The desire to spoon-feed medical residents today

As I begin another year teaching EKGs to our new residents, I find I am increasingly asking myself, “Where to teach?”

I do not mean to imply a geographic sense to the word “where” (although this is difficult, too, as residents move from hospital to hospital in large health care systems like ours as they change rotations), but rather as more of a “level.” What level do I teach our residents the art of EKG reading? Do I keep it rudimentary or do I teach it at the level of a good cardiology fellow? Are we striving for excellence or striving for adequacy in EKG interpretation? Said another way: Do I teach at a Dubin’s level of EKG interpretation or a Marriott’s?

This is not an easy decision for those engaged in teaching medical students and residents.

Every year I am evaluated by the residents for my instruction, and every year I get good marks. But an email received from our program director made me concerned, because a criticism they had heard from the residents was that my instruction was too advanced. (This was a first for me despite using similar core lecture materials year to year.)

Which led me to wonder, is my curriculum too advanced for our newer residents or are medical students not receiving instruction on EKGs in medical schools before residency? Or has is the art of EKG interpretation evolving to simply reading the computer-generated interpretation at the top of the tracing? Should residents just be taught basic ACLS-level tracings or the more subtle findings of hypothermia and hypercalcemia?

I wonder why there’s such a difference now, why there is a draw to spoon-feed our residents rather than to teach them basic principles upon which to grow their understanding. Perhaps residents are flooded. Perhaps they are scared. Or (more likely) perhaps we need to do a better job leading by example. Perhaps, as one fellow of mine said, our attendings in medical schools are so hurried to get back to clinic that they never do chalk-talks or EKG reading with residents any more. Maybe the pressures to make medicine more efficient is robbing from education.

Whatever it is, there is a change.

I’m sure I’m not the only teacher who’s encountered the same difficulty knowing where to teach now. But I continue to believe that our youngest doctors can rise to any challenge they are given as long as they have enough time, so don’t expect it to be any easier from now on, but maybe just a bit slower.

Wes Fisher is a cardiologist who blogs at Dr. Wes.

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  • Suzi Q 38

    “…..Which led me to wonder, is my curriculum too advanced for our newer residents or are medical students not receiving instruction on EKGs in medical schools before residency?……”

    Your guess is as good as anyone’s. It could be a combination of both.

    You should teach curriculum based on what your class can handle, given their intellect, and every class is different.

    Do you have information about each and every student in your class? Where are they from, how long have they lived in this country, what undergrad college did they graduate from, what were their MCAT scores? How were their prior grades in the hard sciences when they went to college? When you give them their quizzes, how does each individual student do with the information your teaching provides?
    Look at the attendance rosters for a month, Do your students attend all of your classes?

    Each class will be different. The way each adult student prefers to learn is different.
    Sometimes you are given a class whose learning abilities are high, and other classes may not be so.

    Many students enjoy visual learning, while others need to interact and practice scenarios with the teacher and other students. Some are fine with just listening to a monotone instructor for two hours…actually this is not usually the case. Students want information that is not only good, but meaningful.

    With every class an assessment needs to be made with each and every student. Once that information is complete, you can “spoon feed” or teach at a higher level given what your group of students at the present time can handle.

    You have to be the chameleon. Before you change your curriculum, find out who you need to teach to, and what level they are (high, average, or low).

    Good Luck.
    Teaching is not as easy as everyone thinks.

  • Patrick Kenney

    Specifically regarding EKGs, my school recently started teaching (and testing) them in the first semester because 3rd year students were unable to read rate, rhythm, and axis on the wards after supposedly studying them in ungraded assignments. It made it much easier to actually understand what was going on when I hit the wards a few months ago…

  • Eric Strong

    Wes, as a fellow EKG teacher, I completely empathize with this post. EKG competency does not seem to be the priority it was when I was in med school or residency. It’s obviously a multifactorial issue, with contributions from hours restrictions, increased hospital focus on bed flow and efficiency, and increased curricular focus on other topics.

    I don’t blame anyone or even the system for this change. Over the past 10 years, I’ve seen an increased focus on QI, ethics, EBM, communication, and patient safety in residency training, all of which are important and rightfully deserved more attention than during the years of my own training. But when the residents have even less time for primarily educational activities, something obviously has to get scaled back. EKGs are seen as a relatively expendable skill, since the combination of cardiology consults and automated interpretations superficially make EKG excellence seem superfluous. Skills at ABG and CXR interpretation have equally suffered.

    Now I focus on a combination of the most critical and most common abnormalities, and refer students/residents to additional resources if their interest extends beyond the subset of topics that our limited time can accommodate (e.g. https://www.youtube.com/playlist?list=PLYojB5NEEakXhL1WoDvNPm1cG57pjE0d7 )

  • rtpinfla

    Have you considered a pre-test? That may give you a place to start and would also give the residents a sense of what you expect them to master.
    And I agree 100% that todays residents can master any challenge and to “lower the bar” would not be appropriate. Where they start is important but where they end up is critical.

  • Mengles

    Have you seen the first 2 years of medical school Dr. Fisher? If it ain’t on boards, med schools don’t teach it.