Teaching procedures in the emergency department (ED) offers many unique advantages and challenges. There are many opportunities to perform procedures, as initial patient assessment, evaluation, and management often occur in the ED. The diverse patient population that presents to the ED may require many different types of procedures, and the bedside presence of an attending and a resident creates many hands-on teaching moments.

However, barriers to teaching in the ED exist as well. Patient education should never interfere with patient safety. Clinical and administrative demands may also decrease the time available for teaching. The unpredictable workload requires flexibility and readiness to teach. The abilities and training of residents vary greatly as well, and the limited exposure to any one individual may make it harder to develop a sense of the learner’s needs.

Teaching is a skill in itself, and as with any skill, it requires practice and refinement. The purpose of this chapter is to present a structured, systematic approach to teaching procedures that is based on principles of adult learning and psychomotor skill learning as well as to review the literature on different teaching methods.

In the 1970s, Malcolm Knowles described characteristics of adult learners that seem especially applicable to skills teaching (1). It is important to incorporate an adult learner’s own experiences and self-assessed needs into a teaching session (1). For example, a few simple questions about a resident’s level and kind of training and the number of times he or she has performed a specific procedure can give the teacher a sense of the resident’s abilities and needs. In addition, adult learners want to learn practical, immediately relevant information through hands-on application, which makes the emergency department an excellent environment for teaching (1). Adult learners favor teaching that focuses on the process rather than rote memorization (1). For instance, describing a method for suture selection is more helpful than just giving the student the correct suture. The bedside presence of teacher and learner offers an excellent opportunity to give feedback, a crucial part of adult learning (2). In a survey of “successful” emergency medicine teachers, respondents identified teaching strategies that echo Knowles’ adult learning principles (3). Additionally, they described good teachers as approachable, eager, prepared to teach, and respectful of the learner (3).

“See one, do one, teach one.” Though the numbers may be grossly underestimated, this often-repeated method of teaching medical procedures contains some of the important concepts in psychomotor skill education, namely, observation, practice, and supervision. Three phases of psychomotor learning have been described (4). During the cognitive phase, the student intellectually analyzes the skill and develops a mental image (4). This is followed by the fixation phase, during which motor patterns are practiced until correct behaviors are well established (4). Finally, during the autonomous phase, the student becomes more expert and develops increasing speed and precision (4). The student moves from initially performing the procedure awkwardly under total conscious control to
performing the procedure smoothly under total or near-total automatic control.

Three important conditions exist that influence the acquisition of new skills (4). Contiguity is the proper sequence and appropriate timing of motor responses. Practice, which comes second, involves rehearsal and fixation of the skill (4). The amount of practice required will vary depending on the ability of the student and the complexity of the task. Feedback is the third and possibly most important condition that influences the learning of psychomotor skills (4). Feedback reinforces accurate performance and corrects errors. Experience without feedback increases confidence but does not improve skill performance (5).

The process of teaching a skill can be similarly divided into three broad phases corresponding to the phases of psychomotor learning already discussed (4). The introductory (cognitive) phase allows the student to develop a mental plan for the procedure (4). During the practice (fixation) phase, the student is supervised while rehearsing the skill and is given feedback to reduce errors and strengthen correct responses (4). The perfecting (autonomous) phase is generally a more extended period during which the student performs the skill under realistic clinical conditions and improves speed and precision (4). A fourth phase that many would add is the teaching phase, which provides the student the opportunity to demonstrate mastery of the skill by successfully teaching it to a new student (6,7). Table 10.1 lists the first three phases divided into the component steps that might occur, for example, in the setting of a procedure workshop (4).

The steps listed in Table 10.1 may need to be slightly modified when at the bedside and depending on the time available. The instructor initiates a brief, focused discussion of the procedure that concentrates on the critical elements, such as surface anatomy; helpful hints; or common errors. Ideally, this discussion should not occur in front of the patient or family, but the family should know about the student-instructor relationship. This will make it easier to coach the student during the actual procedure. In addition, the instructor can surreptitiously guide the student through the procedure while explaining the procedure step by step to the patient or family. Although many families initially balk at having a resident perform a procedure on their child, many change their minds if a supervisor agrees to be there during the critical steps. It is also important to tell each family that even the best can “miss” a procedure. However, if a family refuses to allow the resident to perform the procedure, the supervisor must perform it.

When observing a procedure, the student should be placed as much as possible in the position from which he or she will perform the procedure. This often requires the resident to stand behind the instructor and view the procedure over the instructor’s shoulder (Fig. 10.1). This method facilitates a better understanding of spatial orientation and handedness (8).

Besides the family’s wishes, many other factors must be considered in allowing a trainee to perform a procedure on an actual patient. The patient’s status, the urgency of the situation, the ratio of risks and benefits to the patient, the skill levels of the teacher and trainee, and other clinical demands in the ED will all influence this decision. Although instructors should strive to facilitate every opportunity for students to practice procedures, many situations will require the student to observe or assist only. It is difficult to give universal guidelines, but the overarching principles are that patients should never be exposed to undue risk or discomfort and that residents should graduate with proficiency in the core procedural skills of their specialty.