In this post, Shirin Brady, Janet Skinner and Tim Fawns from the College of Medicine and Veterinary Medicine discuss how they creatively transformed and adapted some of their hands-on teaching at the Emergency Department into a hybrid approach…
The Emergency Department (ED) is a very practical, hands-on place, so people tend to like practical, hands-on teaching and learning. This is difficult to achieve at the best of times, with shift work and rotating groups of staff. Now, during the COVID-19 pandemic, there are significant additional challenges to the practical side of medical education. For example, the two metres restrictions mean that we need to control the number of people in a room, and to clean equipment between use. Reduced access to shared clinical space needs to be complemented with off-site preparation and follow-up tasks. It is vital that we offer learning opportunities alongside clinical exposure that are authentic, credible and help to create a community of practice.
While some of our practical skills teaching continues, albeit with PPE (personal protective equipment) and physical distancing, our larger courses need to be adapted. A hybrid approach can work well, providing learners an accessible platform to discuss, explore and discover new strategies and knowledge before putting it into practice. Some preparatory learning is also essential for on-site simulation, where we need to make the most of limited time. Below, we describe some approaches we have taken to designing hybrid and online activities to support practical learning in emergency medicine.
Introduction to Resuscitation
This is a short course for junior staff to develop the skills and confidence to work in the ED resus team, assessing and managing a range of common presentations. It needs to be adaptable as there are a range of learners on different rotation periods—4 months, 6 months, 1 year, > 1 year—with different backgrounds: junior doctors with range of experience, physician associates, nurse practitioners, etc. It needs to be accessible as they will be working different shift patterns in a busy ED, and have different commitments outside of work (being carers, taking exams, etc.). It also needs to be practical and transferable to their day-to-day working.
For this course, we set up online discussion boards, with the following features:
- Places for students to self-reflect and post their learning needs, giving them more agency in relation to what they need to learn.
- Places to share their own experiences of being part of a resuscitation team and what has worked well or not for them, focusing on non-technical skills, such as communication, leadership and decision-making.
- Clinical scenarios where cases are gradually revealed, depending on the posted answers of the learners, developing their critical thinking and task prioritization for the undifferentiated patient.
This last discussion space leads directly into practical sessions, in which simulation is combined with facilitated self-reflection and critique in a safe learning environment. The scenarios are designed for learners to bring together elements encountered earlier in the course. Due to physical distancing constraints, we are working on streaming the simulation live onto MS Teams to allow remote, online learners to join in debrief discussions. This needs to be handled sensitively, with explicit understanding within the group of the sanctity of the learning environment. Recording the simulation and making it available also allows those within the simulated scenario to view themselves, which can benefit their self-reflection. When they feel ready, learners can request a supervised learning event in the clinical setting, with facilitated self-reflection of technical and non-technical skills.
Emergency Medicine: “Life in the fast Lane”
Teaching anything in the current climate is challenging, but teaching medical students to care for acutely unwell patients presents unique challenges. How can students learn clinical skills without face-to-face patient contact? The answer is they can’t, certainly not in the later clinical years where learning mainly occurs in hospitals and primary care. Hence, medical students have been classed as key workers. However, given the current pressures on clinical areas, face-to-face encounters with any patients are at a premium, never mind ‘really’ sick patients, in areas such as the Emergency Department (ED).
The three-week EM module is undertaken by all year 6 Edinburgh Medical Students, during which they are immersed in the ED and form a core part of the team, learning through clinical experience and impromptu clinical teaching. Opportunities are given to consolidate shop-floor teaching through synchronous and asynchronous online activities. Alongside a 5-week programme of synchronous, online case-based tutorials in acute care, we ask students to do various other tasks. In the ‘patient journey’, they shadow a patient from presentation to admission or discharge, writing a reflective piece on the patient’s expectations, experience and quality of care. Alongside this, they complete a ‘resus case’, where they reflect on the teamworking required to look after an acutely unwell patient. On their final day, they present a ‘one minute wonder’ case, based around a patient they have seen over the course of the module. This normally turns out to be a lively online session with students showcasing a wide variety of topics and everyone (including tutors) learning loads. We also run week-long, asynchronous discussion board cases, where students can explore clinical reasoning through patient cases that develop through student and teacher dialogue.
Through our approaches, we aim to allow learners agency over what they learn, the pace of learning and how they learn it, and to increase flexibility and accessibility. At the same time, it is important to build a community within the online environment, where learners feel safe to express their unknowns and learn from each other. It is not a natural inclination for many to admit they do not know something, and that is the greatest challenge for us: to create that safe environment, that community of learners that enables safe, supported sharing. For this reason, we have set up online ice-breaker activities to get students used to taking part in open dialogue in this unfamiliar context, and we model supportive, non-judgemental online communication.
We also want to continue some of community building that went on within the ED, prior to the COVID-19 pandemic. These included monthly meetings with guest speakers, weekly practical sessions on emergency skills and drills, and more infrequent multidisciplinary teaching days with up to 60 participants and faculty.
Here are a few things we have started:
- An online discussion board where anyone can post about interesting cases they have seen, or things that they have learnt. This allows students to share the learning that may otherwise have occurred in a crowded handover room. It also allows teachers to generate guidance and facilitate asynchronous interaction through guided discussion boards, or instructional videos or links.
- An online journal club with polls, quizzes and a virtual meeting to discuss and present interesting relevant papers.
- Our monthly education meeting is now online, which has hugely increased the attendance and the range of speakers available, as people can join from home or their place of work.
We have not yet figured out what to do with the larger multidisciplinary teaching days, and much of what we have described above is still evolving. However, we are developing a firmer grasp of some principles that are important to our new educational context:
- Encouraging student co-design of learning spaces helps us avoid excluding learners whose current situations and needs we have not anticipated.
- Especially now, things do not always go to plan. Being open to adapting teaching and learning on the fly, and not being too tied to standardising experiences or covering content, allows us to emphasise student engagement and community.
- Scaffolding reflection about learners’ experiences and the complexity of clinical practice helps teachers and students be more aware of what will still need to be learned in the future.
Special thanks to Derek Jones and Gill Aitken for their pedagogical support. Along with Tim, they designed and tutored courses in online teaching and course design that informed aspects of these activities
Shirin graduated from the University of Wales College of Medicine in 2004. She moved to Scotland for her house officer jobs in Glasgow and Edinburgh; before taking off to the other side of the world, where she spent a year in Hamilton, New Zealand, on a medical rotation. She returned to the UK and her first Emergency Medicine post in Portsmouth, after which started her training in Emergency Medicine in the South East Scotland deanery. She completed her training in 2013, and was appointed to a consultant post in Emergency Medicine at the Royal Infirmary Edinburgh shortly after. She has an interest in Simulation Medicine for the development of clinical knowledge and skills, and non-technical skills within the Emergency Department.
Janet is a Consultant in Emergency Medicine in NHS Lothian and the Director of Clinical Skills for Edinburgh Medical School. She organises the year 6 Emergency Medicine module and oversees the MBChB clinical skills and simulation programme.
Dr Tim Fawns is Deputy Programme Director of the MSc in Clinical Education and part-time tutor on the MSc in Digital Education. He is also the director of the international Edinburgh Summer School in Clinical Education. His main academic interests are in education, technology and memory.