2014; 36: 196–200
TWELVE TIPS
Twelve tips for overnight teaching JEREMY B. RICHARDS1,2, SUSAN R. WILCOX2,3, DAVID H. ROBERTS1,2 & RICHARD M. SCHWARTZSTEIN1,2 1
Harvard Medical School, USA, 2Beth Israel Deaconess Medical Center, USA, 3Massachusetts General Hospital, USA
Background: The European Working Time Directive and the United States’ duty hour restrictions have changed resident physicians’ schedules, specifically increasing overnight shifts and decreasing overall time spent in the hospital. As residents’ perception of night shifts is that they have little educational value, efforts to improve educational opportunities and night attending teaching are desirable. However, resources about and recommendations for best practices for overnight teaching by faculty are scarce. Aim: To provide 12 tips to highlight strategies intended to optimize attending physicians’ overnight teaching skills and strategies. Method: The tips provided are based on our experiences and reflections as in-house faculty supervising residents working overnight, by our experience and group discussions as medical educators, and the available literature. Results: The 12 tips presented offer specific strategies to optimize attending physicians’ overnight teaching for resident physicians, specifically highlighting the unique logistics, pedagogy and follow-up of overnight teaching. Conclusion: Preparation for teaching is important in any environment, but understanding the unique timing and circumstances associated with overnight teaching is vital to ensure that overnight teaching is effective. Acknowledging and addressing the physical and cognitive obstacles associated with overnight teaching and learning is necessary to maximize the educational value of overnight teaching.
Introduction Motivations for implementing duty hour restrictions in many European and North American countries (Philibert et al. 2002), included addressing the deleterious effects of increased sleep debt on both learning and clinical performance (Leung & Becker 1992; Pilcher & Huffcutt 1996; Papp et al. 2004). In the European Union, the Working Time Directive dictates that all salaried citizens may not work more than 48 h per week (Leiper 2002). In the United States, duty hour restrictions mandated by the Accreditation Council for Graduate Medicine Education (ACGME) prohibit residents from working more than 80 h a week (Nasca et al. 2010; ACGME 2011). One significant impact of these duty hour limitations, in both Europe and North America, is that interns and residents spend less time in the hospital. Furthermore, duty hour restrictions have led to a shiftwork model of resident training, in which residents more frequently work only overnight on ‘‘night float’’ rotations. Night float rotations were designed to address sleep deprivation and resident health, including potentially improving residents’ mood, decreasing percutaneous injuries, and decreasing motor vehicle crashes (Reed et al. 2010), and to improve patient care. However, night float rotations may consequently interfere with residents’ exposure to educational opportunities (Charap 2004; Woodrow et al. 2006). Working only at night may limit opportunities for housestaff to attend traditional didactics or learn from
attending physicians on rounds or at the bedside. In general, the literature supports this: housestaff identify limited educational value in night float rotations (Bricker & Markert 2010; Luks et al. 2010; Nabi et al. 2013). This is particularly relevant as learning and educational opportunities during training are among the most important factors to residents when selecting a residency training program (Ishida et al. 2012). Overnight supervision of residents by attending physicians improves perceived educational and clinical value by housestaff and faculty, without apparent negative impact on residents’ clinical or decision-making autonomy (Phy et al. 2004; Trowbridge et al. 2010; Haber et al. 2012). Furthermore, the presence of supervising attending physicians results in improved perceptions of overnight care by day teams (Defilippis et al. 2010). However, due to the shiftwork nature of night float rotations and potentially fragmented overnight coverage provided by attending physicians, educational techniques and strategies must be modified to be successful for overnight teaching. In addition, although night float systems decrease the amount of time that residents are in the hospital, such systems are associated with decreased sleep (Chua et al. 2011). Therefore, residents working overnight in a night float system may be less well-rested and less able to engage in cognitively demanding work, including learning, than the same residents on day rotations (Durmer & Dinges 2005; Curcio et al. 2006).
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Abstract
Correspondence: Jeremy B. Richards, MD, MA, 330 Brookline Avenue, KSB-23, Boston, MA 02215, USA. Tel: (617) 667 5864; fax: (617) 667 4849; email: [email protected]
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ISSN 0142–159X print/ISSN 1466–187X online/14/030196–5 ß 2014 Informa UK Ltd. DOI: 10.3109/0142159X.2013.847911
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Twelve tips for overnight teaching
There are resources for residents working overnight shifts, including a consensus statement generated by a 50member panel in the United Kingdom after implementation of the Working Time Directive with specific recommendations on how residents can prepare for, survive, and recover from overnight shifts (Horrocks et al. 2006). Reciprocal resources are lacking for attending physicians working overnight, particularly with regard to how to optimize overnight teaching. In this context, we present the following 12 tips to provide advice to attending physicians working overnight with resident learners. The tips provided in this article are the result of our experience as in-house faculty supervising housestaff working overnight, and are informed both by our experience as medical educators and the available literature. The tips were discussed in an iterative fashion, with candidate ideas accepted or rejected by consensus based on perceived utility to medical educators in a variety of clinical settings. While educational strategies used during traditional didactics can be and are applied to night teaching, modifications are necessary to address the shift-like nature of housestaff and attending coverage, and the specifics of nocturnal teaching. Given these considerations, these 12 tips are organized in three sections – reflection and preparation ( practical tips for preparing for overnight teaching), pedagogy (theory and strategies for providing high-value teaching to housestaff), and follow-up (recommendations for reinforcing teaching points.)
Reflection and preparation
educational information to optimize patient care and identify teaching opportunities. For example, overnight faculty physicians can compare their own assessments of patients with the housestaffs’ assessment as a means of determining learners’ fund of knowledge and clinical acumen (see tip 4 below). Finally, given that the nature of the relationship between faculty and residents who intersect only at night can be quite limited, familiarity with the patients and their clinical issues demonstrates engagement and interest to learners, and can reinforce a commitment to overnight teaching.
Tip 3 Reflect on previous overnight teaching experiences As noted above, attending physician overnight coverage may vary depending on specialty and institutional culture and requirements; some coverage schemes obligate that attending physicians provide sporadic, non-consecutive overnight coverage while other institutions assign attending physicians to consecutive blocks of nights (Almoosa et al. 2010). Regardless, reflecting on the educational encounters from one’s last overnight shift, whether it was a day ago or a month ago, may identify teaching strategies that worked well for overnight learners. Reflection on teaching experiences is critical in any environment, but may be especially important for overnight teaching given the unique timing and circumstances (Hewson 1991; Irby 1992; Pinsky et al. 1998).
Tip 1
Tip 4
Plan to be awake
Assess your learners
Attending physicians must prepare to be awake throughout the night. This is important for availability for clinical care as well as for identifying teaching opportunities. Without preparation, however, expected fatigue will occur and even the most enthusiastic attending physician will be less inclined to teach, and less able to teach well. If attending physician overnight coverage is sporadic (i.e. an attending physician covers an overnight shift once or twice a month on non-consecutive nights), then a nap on the day the overnight shift begins, or intermittently during the night, may decrease night fatigue (Amin et al. 2012; Ruggiero & Redeker 2013). Planning for a truncated day after the overnight shift can also allow the attending physician to be able and willing to stay awake throughout the night and take time to teach.
Attending physicians working overnight may have only sporadic or very limited longitudinal interaction with residents. Given these limitations, faculty physicians should be proactive in contacting learners early in the overnight shift to assess their competency, determine their knowledge level, determine which patients and clinical issues concern them, and assess clinical reasoning abilities. Early assessment of resident competence can allow attending physicians to anticipate the degree of supervision that will be necessary, as well as determine the level of sophistication of teaching topics overnight. Learner assessment can occur while reviewing the patient census with housestaff early in the overnight shift. Reviewing the census (tip 2) prior to meeting with housestaff enables attending physicians to focus on the residents’ mastery of the clinical problems on the service and the potential for overnight crises, which can provide important information regarding residents’ clinical reasoning skills and fund of knowledge. Furthermore, reviewing the census can provide a concomitant educational opportunity, as attending physicians can model their approach to learning about patients and what clinical issues may be of concern overnight.
Tip 2 Review the census Becoming familiar with the patient census (the list of ones’ inpatients) by reviewing sign-out from the day staff or by perusing medical records provides important clinical and
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Pedagogy Tip 5
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Create a learning environment The fatigue and circadian disruption associated with working overnight can substantively decrease residents’ enthusiasm both for being at work and for engaging in cognitively demanding activities such as learning. Assessing residents’ knowledge level and clinical ability (tip 4) sets the stage for creating a learning environment, but it is necessary for attending physicians to explicitly acknowledge that teaching and learning will be a component of the overnight shift to frame residents’ expectations and attitudes towards overnight learning. Furthermore, attending physicians should assess the learners’ interest in and willingness to engage in overnight teaching, as effective teaching cannot occur in the absence of a participatory and, ideally, motivated learner (Mann 1999; Sobral 2004). In essence, residents and attending physicians need to enter into an educational contract to provide a context for the night’s work (Pratt & Magill 1983). Despite the formal implications of the term, an educational contract for overnight teaching and learning is an informal agreement between the attending physician and learners, and helps establish appropriate resident attitudes regarding teaching.
Tip 7 Reinforce mechanisms of disease As clinical encounters during overnight shifts can be unanticipated – such as an acute clinical deterioration of an established patient or an admission for an unanticipated clinical problem – predicting the nature and content of all possible teaching opportunities is unrealistic. Faculty should make efforts to address underlying molecular, biochemical, physiologic or pathophysiologic mechanisms of common problems that occur in a wide range of diseases, e.g. dyspnea, gas-exchange disorders, acid-base problems, etc. Teaching first principles not only reminds learners of fundamental mechanisms of disease, but reinforces tools and concepts that will be applicable to other clinical scenarios and helps learners transition from knowing a fact to understanding a concept. Finally, teaching in a manner that encourages active learning (Melo Prado et al. 2011) and emphasizes the importance of deliberate practice (Duvivier et al. 2011) in knowledge and skill acquisition will further solidify lessons learned on overnight shifts. Encouraging learners to rethink assumptions made by the day team can emphasize the importance of recognizing and avoiding cognitive biases such as anchoring on a particular diagnosis (Croskerry 2003).
Tip 8 De-emphasize shift mentality
Tip 6 Go to the bedside Certain pedagogic principles transfer from day to night teaching. Bedside teaching and emphasis on patient-centered teaching points, for example, are important during both day and night activities. Lessons imparted by overnight attending physicians that are explicitly focused on and based upon patient problems can be particularly memorable and engaging for learners (Janicik & Fletcher 2003). Given decreased cognitive capacity and retention associated with fatigue, interventions that increase the memorability of a teaching point are particularly important when teaching overnight. In addition, bedside teaching is preferred by both patients and residents (Gonzalo et al. 2010). Given the prevalence of electronic medical records and remote electronic monitoring of physiological parameters, bedside teaching also provides an important opportunity for faculty to model care that highlights the human aspect of medicine, the skills of careful observation and physical diagnosis, and the ethos that high quality medicine is dependent upon doctor-patient contact. When incorporating bedside teaching into overnight teaching, care should be taken not to unnecessarily wake patients who would otherwise be sleeping, both to avoid disrupting patients’ recuperation and to model patientcentered clinical care. Bedside teaching is most appropriate during overnight rounds (e.g. with sedated critically ill patients) or for management of acute issues that require realtime patient assessment. 198
Due to the fragmented nature of night coverage and the temporal separation from the ‘‘regular’’ day team, the night shift may adopt a very short-term perspective on patient care. The phrase ‘‘keep them alive ‘til 7:05’’ is occasionally invoked in overnight clinical care, and reflects a mentality that holistic patient care is less important at night. While resident physicians generally do not endorse this short-term perspective towards overnight work (Szymczak et al. 2010), if such shiftwork attitudes are perceived by overnight attending physicians, they should be de-emphasized and the importance of comprehensive clinical management on patients’ overall clinical course should be reinforced.
Tip 9 Support autonomy Housestaff cite autonomy as a positive aspect of overnight coverage (Haber et al. 2012), and it is appropriate to support autonomous clinical decision making after assessing residents’ clinical acumen and knowledge. While certain residents require more oversight than others, identifying the appropriate degree of autonomy and then allowing overnight residents to operate within that limit will increase their confidence and accentuate a positive aspect of overnight coverage. Depending on the responsibilities of the overnight attending, close supervision of overnight residents may simply not be possible and it is important to identify triggers for which residents should contact the attending. As a general principle, residents
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Twelve tips for overnight teaching
should be encouraged to think through a problem or admission before the attending reviews the case unless clinical circumstances mandate earlier involvement. This approach supports autonomy and provides the attending with greater insight into residents’ performance and reasoning abilities. In addition, night faculty should intermittently contact residents to further decrease the risk of missing a critical event (and, by extension, missing an opportunity to teach). In this context, assessment of the residents (tip 4), establishing a learning environment (tip 5), and being clear and explicit in goals and expectations for communication are important components of determining the degree of autonomy that should be granted. We often tell residents as they transition from their role as interns that they ‘‘still need to know the serum potassium, but you can’t let the intern whom you are supervising know that you checked it’’. To some degree, the same principle applies to the night faculty.
Follow-up Tip 10 Encourage reflection and provide feedback The importance of overnight coverage and the decisions made and care provided can be diminished by the shiftwork nature of the night float system, and the sense that important care decisions are primarily made by the day team. Explicitly highlighting the positive results of decisions and encouraging residents to reflect on the night are powerful means of demonstrating the value of the clinical care they provided overnight. Feedback is critical in all aspects of training, but is generally absent from overnight coverage responsibilities (Akl et al. 2006). The presence of an overnight supervising physician is an important opportunity for feedback. Whether the overnight attending covers one or several consecutive nights, constructive and developmental commentary on residents’ overnight performance is incredibly valuable, particularly because it is based almost entirely on observations of clinical performance. The importance of such feedback is only accentuated by the relative paucity of such communications in the majority of residents’ overnight work. There are many previously validated tools to assist faculty in assessing and providing structured feedback to learners (Kogan et al. 2009); however, depending on the transitions of care at the end of a night shift, face-to-face feedback may not always be logistically possible, particularly if the overnight attending is not covering longitudinal shifts. In these instances, leveraging technology for feedback and follow-up is a reasonable alternative (see tip 12 below).
Tip 11
made by an attending physician regarding such an overnight event can be refined and recycled for future encounters. Common and clinically relevant topics for overnight teaching will vary between institutions and between disciplines (medical, surgical, obstetric, etc.), but some overnight occurrences are common even across specialties. Maintaining a list of key patients, clinical events, and related teaching points will provide teaching materials for future overnight teaching opportunities.
Tip 12 Go digital for follow-up Millennial learners, or learners born from 1982 to 2000, are generally adept at technologic means of communication, and using email or other web-based tools (e.g. Twitter) can be an effective strategy for follow-up, particularly given the fragmented nature of attending physician supervision for night float rotations (Roberts et al. 2012; Forgie et al. 2013). Meaningful follow-up via e-mail can include a succinct, formative commentary on a resident’s performance in a specific setting. Summative assessment is generally not appropriate outside of face-to-face or more extensive written feedback, but a focused comment with an explicit example can reinforce good performance. In addition, email follow-up can expand upon a teaching point made overnight. A citation or an article can accompany a focused e-mail to provide further information for an interested learner, and demonstrates to residents the importance of learning, even on overnight rotations. Of course, care must be taken with regard to identifiable patient information, particularly if using social media platforms for post-shift electronic communication (Farnan et al. 2013).
Conclusion Fatigue and decreased cognitive capacity can affect both residents and attending physicians at night, and acknowledgement of these biological consequences of decreased sleep is the first step in maximizing the potential of overnight teaching. As such, physical preparation for working overnight is a critical component of being able to provide successful overnight teaching. Furthermore, a modified pedagogy and focused follow-up can maximize overnight learning opportunities. The specific tips and strategies reviewed above can be applied by attending physicians, whether providing sporadic or consecutive overnight coverage, to increase residents’ learning and understanding of key concepts necessary for high-quality clinical care. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.
Keep a list of key patients and teaching points
Notes on Contributors
An issue that occurs overnight that requires a resident’s attention is likely to occur again in the future. A teaching point
JEREMY B. RICHARDS, MD, MA, is a pulmonary and critical care physician at the Beth Israel Deaconess Medical Center and the Carl J. Shapiro Institute
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for Education and Research and an Instructor in Medicine at Harvard Medical School, in Boston, MA. SUSAN R. WILCOX, MD, is an Instructor in Surgery at Harvard Medical School, and an Emergency Medicine and Surgical Intensive Care Unit physician at Massachusetts General Hospital, Boston, MA. DAVID H. ROBERTS, MD, is an Associate Professor of Medicine at Harvard Medical School, and is associate director of the Shapiro Institute for Education and Research at Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, MA. RICHARD M. SCHWARTZSTEIN, MD, is the Director of the Academy at Harvard Medical School and Ellen and Melvin Gordon Professor of Medical Education, Beth Israel Deaconess Medical Center, Boston, MA.
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Irby DM. 1992. What clinical teachers in medicine need to know. Acad Med 67:630–638. Ishida Y, Hosoya Y, Sata N, Yasuda Y, Lefor AT. 2012. Educational factors outweigh the importance of lifestyle factors for residency program applicants: An international comparative study. J Surg Educ 69(2):167–172. Janicik RW, Fletcher KE. 2003. Teaching at the bedside: A new model. Med Teach 25(2):127–130. Kogan JR, Holmboe ES, Hauer KE. 2009. Tools for direct observation and assessment of clinical skills of medical trainees – a systematic review. J Am Med Assoc 302(12):1316–1326. Leiper R. 2002. Applying the Working Time Directive to doctors in training. Br Med J 325:S65. Leung L, Becker CE. 1992. Sleep-deprivation and house staff performance: Update 1984–1991. J Occup Med 34:1153–1160. Luks AM, Smith CS, Robins L, Wipf JE. 2010. Resident perceptions of the educational value of night float rotations. Teach Learn Med 22(3):196–201. Mann KV. 1999. Motivation in medical education: How theory can inform our practice. Acad Med 74(3):237–239. Melo Prado H, Hannois Falbo G, Rodrigues Falbo A, Natal Figueiroa J. 2011. Active learning on the ward: Outcomes from a comparative trial with traditional methods. Med Educ 45(3):273–279. Nabi H, Harley S, Murphy E. 2013. The perils and triumphs of night surgical residents across South Australia. J Surg Educ 70(2):265–272. Nasca TJ, Day SH, Amis Jr ES. 2010. ACGME Duty Hour Task Force. 2010. The new recommendations on duty hours from the ACGME Task Force. N Engl J Med 363:e3. Papp KK, Stoller EP, Sage P, Aikens JE, Owens J, Avidan A, Phillips B, Rosen R, Strohl KP. 2004. The effects of sleep loss and fatigue on resident-physicians: A multi-institutional, mixed methods study. Acad Med. 79(5):394–406. Phy MP, Offord KP, Manning DM, Bundrick JB, Huddleston JM. 2004. Increased faculty presence on inpatient teaching services. Mayo Clin Proc 79(3):332–336. Philibert I, Friedmann P, Williams WT. 2002. ACGME Work Group on Resident Duty Hours. Accreditation Council for Graduate Medical Education. 2002. New requirements for resident duty hours. J Am Med Assoc 288(9):1112–1114. Pilcher JJ, Huffcutt AI. 1996. Effects of sleep deprivation on performance: A meta-analysis. Sleep 19:318–326. Pinsky LE, Monson D, Irby DM. 1998. How excellent teachers are made: Reflecting on success to improve teaching. Adv Health Sci Educ 2:207–215. Pratt D, Magill MK. 1983. Educational contracts: A basis for effective clinical teaching. J Med Educ 58(6):462–467. Reed DA, Fletcher KE, Arora VM. 2010. Systematic review: Association of shift length, protected sleep time, and night float with patient care, residents’ health, and education. Ann Intern Med 153:829–842. Roberts DH, Newman LR, Schwartzstein RM. 2012. Twelve tips for facilitating Millennials’ learning. Med Teach 34(4):274–278. Ruggiero JS, Redeker NS. 2013. Effects of napping on sleepiness and sleeprelated performance deficits in night-shift workers: A systematic review. Biol Res Nurs. Epub ahead of print. Sobral DT. 2004. What kind of motivation drives medical students learning quests? Med Educ 38:950–957. Szymczak JE, Brooks JV, Volpp KG, Bosk CL. 2010. To leave or lie? Are concerns about a shift-work mentality and eroding professionalism as a result of duty-hour rules justified? Milbank Q 88(3):350–381. Trowbridge RL, Almeder L, Jacquet M, Fairfield KM. 2010. The effect of overnight in-house attending coverage on perceptions of care and education on a general medical service. J Grad Med Educ 2(1):53–56. Woodrow SI, Seqouin C, Armbruster J, Hamstra SJ, Hodges B. 2006. Duty hours reforms in the United States, France and Canada: Is it time to refocus our attention on education? Acad Med 81(12):1045–1051.
TWELVE TIPS
Twelve tips for overnight teaching JEREMY B. RICHARDS1,2, SUSAN R. WILCOX2,3, DAVID H. ROBERTS1,2 & RICHARD M. SCHWARTZSTEIN1,2 1
Harvard Medical School, USA, 2Beth Israel Deaconess Medical Center, USA, 3Massachusetts General Hospital, USA
Background: The European Working Time Directive and the United States’ duty hour restrictions have changed resident physicians’ schedules, specifically increasing overnight shifts and decreasing overall time spent in the hospital. As residents’ perception of night shifts is that they have little educational value, efforts to improve educational opportunities and night attending teaching are desirable. However, resources about and recommendations for best practices for overnight teaching by faculty are scarce. Aim: To provide 12 tips to highlight strategies intended to optimize attending physicians’ overnight teaching skills and strategies. Method: The tips provided are based on our experiences and reflections as in-house faculty supervising residents working overnight, by our experience and group discussions as medical educators, and the available literature. Results: The 12 tips presented offer specific strategies to optimize attending physicians’ overnight teaching for resident physicians, specifically highlighting the unique logistics, pedagogy and follow-up of overnight teaching. Conclusion: Preparation for teaching is important in any environment, but understanding the unique timing and circumstances associated with overnight teaching is vital to ensure that overnight teaching is effective. Acknowledging and addressing the physical and cognitive obstacles associated with overnight teaching and learning is necessary to maximize the educational value of overnight teaching.
Introduction Motivations for implementing duty hour restrictions in many European and North American countries (Philibert et al. 2002), included addressing the deleterious effects of increased sleep debt on both learning and clinical performance (Leung & Becker 1992; Pilcher & Huffcutt 1996; Papp et al. 2004). In the European Union, the Working Time Directive dictates that all salaried citizens may not work more than 48 h per week (Leiper 2002). In the United States, duty hour restrictions mandated by the Accreditation Council for Graduate Medicine Education (ACGME) prohibit residents from working more than 80 h a week (Nasca et al. 2010; ACGME 2011). One significant impact of these duty hour limitations, in both Europe and North America, is that interns and residents spend less time in the hospital. Furthermore, duty hour restrictions have led to a shiftwork model of resident training, in which residents more frequently work only overnight on ‘‘night float’’ rotations. Night float rotations were designed to address sleep deprivation and resident health, including potentially improving residents’ mood, decreasing percutaneous injuries, and decreasing motor vehicle crashes (Reed et al. 2010), and to improve patient care. However, night float rotations may consequently interfere with residents’ exposure to educational opportunities (Charap 2004; Woodrow et al. 2006). Working only at night may limit opportunities for housestaff to attend traditional didactics or learn from
attending physicians on rounds or at the bedside. In general, the literature supports this: housestaff identify limited educational value in night float rotations (Bricker & Markert 2010; Luks et al. 2010; Nabi et al. 2013). This is particularly relevant as learning and educational opportunities during training are among the most important factors to residents when selecting a residency training program (Ishida et al. 2012). Overnight supervision of residents by attending physicians improves perceived educational and clinical value by housestaff and faculty, without apparent negative impact on residents’ clinical or decision-making autonomy (Phy et al. 2004; Trowbridge et al. 2010; Haber et al. 2012). Furthermore, the presence of supervising attending physicians results in improved perceptions of overnight care by day teams (Defilippis et al. 2010). However, due to the shiftwork nature of night float rotations and potentially fragmented overnight coverage provided by attending physicians, educational techniques and strategies must be modified to be successful for overnight teaching. In addition, although night float systems decrease the amount of time that residents are in the hospital, such systems are associated with decreased sleep (Chua et al. 2011). Therefore, residents working overnight in a night float system may be less well-rested and less able to engage in cognitively demanding work, including learning, than the same residents on day rotations (Durmer & Dinges 2005; Curcio et al. 2006).
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Abstract
Correspondence: Jeremy B. Richards, MD, MA, 330 Brookline Avenue, KSB-23, Boston, MA 02215, USA. Tel: (617) 667 5864; fax: (617) 667 4849; email: [email protected]
196
ISSN 0142–159X print/ISSN 1466–187X online/14/030196–5 ß 2014 Informa UK Ltd. DOI: 10.3109/0142159X.2013.847911
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Twelve tips for overnight teaching
There are resources for residents working overnight shifts, including a consensus statement generated by a 50member panel in the United Kingdom after implementation of the Working Time Directive with specific recommendations on how residents can prepare for, survive, and recover from overnight shifts (Horrocks et al. 2006). Reciprocal resources are lacking for attending physicians working overnight, particularly with regard to how to optimize overnight teaching. In this context, we present the following 12 tips to provide advice to attending physicians working overnight with resident learners. The tips provided in this article are the result of our experience as in-house faculty supervising housestaff working overnight, and are informed both by our experience as medical educators and the available literature. The tips were discussed in an iterative fashion, with candidate ideas accepted or rejected by consensus based on perceived utility to medical educators in a variety of clinical settings. While educational strategies used during traditional didactics can be and are applied to night teaching, modifications are necessary to address the shift-like nature of housestaff and attending coverage, and the specifics of nocturnal teaching. Given these considerations, these 12 tips are organized in three sections – reflection and preparation ( practical tips for preparing for overnight teaching), pedagogy (theory and strategies for providing high-value teaching to housestaff), and follow-up (recommendations for reinforcing teaching points.)
Reflection and preparation
educational information to optimize patient care and identify teaching opportunities. For example, overnight faculty physicians can compare their own assessments of patients with the housestaffs’ assessment as a means of determining learners’ fund of knowledge and clinical acumen (see tip 4 below). Finally, given that the nature of the relationship between faculty and residents who intersect only at night can be quite limited, familiarity with the patients and their clinical issues demonstrates engagement and interest to learners, and can reinforce a commitment to overnight teaching.
Tip 3 Reflect on previous overnight teaching experiences As noted above, attending physician overnight coverage may vary depending on specialty and institutional culture and requirements; some coverage schemes obligate that attending physicians provide sporadic, non-consecutive overnight coverage while other institutions assign attending physicians to consecutive blocks of nights (Almoosa et al. 2010). Regardless, reflecting on the educational encounters from one’s last overnight shift, whether it was a day ago or a month ago, may identify teaching strategies that worked well for overnight learners. Reflection on teaching experiences is critical in any environment, but may be especially important for overnight teaching given the unique timing and circumstances (Hewson 1991; Irby 1992; Pinsky et al. 1998).
Tip 1
Tip 4
Plan to be awake
Assess your learners
Attending physicians must prepare to be awake throughout the night. This is important for availability for clinical care as well as for identifying teaching opportunities. Without preparation, however, expected fatigue will occur and even the most enthusiastic attending physician will be less inclined to teach, and less able to teach well. If attending physician overnight coverage is sporadic (i.e. an attending physician covers an overnight shift once or twice a month on non-consecutive nights), then a nap on the day the overnight shift begins, or intermittently during the night, may decrease night fatigue (Amin et al. 2012; Ruggiero & Redeker 2013). Planning for a truncated day after the overnight shift can also allow the attending physician to be able and willing to stay awake throughout the night and take time to teach.
Attending physicians working overnight may have only sporadic or very limited longitudinal interaction with residents. Given these limitations, faculty physicians should be proactive in contacting learners early in the overnight shift to assess their competency, determine their knowledge level, determine which patients and clinical issues concern them, and assess clinical reasoning abilities. Early assessment of resident competence can allow attending physicians to anticipate the degree of supervision that will be necessary, as well as determine the level of sophistication of teaching topics overnight. Learner assessment can occur while reviewing the patient census with housestaff early in the overnight shift. Reviewing the census (tip 2) prior to meeting with housestaff enables attending physicians to focus on the residents’ mastery of the clinical problems on the service and the potential for overnight crises, which can provide important information regarding residents’ clinical reasoning skills and fund of knowledge. Furthermore, reviewing the census can provide a concomitant educational opportunity, as attending physicians can model their approach to learning about patients and what clinical issues may be of concern overnight.
Tip 2 Review the census Becoming familiar with the patient census (the list of ones’ inpatients) by reviewing sign-out from the day staff or by perusing medical records provides important clinical and
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Pedagogy Tip 5
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Create a learning environment The fatigue and circadian disruption associated with working overnight can substantively decrease residents’ enthusiasm both for being at work and for engaging in cognitively demanding activities such as learning. Assessing residents’ knowledge level and clinical ability (tip 4) sets the stage for creating a learning environment, but it is necessary for attending physicians to explicitly acknowledge that teaching and learning will be a component of the overnight shift to frame residents’ expectations and attitudes towards overnight learning. Furthermore, attending physicians should assess the learners’ interest in and willingness to engage in overnight teaching, as effective teaching cannot occur in the absence of a participatory and, ideally, motivated learner (Mann 1999; Sobral 2004). In essence, residents and attending physicians need to enter into an educational contract to provide a context for the night’s work (Pratt & Magill 1983). Despite the formal implications of the term, an educational contract for overnight teaching and learning is an informal agreement between the attending physician and learners, and helps establish appropriate resident attitudes regarding teaching.
Tip 7 Reinforce mechanisms of disease As clinical encounters during overnight shifts can be unanticipated – such as an acute clinical deterioration of an established patient or an admission for an unanticipated clinical problem – predicting the nature and content of all possible teaching opportunities is unrealistic. Faculty should make efforts to address underlying molecular, biochemical, physiologic or pathophysiologic mechanisms of common problems that occur in a wide range of diseases, e.g. dyspnea, gas-exchange disorders, acid-base problems, etc. Teaching first principles not only reminds learners of fundamental mechanisms of disease, but reinforces tools and concepts that will be applicable to other clinical scenarios and helps learners transition from knowing a fact to understanding a concept. Finally, teaching in a manner that encourages active learning (Melo Prado et al. 2011) and emphasizes the importance of deliberate practice (Duvivier et al. 2011) in knowledge and skill acquisition will further solidify lessons learned on overnight shifts. Encouraging learners to rethink assumptions made by the day team can emphasize the importance of recognizing and avoiding cognitive biases such as anchoring on a particular diagnosis (Croskerry 2003).
Tip 8 De-emphasize shift mentality
Tip 6 Go to the bedside Certain pedagogic principles transfer from day to night teaching. Bedside teaching and emphasis on patient-centered teaching points, for example, are important during both day and night activities. Lessons imparted by overnight attending physicians that are explicitly focused on and based upon patient problems can be particularly memorable and engaging for learners (Janicik & Fletcher 2003). Given decreased cognitive capacity and retention associated with fatigue, interventions that increase the memorability of a teaching point are particularly important when teaching overnight. In addition, bedside teaching is preferred by both patients and residents (Gonzalo et al. 2010). Given the prevalence of electronic medical records and remote electronic monitoring of physiological parameters, bedside teaching also provides an important opportunity for faculty to model care that highlights the human aspect of medicine, the skills of careful observation and physical diagnosis, and the ethos that high quality medicine is dependent upon doctor-patient contact. When incorporating bedside teaching into overnight teaching, care should be taken not to unnecessarily wake patients who would otherwise be sleeping, both to avoid disrupting patients’ recuperation and to model patientcentered clinical care. Bedside teaching is most appropriate during overnight rounds (e.g. with sedated critically ill patients) or for management of acute issues that require realtime patient assessment. 198
Due to the fragmented nature of night coverage and the temporal separation from the ‘‘regular’’ day team, the night shift may adopt a very short-term perspective on patient care. The phrase ‘‘keep them alive ‘til 7:05’’ is occasionally invoked in overnight clinical care, and reflects a mentality that holistic patient care is less important at night. While resident physicians generally do not endorse this short-term perspective towards overnight work (Szymczak et al. 2010), if such shiftwork attitudes are perceived by overnight attending physicians, they should be de-emphasized and the importance of comprehensive clinical management on patients’ overall clinical course should be reinforced.
Tip 9 Support autonomy Housestaff cite autonomy as a positive aspect of overnight coverage (Haber et al. 2012), and it is appropriate to support autonomous clinical decision making after assessing residents’ clinical acumen and knowledge. While certain residents require more oversight than others, identifying the appropriate degree of autonomy and then allowing overnight residents to operate within that limit will increase their confidence and accentuate a positive aspect of overnight coverage. Depending on the responsibilities of the overnight attending, close supervision of overnight residents may simply not be possible and it is important to identify triggers for which residents should contact the attending. As a general principle, residents
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Twelve tips for overnight teaching
should be encouraged to think through a problem or admission before the attending reviews the case unless clinical circumstances mandate earlier involvement. This approach supports autonomy and provides the attending with greater insight into residents’ performance and reasoning abilities. In addition, night faculty should intermittently contact residents to further decrease the risk of missing a critical event (and, by extension, missing an opportunity to teach). In this context, assessment of the residents (tip 4), establishing a learning environment (tip 5), and being clear and explicit in goals and expectations for communication are important components of determining the degree of autonomy that should be granted. We often tell residents as they transition from their role as interns that they ‘‘still need to know the serum potassium, but you can’t let the intern whom you are supervising know that you checked it’’. To some degree, the same principle applies to the night faculty.
Follow-up Tip 10 Encourage reflection and provide feedback The importance of overnight coverage and the decisions made and care provided can be diminished by the shiftwork nature of the night float system, and the sense that important care decisions are primarily made by the day team. Explicitly highlighting the positive results of decisions and encouraging residents to reflect on the night are powerful means of demonstrating the value of the clinical care they provided overnight. Feedback is critical in all aspects of training, but is generally absent from overnight coverage responsibilities (Akl et al. 2006). The presence of an overnight supervising physician is an important opportunity for feedback. Whether the overnight attending covers one or several consecutive nights, constructive and developmental commentary on residents’ overnight performance is incredibly valuable, particularly because it is based almost entirely on observations of clinical performance. The importance of such feedback is only accentuated by the relative paucity of such communications in the majority of residents’ overnight work. There are many previously validated tools to assist faculty in assessing and providing structured feedback to learners (Kogan et al. 2009); however, depending on the transitions of care at the end of a night shift, face-to-face feedback may not always be logistically possible, particularly if the overnight attending is not covering longitudinal shifts. In these instances, leveraging technology for feedback and follow-up is a reasonable alternative (see tip 12 below).
Tip 11
made by an attending physician regarding such an overnight event can be refined and recycled for future encounters. Common and clinically relevant topics for overnight teaching will vary between institutions and between disciplines (medical, surgical, obstetric, etc.), but some overnight occurrences are common even across specialties. Maintaining a list of key patients, clinical events, and related teaching points will provide teaching materials for future overnight teaching opportunities.
Tip 12 Go digital for follow-up Millennial learners, or learners born from 1982 to 2000, are generally adept at technologic means of communication, and using email or other web-based tools (e.g. Twitter) can be an effective strategy for follow-up, particularly given the fragmented nature of attending physician supervision for night float rotations (Roberts et al. 2012; Forgie et al. 2013). Meaningful follow-up via e-mail can include a succinct, formative commentary on a resident’s performance in a specific setting. Summative assessment is generally not appropriate outside of face-to-face or more extensive written feedback, but a focused comment with an explicit example can reinforce good performance. In addition, email follow-up can expand upon a teaching point made overnight. A citation or an article can accompany a focused e-mail to provide further information for an interested learner, and demonstrates to residents the importance of learning, even on overnight rotations. Of course, care must be taken with regard to identifiable patient information, particularly if using social media platforms for post-shift electronic communication (Farnan et al. 2013).
Conclusion Fatigue and decreased cognitive capacity can affect both residents and attending physicians at night, and acknowledgement of these biological consequences of decreased sleep is the first step in maximizing the potential of overnight teaching. As such, physical preparation for working overnight is a critical component of being able to provide successful overnight teaching. Furthermore, a modified pedagogy and focused follow-up can maximize overnight learning opportunities. The specific tips and strategies reviewed above can be applied by attending physicians, whether providing sporadic or consecutive overnight coverage, to increase residents’ learning and understanding of key concepts necessary for high-quality clinical care. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.
Keep a list of key patients and teaching points
Notes on Contributors
An issue that occurs overnight that requires a resident’s attention is likely to occur again in the future. A teaching point
JEREMY B. RICHARDS, MD, MA, is a pulmonary and critical care physician at the Beth Israel Deaconess Medical Center and the Carl J. Shapiro Institute
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for Education and Research and an Instructor in Medicine at Harvard Medical School, in Boston, MA. SUSAN R. WILCOX, MD, is an Instructor in Surgery at Harvard Medical School, and an Emergency Medicine and Surgical Intensive Care Unit physician at Massachusetts General Hospital, Boston, MA. DAVID H. ROBERTS, MD, is an Associate Professor of Medicine at Harvard Medical School, and is associate director of the Shapiro Institute for Education and Research at Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, MA. RICHARD M. SCHWARTZSTEIN, MD, is the Director of the Academy at Harvard Medical School and Ellen and Melvin Gordon Professor of Medical Education, Beth Israel Deaconess Medical Center, Boston, MA.
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