Learning Experiences in the ED

Introduction

Every student, regardless of the area and grade, should have recognized that the process of learning is different depending on the environment and the situation. For medical students, it very often depends on the clinical rotation, the type of structure of the hospital and the epidemiologic profile of the population in the area. Thinking about the Emergency Department (ED), we have critical patients, urgent measures to be taken and no much time to have second thoughts, all of this in a very dynamic – sometimes chaotic – environment.

What is the evidence on Medical Education in the ED? How can we improve our experience as a student in such context? Is it possible to have – and give – good feedback? These are some of the points we are discussing in this article, which features a quick conversation with one of the most incredible and enthusiastic emergency physicians I ever know – and who has taught me a lot.

Juliana is an Emergency Physician. I had the pleasure to learn from her with in the field, as well as attending some of her brilliant lectures for the EMIG which I’m part of. She work as an emergency physician in São Paulo and th coordinator of the “Basic and Advanced Airway Digital Course."

What are the singularities you see when giving and receiving feedback in Emergency Department?

“It’s a very dynamic environment and, sometimes, the moment for feedback can be completely ignored if the opportunity is not taken at the right time since the room can always become even more chaotic. For me, one of the greatest advantages is that everything is happening here and now, and the learner can be observed and taught closely. However, this could be a problem if the learner feels insecure while being watched, or if the professor interferes too much during the procedure or the history taking and examination.”

How do you think learning takes place in this environment? Is it possible to learn and teach with each case without disturbing the emergency dynamics?

As I said earlier, although it is a very dynamic environment, I see an emergency department as a valuable environment for the teaching-learning process because we can take advantage from each case in its entirety (from the evaluation to the outcome) or in key situations, important for that learner. Also, the fact that the patient is right there, requiring interventions, instigates the student to want to participate, take action and understand what is going on. Another thing I like very much about teaching in this environment is how we can be very practical in exemplifying and exercising the ED mindset, developing in the learner the clinical reasoning of the emergency, which, as we know, operates in a different logic.”

With the recognition of the specialty in Brazil, what can change in relation to the teaching and mentoring in the emergency department?

“I think the change that many of us are already experiencing is to have emergency medicine specialists in these settings, which qualifies the teaching of mindset and the purpose of acute and severe patient care.”

What tips would you give to students who go through emergency medicine internships to learn more and better?

“One exercise I often do with my students is to always think not about what the patient has, but what he needs. In many cases, the definitive diagnosis is absolutely secondary in immediate care. That is the mindset. Another important point is to observe the emergency room like an orchestra, which the emergency physician is there to conduct: how do we organize physical space? What should I solve first? What patient needs most of my attention right now? What people from the multidisciplinary team are fundamental there? these are skills that we develop with practice, sometimes even without noticing, but when we pay attention to all of this we understand the complexity of the critical care, of the specialty, and the potential that the emergency medicine has in changing patient’s outcomes.”

And for teachers and residents, what tips would you give to improve students learning from the ED routine?

“Everything that shows up is an opportunity for learning, including an empty room, without patients: if you knew how much students don’t know about the physical organization of the room, support materials and ventilators, monitors, defibrillators, multi-professional teams and so on, we would not feel moments without patients as idle time. So I wanted to tell you never to let go of these moments. Another thing that is poorly discussed by us, but that in the Emergency Medicine is essential: health policies, emergency departments situation, organization of health structures. Emergency medicine is an excellent thermometer to measure the efficiency of the system and, if we stop and think a little, to discuss and debate the context that we are inserted (even without all the answers), we develop a more critical and interested generation, not only in Emergency Medicine but in improving the system as a whole.”