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Components of a Teaching Team

2020; Accreditation Council for Graduate Medical Education; Volume: 12; Issue: 3 Linguagem: Inglês

10.4300/jgme-d-19-00744.1

1949-8349

Lindsay Ripley,

Innovations in Medical Education

The medical students speak timidly, using phrases that avoid commitment, like “maybe we should consider . . .” They search the room when putting forth an idea they have generated, looking for signs of approval, quick to retract a statement if their seeking eyes reach frowns. They refer to the notes they clutch, culminations of hours of work. Creating these documents would have been second nature for others in the room, but it is foreign to them. It represents a new way of thinking.While others are talking, the intern clacks away on her keyboard. Unless she is the one presenting, she pays no attention to the events in the room. She is like a racehorse with blinders on—she can only reach the end in the most efficient manner if she shuts everything out and pushes through. Each minute not put toward completing her tasks is a minute added to when she can eat, when she can pee, when she can go home, when she can sleep.The intern is here to learn, but newly acquired doctorhood brings incredible responsibility, forcing her to focus on handling urgent medical situations and mastering the computer system. Education takes a backseat to patient care. She does not wax poetic about the physiology of a nephron, as the students might. Survival mode does not allow her that luxury.The senior resident watches and listens intermittently. He is the man on the ground and the nominal leader. As such, he is torn in several directions and is distracted, responsible for the team and the overall care of every patient. Like a proud parent at a school play, he mouths along with the medical students as they present, reciting much-practiced lines. If they miss an important component on the physical exam, he points to it on his own body to jog their memories.However, when a team member misspeaks, the senior resident is quick to jump in and explain that what they are saying is not reflective of his thought process. He feels a need to justify his clinical decision-making to the attending. Presentations are like a game of telephone that goes from the senior to the intern, and then ends with the students. You never know what might get lost in translation and emerge unrecognizable on the other side.At the top of this artificial pyramid is El Jefe, the attending, or in my case La Jefa. I just finished my first 2-week stint as a teaching attending. What were my responsibilities? I struggled to answer that question. Leading up to the first day, I listened to podcasts, read a few articles on medical teaching, and polled my physician friends about practices they had most liked in their attendings. Many suggestions were thrown out, with some treated not as suggestions but as mandates—if you don't do this, you're not a good teaching attending. I grew increasingly nervous, desperate not to seem like a fraud. Imposter syndrome had its grips on me again.The entire team hit the ground running. In addition to fulfilling the requirements for supervision and performing didactic teaching, I did my best to impart information that was gleaned from clinical experience and focused on methods and practicality. Even more so, I tried to push everybody to develop their clinical reasoning. It is on rounds, rather than the dry erase board, where this kind of education, unique to medical training, happens.The meat of rounds involves the students and interns telling the rest of the team about each patient: the history, the evidence, the assessment, and the plan. Often, the senior resident and the attending team up, challenging the others to look both backward at what they have claimed, to elucidate their understanding of what is going on, and forward to what they have not said to provide a more detailed plan of action. Understandably, all but the most precocious learners have to be nudged to provide this information. Integrating different types of data to make a diagnosis, and using that diagnosis to formulate a logical plan, takes practice.I asked what made them decide that a patient had a certain illness, why they wanted to enact their proposed plan, if changes in certain variables would alter their convictions. At times I went so far as to play devil's advocate. And, of course, I drilled them with an experienced clinician's favorite question: “How would that change management?” Not infrequently, the tables turned—the alliance between the senior and me dissolved, and he found himself in the hot seat. Perhaps “lukewarm” is more accurate—I wanted to question thought processes, but not in an environment that was so anxiety producing as to counteract learning.For the whole 2 weeks, I saw myself in each level of trainee. Six years ago, I was the third-year medical student who struggled to understand what I was supposed to say and do, while being desperate to impress for good evaluations. Five years ago, I was the fourth-year medical student trying to prepare for intern year, but whose toes were repeatedly stepped on by the actual interns, leaving me feeling incredibly redundant.Four years ago, I was the new intern whose pager would not stop going off, overwhelmed by the volume of patients and fighting to simply keep my head above water. At home trying to fall asleep at night, auditory hallucinations of my pager's wail would leave me wide awake. Three years ago, I was the green senior resident, suddenly thrust from a following into a leading role. After surviving my first 30-hour call as that senior resident, I went to the bathroom and cried. We had admitted 10 patients in a 14-hour period, and I was guilt-ridden about not having done everything perfectly.Then I somehow found myself as the attending. When I walked in each morning, plopped down at the table and waited to be presented to, the team lined up to do so. When I told the students to prepare teaching, they came up with diagrams and PowerPoints. When I gave feedback to the trainees, they took it in stride and made changes. The whole process was a demonstration in adaptation, how each of us managed to fill the shoes we found upon our feet.As I said goodbye to the team on the last day, I referenced this being my first time attending on a teaching team. One of the medical students did a double take. “Wait, what? This was your first time?” He seemed in disbelief. Not because I had done such a great job in his eyes, but because he was so entrenched in his own level of training, in all the new things that were being required of him, he had forgotten that others might also be navigating new situations. He could barely fathom what lay ahead. I, on the other hand, contained all of their experiences within me, plus a new one of my own.