching? Does this come at the expense of your documentation?
Yes. I hire a scribe to offset time for patient discussions.
What is your method for reviewing learners' notes and how do you provide feedback on documentation?
On-shift. By asking them socratically how different parties, consultants, PMD's, lawyers, and the patients themselves would interpret their documentation in the event that their diagnosis is correct...or if it was completely wrong.
Do you feel departmental flow and metrics adversely affect teaching? What is your approach to excelling at both?
It's a fine balance. Much like showing compassion and patient counseling, teaching is a corner that could be cut but I choose not to. I also preferentially pick up patients myself that are low yield so I do not need to spend time listening to presentations where I anticipate little teaching opportunity.
It can be difficult to sit back and let senior learners struggle what is your approach to not taking over prematurely?
As a life-long learner and a simulation lab director, I am continually developing my airway and procedural skills in general. I focus particularly on managing learners who are having challenges in completing procedures and this allows me to continue teaching, even when they are struggling while avoiding putting patients at risk.
Do you start a teaching shift with certain objectives or develop them as a shift unfolds?
If the residency leadership team has identified a weakness during our monthly reviews, I make that weakness the goal of the shift. Otherwise, I try to huddle with the resident at the start of the shift to see what they have self-identified as a learning goal.
Do you typically see patients before or after they are presented to you?
After unless I "discover" an interesting patient of my own that I intended to see alone but is just so fascinating that I send the resident in redundantly.
How do you boost morale amongst learners on shift?
I like to both say the words and physically, "take a moment" and point out the countless great wins we have every day: recognition of subtle EKG changes, transforming a terrified patient into a calm one, early recognition and resuscitation of a deadly disease, and force them to not overlook the victories, that can so easily get overshadowed by the frustrations.
How do you provide learners feedback?
On shift, after shift, written and verbal.
Are there any resources you use regularly with learners to educate during a shift?
Up to Date, EM-RAP, and YouTube.
What are your three favorite topics to teach during a shift?
Difficult airways, excited delirium, and ultrasound of the hypotensive patient.
Who are three other educators you'd like to answer these questions?
Jerry Hoffman and Gary Greenwald
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