This chapter was reproduced from the Emergency Medicine Clerkship Primer, 2008, Chapter 22, with the permission of the Editor, for ease of viewing on mobile devices.
By becoming an “active learner,” you can optimize your experience in the emergency department, thus achieving your own personal educational goals. Active learning often requires more upfront effort from the learner but, in return, the teaching can be-come more individualized. Several ways to engage in active learning that will enhance your rotation experience include the following: prepare before your rotation, solicit feedback, set your own goals, verbalize an assessment and management plan, prepare follow-up cards, maintain a “peripheral brain,” develop a question log, have a positive attitude, and exhibit professionalism.
Prepare Before Your Rotation
Before your rotation starts, spend a few weeks reading about common chief complaints encountered in the emergency department. These topics are covered in various emergency medicine textbooks and numerous educational Web sites. By spending time reviewing these topics, you can build on your fund of medical knowledge from Day 1 of your rotation. Common chief complaints you will encounter in the emergency department are shown in the box on this page.
Common Complaints in the Emergency Department
- Abdominal pain
- Altered mental status
- Back pain
- Chest pain
- Musculoskeletal injury, trauma, and wound care
- Nausea and vomiting
- Shortness of breath
Solicit Feedback From Your Supervisors
Receiving feedback about your clinical performance is crucial for medical students to reinforce behaviors or skills performed well or to high-light areas that could benefit from improvement. Feel welcome to solicit feedback on your performance from your supervisors. This can be done at the conclusion of a case presentation, after a patient encounter, or at the end of a clinical shift.
When actively soliciting feedback, ask focused questions (see the box on the next page). Focused questions make it easier for the supervisor to give you concrete feedback on a particular skill or action.
Solicit Feedback From a Nurse
Nurses are an integral part of the emergency department team. Soliciting feedback from the nurses serves two functions. First, it demonstrates that you value their opinion. Second, nurses often can provide valuable insight into your patient and staff communication skills, order writing, and basic procedural skills such as phlebotomy.
Suggestions for Soliciting Feedback
- Having seen a few of my notes, what could I do to improve my documentation?
- Do you have any suggestions how I can better focus my case presentations?
- How do you think I can improve my procedural skills?
- I would like to get better at reading ECGs, do you have any suggestions?
Set Your Own Goals
Throughout your rotation, you will be supervised by a number of different faculty members and residents. This is often the case because of the shift work scheduling that is inherent to our specialty. As a result, you will experience less continuity with your teachers compared with other clinical rotations. When you work with a new preceptor, it can be helpful to let them know about your career interests and individual goals that you have set for yourself for the rotation. This will help your supervisor focus his or her teaching and possibly direct certain cases or procedural opportunities your way to further enhance your experience. Individual goals might include the following:
- Procedures (e.g., suturing skills, ABG sampling, or bedside ultrasonography)
- Examination skills (e.g., cardiac, neurologic, or musculoskeletal)
- General approach to a type of patient (trauma, septic, or seizure)
- Chart documentation
- Interpretation skills (e.g., reading orthopedic plain films or ECGs)
- Presentation skills (e.g., to supervisor or consultants or at rounds)
Verbalize an Assessment and Management Plan
One trait that often sets stellar students apart from others is the ability to formulate and verbalize an assessment and management plan when presenting a case to their preceptor. When presenting a case, many students can verbalize their H&PE findings. However, many students will pause after presenting the subjective and objective portions of a case as if expecting feedback, reassurance, or validation. Instead, verbalize what you think is going on with your patient, the differential diagnosis (from emergent to least emergent, sharing the likelihood of each), and your proposed management plan. Rather than functioning as just a “reporter” of information, at this stage in your training, you should be functioning as an “interpreter” of the data and a “manager” of the patient. By providing your differential diagnosis, assessment, and plan, you will be giving your supervisor greater insight into your knowledge base and thought process.
Prepare Follow-up Cards
The lack of follow-up of emergency department patients is a perceived negative aspect of emergency medicine that some medical students cite in their career decisionmaking process. To continually learn and improve, students should maintain index cards of interesting patients who are admitted to the hospital or discharged home. Checking hospital records or talking with the admitting team a few days later can lead to invaluable learning experiences. You can also talk with your supervisor about calling a patient who was discharged home to see how he or she is doing. Obtaining follow-up should be a long-term means to engage in active learning, not only during medical school but also during residency training and beyond. An added benefit of obtaining follow-up of admitted patients is that the student can now inform the supervisor of the interesting outcomes or diagnoses. This demonstrates to the supervisor that you are actively trying to learn outside of your time in the emergency department and are engaging in practice-based learning.
Maintain a “Peripheral Brain”
There are many pearls of wisdom to be learned during your emergency medicine clerkship. Writing these down on index cards or inputting them into a PDA can further solidify information retention. During your emergency medicine clerkship, add relevant bedside teaching points, lecture concepts, and publication data. This may include high-yield items such as indications for thrombolytic therapy in acute myocardial infarction or stroke, the pneumonia severity index scoring system from the PORT study, and NEXUS criteria for clinical clearance of the cervical spine. This “peripheral brain” should be continually updated throughout medical school, residency, and postresidency.
Develop a Question Log
During each shift, generate a list of questions to research some time during the rotation. Questions can be based on any aspect of patient care and can include reviewing medication information, managing a case, developing a differential diagnosis, formulating a diagnostic work-up for a particular presentation, or reviewing a procedural technique. Research the literature and read more about your patient’s disease process when you get home. While on shift, as a self-reminder, you can email yourself this list of “homework” questions. Reading about clinically relevant topics that you have encountered helps build your knowledge base.
Have a Positive Attitude
The emergency department team thrives on working cohesively as a group and is, as a whole, an enthusiastic and high-energy team. Instructors are more amenable to teaching students if they demonstrate an enthusiasm for learning, want to be in the emergency department, and are open to feedback.
This is your time to shine in the eyes of the faculty. Arrive early, work hard, and stay late. You do not want to be thought of as the student who just wants to get the shift over with. Do not spend your time surfing the Internet. You are in the emergency department to learn. Stay on top of your patients. When something happens with one of your patients, you should be the first one to know about it. If a lab result is not back in a timely fashion, call the lab to see if it has received the specimen. Dress appropriately for the emergency department: scrubs or professional attire (no tee shirts, sweatshirts, or blue jeans). Make sure your patients are well cared for at all times. Remember, you are your patient’s student doctor.
How to Be an Active Learner
- Solicit feedback.
- Set goals.
- Verbalize an assessment and management plan.
- Prepare follow-up cards.
- Maintain a peripheral brain.
- Develop a question log.
- Have a positive attitude.
- Exhibit professionalism
Students Applying to Emergency Medicine Residency Training Programs
One last tip for maximizing your emergency medicine clerkship applies primarily to those applying for an emergency medicine residency position. Because students rarely work consistently with the same faculty member, letters of recommendation for residency applications may be difficult to obtain. Often, clerkship directors will write a composite letter, summarizing the comments from various faculty members who have worked with you. If, however, you are going to request a letter from a single faculty member, it is important that you let the faculty member on shift know that you are applying to emergency medicine so he or she will pay special attention to your skills and knowledge base.
It is no secret that you will eventually be asking for a letter of recommendation from the department, and the evaluators will want to have something specific to write about. If possible, with permission, consider modifying your clinical schedule to work multiple shifts with the same faculty member. By doing so, faculty members will have the opportunity to work with you on several shifts and will be able to provide a more detailed letter of recommendation. This may or may not be possible and is often based on the number of students working clinically in the emergency department during a particular rotation.
Getting the most out of your emergency medicine clerkship revolves around maintaining a positive attitude, working diligently, and taking an ongoing and active role in learning. Applying this philosophy will serve you well during medical school, in residency training, and beyond.
- Mahadevan SV, Garmel GM. The outstanding medical student in emer-gency medicine. Acad Emerg Med. 2001;8:402–403.
- This article describes strategies for medical students to use during their emergency medicine rotation.
- Pangaro L. A new vocabulary and other innovations for improving descriptive in-training evaluations. Acad Med. 1999;74:1203–1207.
- This article provides a new evaluation approach to help faculty evaluate trainees. This approach describes the progress of trainees from “reporter” to “interpreter” to “manager” to “educator” status (RIME methodology).