The Emergency Department. It can be one of the most stressful rotations for an intern as well as one of the most beneficial for their education. Emergency Departments (EDs) often have structured education programmes tailored to learning objectives for emergency medicine. This is in addition to hospital based provocation training programmes. The additional educational opportunities are often appreciated by interns. However, gaps appear to exist for a significant number of interns. For instance, an intern may be on nights when a critical teaching session occurs. An important topic may be missed entirely.
“Is there more that be done to improve intern education in the ED?”
The Australian Curriculum Framework for Junior Doctors (ACFJD) was a noble effort in the late noughties to provide guidance on what areas and specific skills interns should aim to develop by the end of the year. As a framework, the ACFJD was non-binding (not really a curriculum as such).
In practice the ACFJD was seldom used in local departments and very few interns were aware of it or its educational potential. Furthermore, the ACFJD as with much other research conducted on what interns learn in ED has a ‘top-down’ design; i.e. what senior clinicians or medical educators feel is important or essential for interns to learn. These hypotheses are tested through different techniques to see if an objective aspect of ED education can be improved (e.g. documentation, clinical skills, managing aggressive patients). Whilst this is great and studies often show improvements, are we missing the point? Is this what interns want to learn?
What do the Interns Think and what did I do about it?
What we need is to find out and validate what is important for interns to learn, from the interns themselves.
Surprisingly, this has not been done in Emergency Medicine, despite the literature dating back to the 1980s highlighting the importance of interns contributing to curriculum development (Harden et al 1986).
So this is what I did: ‘bottom-up’ research or what is known in business as ‘learning from below’.
Can interns teach us as medical educators what they want to gain from rotations in emergency?
Yes they can!
The Study and Methods
In early 2014, I conducted a qualitative research study on the intern cohort at St Vincent’s Hospital Sydney. Twenty-two of the 32 interns participated and had 30 minute semi-structured interviews with me. They were prompted to think about three experiences over the past year where they either had learned something or felt they wanted to have learned something. A final unstructured section enabled the interns to highlight anything else missed in the interview, other areas they wanted to learn but didn’t or whether their peers should perhaps have learned things that they feel their colleagues hadn’t up to that point. Interviews were recorded, professionally transcribed and manually analysed using a validated open axial coding method where codes were derived inductively from the literature. Essentially this means themes from the interviews were identified and then specific areas of the themes were isolated and analysed for frequency amongst all the interns.
The results were quite interesting. Unsurprisingly, interns wanted to learn clinical procedures & management of common conditions that occur often in the ED. Developing Basic and Advanced Life Support skills were also valued highly.
These objectives are well-represented in the ACFJD and literature but there were many aspects that weren’t.
What is more interesting is that they are not well represented in the educational or clinical literature if at all.
Key areas interns wanted to learn from this study include:
‘Clinical’ and Professional Personal Development (PPD) objectives:
As a junior doctor reading this, some of these things may not come as a surprise, but some might. Reflective practice is sometimes not liked or appreciated by doctors but every single intern in the study highlighted how they had used reflection (formally or informally) to learn at some point during their internship.
This is both astonishing and excellent, but can we harness this desire to use reflection for learning, touted as one of the most effective ways of continual professional development in medicine?
One result that jumps out is developing proactivity for learning. Interns described they felt as they became a junior doctor that they would get all the knowledge needed from formal training programmes. However by the end of the year, 87% of the interns recognised this was not the case and if they wanted to develop themselves for their chosen career and future, they needed to be proactive to seek out their own education. For example a quote from one of the participants: “In the emergency department, when so many things [procedures] come up, the registrars are often quite happy to help you out and let you do them. They just need to know that you want to do them.” Residents and registrars will agree with this comment, but the challenge is instilling this construct of education into interns early, so they can benefit from the proactivity through their first year, especially in the opportunity-rich emergency departments. This concept is well-described in social science literature as helping learners transition from pedagogical learning (child based or ‘rote learning’ where spoon feeding information dominates) to andragogical or ‘adult’ learning. Adult learning recognises that adults know what they want to learn and the challenge for teachers is supporting them. Do we need to be teaching or highlighting this? I would say it is very important to do so!
Lastly, interns learned to pick teachers that were most aligned to their own ways of learning (e.g. Visual, Auditory, Kinetic to name one example theory of learning styles. Teachers that could support an interns’ preference were popular and led to better retention of knowledge after ED rotations. This has been clearly shown in the educational literature. But equally there were teachers who were not performing well.
Another quote: “That particular registrar, it wasn’t one of his personal strengths. I learned to pick & choose the people who are more likely to help me with my education, I get a sense of what their skills are and whether communication is one of them”. Should this registrar improve their education skills or just not teach? Ultimately it is us as educational leaders to identify those who are not meeting interns’ needs and help develop them. After all, teaching is one of the expectation of all doctors.
Overall this study shows there are significant unmet learning needs in interns who rotate through emergency. This study has ‘validity’ for the cohort of interns at St Vincent’s in 2014 but is not supposed to be generalisable as a qualitative study. Instead, it is designed to make you think about your own departments and whether you should be asking interns what they want to learn. Indeed if you are an intern, you should highlight what you want to gain from your ED rotations to your educational supervisors so you can work to meeting your goals with your teachers.
Could this be a paradigm shift in medical education? Perhaps. Adults are responsible for their own learning and development, never more so than in medicine where lifelong learning is an expectation. So should we be developing the educational maturity of interns rotating through emergency? I think so, and I think we need more ‘bottom-up’ research to validate this philosophy.
Here is an overview of the objectives I uncovered that may influence future curriculum development:
Ultimately the main objective of medical education is to improve clinical services, knowledge and ability to benefit patients. With a workforce from the intern level that is better able to learn from all clinical and professional encounters by encouraging proactivity to learn & reflective practice, we will be setting ourselves up to succeed as a knowledgeable and motivated workforce for the patients we serve.
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