Author	Affiliation
Sreeja Natesan, MD	Duke University, Division of Emergency Medicine, Durham, North Carolina
John Bailitz, MD	Northwestern University, Feinberg School of Medicine, Department of Emergency Medicine, Chicago, Illinois
Andrew King, MD	The Ohio State University Wexner Medical Center, Department of Emergency Medicine, Columbus, Ohio
Sara M. Krzyzaniak, MD	University of Illinois College of Medicine at Peoria/OSF Healthcare, Department of Emergency Medicine, Peoria, Illinois
Sarah K. Kennedy, MD	Indiana University School of Medicine, Department of Emergency Medicine, Indianapolis, Indiana
Albert J. Kim, MD, MACM	Washington University in Saint Louis School of Medicine, Department of Emergency Medicine, St. Louis, Missouri
Richard Byyny, MD	Denver Health Medical Center, Department of Emergency Medicine, Denver, Colorado
Michael Gottlieb, MD	Rush Medical Center, Department of Emergency medicine, Chicago, Illinois

Background
Critical appraisal of the literature
Instructor teaching strategies
Clinical teaching models
Incorporating technology
Limitations
Conclusion

BACKGROUND

Emergency medicine (EM) is a dynamic specialty that requires not only an acquisition of vast amounts of medical knowledge, but also the ability to prioritize and task switch efficiently and effectively to combat the chaos, high patient volume, and variable acuity within a given shift. Additionally, mounting pressures are placed on EM faculty to use less time to care for a larger volume of patients while increasing patient satisfaction scores, documentation, billing, and academic productivity.^1,2 All of these factors can make the emergency department (ED) a challenging environment for clinical teaching.³ Moreover, EM faculty concerns over time constraints and patient census variability are reflected in a decline of bedside teaching in the clinical setting.^2,4-6 There is mounting evidence that clinician educators often feel ill prepared to teach in this dynamic clinical environment due to a lack of a consolidative resource.^7-13 A set of guidelines may help assist in the development of skills for educators to help bridge this gap.

However, the ED environment provides unique opportunities for clinical teaching due to the breadth of pathology, spectrum of acuity, and large number of clinical encounters. When surveyed, students rated the ED as the most valued rotation for learning opportunities.¹⁴ Therefore, it is essential that all emergency clinicians who work with learners develop strong clinical teaching skills to maximize this educational opportunity. This article provides a narrative summary of the literature and best practice recommendations for clinical teaching in medical education with a focus on their application within the ED environment.

CRITICAL APPRAISAL OF THE LITERATURE

This article is the fourth in a series of evidence-based best practice reviews from the Council of Emergency Medicine Residency Directors (CORD) Best Practices Subcommittee.^15-17 With assistance of a medical librarian, we performed a search of Embase, CINAHL, Ovid MEDLINE, and PsycINFO for articles published from inception to April 23, 2018, using keywords and medical subheadings (MeSH) terms focused on teaching at the patient’s bedside. The full search strategy is available in the Appendix. Bibliographies of all relevant articles were reviewed for additional studies. We used social media to further augment the search by placing several calls on Twitter among the #FOAMed and #MedEd communities to gather additional article recommendations. Articles were screened independently by two of the authors to evaluate for any papers addressing the following three themes, which were determined a priori: instructor teaching strategies, clinical teaching models, and incorporation of technology. We included articles if either author recommended inclusion.

The search yielded a total of 2,514 articles, of which 123 were deemed to be directly relevant for inclusion in this review. When supporting data were not available, recommendations were made based upon the authors’ combined experience and consensus opinion. The level and grade of evidence was provided for each best practice statement according to the Oxford Centre for Evidence-Based Medicine criteria (Tables 1 and 2).¹⁷ Prior to submission, the manuscript was reviewed by the entire CORD Best Practices Subcommittee. It was subsequently posted to the CORD website for two weeks for review and feedback from the entire CORD community.

INSTRUCTOR TEACHING STRATEGIES

1. Preparation

As in most areas in life, preparation is the key to success in clinical and bedside teaching. Adequate planning and preparation by the instructor, learner, and even the patient will result in a much more effective learning experience for all involved.¹⁸ Preparing for didactic teaching, development of teaching scripts, and review of physical examination skills prior to a shift can help alleviate instructor uncertainty and improve instructor confidence.^5,6,18-22

Educators should consider priming the learner for the anticipated shift. Prior to the beginning of each teaching shift, the instructor should work with the learner to set clear expectations and goals.³ This includes orienting the learner to the plan for clinical teaching, getting buy-in from the learner, and setting relevant and achievable learning objectives by aligning the instructor’s and learner’s goals.^{3, 18-21, 23-29}

Patients are integral to bedside teaching by delivering a unique perspective into their illness and educating learners about their disease course. The incorporation of patients into clinical teaching adds a level of complexity for preparation and planning.¹⁸ For bedside teaching, the instructor should help prepare the patient and teaching team. This should be done by setting expectations for the interaction with the patient, such as maintaining a respectful and professional tone, avoiding medical jargon, and involving the patient and his or her family.^30,31 When incorporating a patient into bedside teaching, one should seek the patient’s permission first and set expectations prior to the encounter.^{6,20,21,23,25,26,30,32,33} However, care must be taken not to create a blind spot in clinical teaching by only focusing on specific sets of patients while avoiding others (e.g., those with communicable diseases or those deemed “difficult” patients).³³ Patients’ autonomy should be respected at all times and they should be explicitly encouraged to ask questions, clarify or amend data, and to provide feedback to their medical team.^34,35

2. Instructor Characteristics

Trust and support are important in clinical teaching. Establishing a collegial and supportive teacher-learner relationship is essential to create a culture that promotes effective knowledge acquisition, professional growth, and lifelong learning habits.^20,27,36-38 Learners have a tendency to mirror the behavior of instructors they feel are professional and competent. In knowing this, instructors should demonstrate empathy and compassion, teaching both medical knowledge and professionalism skills. Learners value instructors who can push them to their zone of proximal development (the difference between what a learner can do without help and what they can do with help) while maintaining a safe learning environment.^{19,20,30,39-41} To help achieve this, educators should avoid “read my mind” questions.^19,42 If a learner is struggling with a question, it can be beneficial to ask whether they understand the question at hand or if it was too ambiguous. An appropriate balance should be maintained between autonomy and supervision to help foster a supportive relationship with the learner while providing an opportunity for growth.^40,43,44 Additionally, learners appreciate a positive attitude and enthusiasm for teaching, as well as candor from teachers about their own knowledge deficits.^18,27,45,46 Table 3 provides a summary of qualities considered by learners to be essential in an effective clinical teacher.^{18,19,31,47,48}

3. Knowledge Integration Strategies

Learners, while very eager and enthusiastic, may struggle with knowledge integration and retention. As an instructor, it is important to be cognizant of barriers to learning and how to overcome them. Several theories and strategies can be applied to clinical practice to help with knowledge acquisition and retention.

A. Cognitive Load Theory

The theory that the human brain can process only a finite amount of information at one given time, creating a bottleneck effect for learning is known as cognitive load theory.^49-51 When the cognitive load is exceeded, learning and performance are both impaired. This can be avoided by selecting relevant teaching pearls that correspond to your learner’s level while avoiding teaching too much information at one time. In addition to the quantity of knowledge, educators should strive to reduce extraneous load. Extraneous load is the part of the working memory that engages in work that is not crucial to completing the learning task.^50-53 Another technique in the clinical realm is to reduce extraneous activities to let the resident or student focus more on specific tasks.

B. Interleaving

Interleaving is when the learner alternates between semi-related topics rather than exclusively focusing on a single area for an extended period of time.^54,55 One practical clinical application of interleaving would be for the learner to first see a patient with shortness of breath who has congestive heart failure, followed by a patient with shortness of breath due to chronic obstructive pulmonary disease. The learner can then compare and contrast the two different presentations.

C. Spaced Repetition/Retrieval Practice

Spaced repetition is when the learner spreads out studying or recall of information over time to enhance retrieval and retention.^54,55 Retrieval practice is another strategy focused on knowledge retention, wherein the learner is asked to bring learned information from long-term memory back into use.⁵⁴ One example using this concept is having the learner reiterate teaching points later in the shift, at sign out, or even on a subsequent shift to help space the acquired knowledge and encourage recall of the information at a later time. Technology, in the form of flash card programs and applications (apps) (e.g., Quizlet, Anki, Flashcard Machine, Study Blue, Study Stack) or in email form can also serve to remind the learner of information at a later date.

D. Importance of “Wait-time” and “Think-time”

It is important to allow adequate time for the learner to process and recall information. When teaching, an instructor typically poses a question and then waits for the learner to reply, known as “wait time 1.” The time after the learner response is known as “wait time 2.” After proposing a question to a learner, previous studies have shown that an instructor typically waits an average of only 1.5 seconds prior to interjecting the answer.^56,57 However, studies have found that waiting three seconds or longer (especially after “wait time 2”) allowed the learner time to process the question and decreased failure-to-respond rates, increased perception of caring (thereby encouraging the learner to engage more actively), and increased the total number of responses received.^56,57

4. Environmental and Timing Considerations

Clinical teaching should never hinder or delay care for patients, especially the critically ill; safety and the oath to “do no harm” take precedence over educational benefit.⁴¹ An instructor should select an appropriate “moment” for clinical teaching while minimizing distractions and engaging learners.^6,23 In a busy ED environment, it is necessary to remind learners that interruptions frequently occur based on patient care demands. The responsibility falls on both the learner and instructor to revisit any interrupted teaching interaction to complete open discussions and teaching points.⁵⁸ In caring for an acutely ill patient, it can be highly valuable for the learner to observe how a seasoned instructor provides medical care and communicates effectively with the patient, family, and team members.^4,59 After the event, the instructor should debrief to allow discussion of medical decision-making, alternatives, and possible outcomes.³

It is important for the instructor to be aware of the learner’s mindset and select teaching opportunities for when the learner will be most receptive.³ If the learner is falling behind on his or her current patients and has several new patients to see, the instructor should select a different time to provide clinical teaching. Selecting a time when the learner is more receptive and has more available learning capacity will enhance knowledge retention.^50-53 Allowing time after clinical teaching to answer clarifying questions and explain the thought process of decision-making are essential for learning and retention while providing guidance on future learning.^19,41

Several strategies can be used to make on-shift teaching more efficient.^6,32,60 The teacher could ask the learner to briefly review the literature for a given illness and then teach this back to the instructor and other learners.^{23,30,31,37,60,61} This will instill lessons of lifelong learning, such as strategies for accessing the literature on shift, and provides an opportunity for the learner to develop advanced knowledge on a specific topic while freeing up the teacher to see the patient. However, asking the learner to review literature should not distract from the clinical experience or teaching, and care must be taken to not overuse this practice. Additionally, it is important for the teacher to set aside time for the learner to report back the information they learned on their search. Setting a time limit for the team (e.g., less than five minutes) to keep the teaching session brief will support the learning environment without compromising ED throughput.^4,25 Additionally, this ensures that teaching points remain brief, thereby avoiding the tendency to over-teach (i.e., covering an excessive amount of material in a short time span).^50,51 The use of a dedicated teaching shift to protect the teacher and learner from tasks and duties that may distract from an instructional goal is another effective strategy to optimize the time available for teaching in the clinical environment.⁶³

5. Interprofessional Considerations

Medicine has placed an increasing emphasis on the importance of interprofessional teams for the delivery of safe, efficient, cost-effective, and patient-centered care. Studies have found that non-physician colleagues who are actively involved in bedside teaching can help to improve communication around the care plan, enhance provider satisfaction with communication, reduce errors, aid in the diagnosis, shorten hospital length of stay, and reduce total hospital charges.^18,26,64 Even if other providers (e.g., nurses, technicians, and pharmacists) are unable to be physically present at the bedside, securing buy-in from interprofessional providers and institutions for the importance of clinical teaching can minimize distractions during clinical teaching, and improve the learning experience for all involved.^6,25,65

 

BEST PRACTICE RECOMMENDATIONS

 

Adequate preparation is crucial to the success of clinical teaching. This includes setting clear expectations, priming the learner, and seeking patient permission prior to bedside teaching (Level 2b, Grade B).

 

Learners will emulate behaviors of physicians they perceive as competent and professional. Instructors should capitalize on teachable moments and model efficient bedside history and examination skills, communication styles, respect, compassion, and humanism (Level 2b, Grade B).

 

Consider reducing cognitive load, interleaving, using spaced/retrieval practice, and increasing wait times after asking questions to allow the learner time to process and respond (Level 2a, Grade B).

 

During critically ill patient encounters, allow time to debrief after the event. Also, consider incorporating short bedside teaching points during a patient’s evaluation (Level 5, Grade D).

 

Incorporate additional members of the care team (e.g., nurses, pharmacists, technicians) into clinical teaching encounters (Level 2b, Grade B).

 

CLINICAL TEACHING MODELS

It is important to use a variety of teaching strategies in the ED and tailor them to the individual learner and situation. Being creative and innovative with teaching techniques ensures that the sessions are memorable and meaningful for learners.²⁸ We highlight several, well-described teaching models and describe how they can be used in the ED including the Socratic method, Aunt Minnie, the One-Minute Preceptor (OMP), SNAPPS, ED STAT, teaching scripts, and bedside presentation/rounds. Table 4 includes a summary of each of these teaching techniques with a description and example of how to implement them clinically. Additional resources for those interested in learning more are available in the Appendix.

A. Socratic Method

In the Socratic method, the instructor poses a series of questions to a learner. One recent study found that this was the most frequently used teaching method in the ED and was used more often among higher-acuity patients, with more senior residents, and when multiple learners were present.⁶⁶ In contrast, “pimping” (as it has been colloquially known) is an alternate approach dating back to 17th century London and is frequently confused with the Socratic method.^67,68 The difference lies in the intent of the instructor toward the learner.⁶⁸ While the Socratic method is a well-established model for improving learning and recall, pimping has a less desirable intent. It is often viewed as a “sport” aimed at reinforcing the power dynamic and hierarchy of medical training.^69-73 Using increasingly difficult questions until the learner is unable to answer, the teacher shames or embarrasses the learner. Not surprisingly, this tactic impairs the trust relationship and inhibits learning.

Questioning, in general, as a teaching method has been found to be very efficient and effective.^54,56,57,74 Students have been shown to better recall knowledge if it is taught after asking a question.⁷⁵ Using this technique, advanced learners can be challenged while still teaching novices by targeting teaching and communication to meet the learner’s specific needs.^{23,27,30,36,37,40,42,44,60,67,76} To determine a learner’s existing knowledge, skills, and gaps, teachers can use probing questions (e.g., “why?” and “how would you approach…?”) to guide individualized, specific teaching to the learner, regardless of his or her level of training.^{4,18,19,23,28,41} Low-level questions can be used to assess factual recall, while higher-level questions assess problem-solving skills, analysis, and synthesis of the information.^{24,30,32,34,36,37,40,42,43} It is important to push a learner from basic knowledge into critical thinking and problem-solving skills through questioning. One strategy to help improve learning when approaching less familiar topics is to provide basic starting points to create the scaffolding for further problem-solving. However, when using questions as part of clinical teaching, it is essential that the learner feel safe to answer incorrectly with an emphasis on learning rather than “correct answers.”⁶⁸

Three types of questioning have been found to be the most effective for learning: broadening, targeting, and up-the-ladder.⁴⁴ Broadening involves asking “what if” scenarios to add educational examples beyond the current case. Targeting is the practice of asking specific questions to specific team members. The up-the-ladder technique (also referred to as “step-up questioning”) occurs when the teacher asks the same question to progressively more advanced learners. An advantage of the up-the-ladder technique is that it respects the educational advancement order and avoids the challenges of having a junior learner respond once a more senior learner has answered incorrectly.⁷⁷

When using the Socratic method, it is important to identify the avoidant learner and gently draw him or her into the discussion. This may be facilitated by beginning with simple questions or those that you previously have confirmed the learner is able to answer correctly. While it is important to incorporate evidence-based medicine into teaching, questions that are overly advanced or not familiar to the team should be minimized as they have been shown to be less effective.^40,44,78

Finally, lowering the stakes of the Socratic method may be accomplished by incorporating humor, explicitly stating expectations, and refraining from ego-driven discussions. The emphasis should be placed on positive reinforcement and framing questions as “learning opportunities.”⁷⁷ Trainees should be reminded that more can be learned from incorrect answers than correct ones, as incorrect answers shed light into the learner’s knowledge gaps. The Socratic method is frequently combined with many of the techniques that follow to enhance learning and retention.

B. Aunt Minnie

In the ED, many diagnoses occur through pattern recognition by aligning the history and physical examination with prior experiences and expertise. The “Aunt Minnie” approach is a teaching method focused on learning pattern recognition or heuristics for facilitating diagnostic efficiency. This is ideal for typical presentations of common, low-to-moderate acuity clinical complaints and allows learners to increase their repository of patient experiences as they develop their clinical gestalt. This strategy is based on the principle that, “if the lady across the street walks like your Aunt Minnie and dresses like your Aunt Minnie, she probably is your Aunt Minnie, even if you cannot identify her face.”⁷⁹ On a deeper level, this is informed by the concept of System 1 (e.g., unconscious, automatic) and System 2 (e.g., slow, effortful) thinking.⁸⁰ This method can be used in the ED to efficiently balance clinical care while incorporating clinical teaching of learners.^79,81

For an instructor, it is important to recognize when this technique is appropriate (e.g., common ambulatory complaints) and when the model should not be used (e.g., rare or complex diseases).^82,83 In the latter, learners may need to use a more strategic approach (i.e., System 2 thinking).^82,83 This also provides an opportunity for educators to teach learners how to develop their gestalt. The Aunt Minnie method relies on an instructor with a good foundation of clinical experience to help facilitate the formation of pattern-recognition skills for the learner. The instructor should not be afraid to share his or her own uncertainty and doubt with the learner in more complex cases to prevent the formation of incorrect associations.

C. One-Minute Preceptor (OMP)

The OMP model was initially described in 1992 by Neher and colleagues as a method to efficiently balance teaching while simultaneously providing effective patient care.⁸⁴ This model is particularly well-suited for the busy ED environment. The OMP is a learner-centered model of instruction that is based on five microskills, as described in Table 4.^58,84-88

The OMP model has shown high satisfaction among both learners and instructors with learners preferring the OMP model over the traditional precepting model.⁸⁶ When evaluating the OMP, instructors have stated that it was more effective and efficient than the traditional model, allowing them to provide more information in the same amount of time.⁸⁹ Multiple studies have demonstrated that teachers using the OMP feel more confident in their ability to assess the learner’s knowledge and clinical reasoning skills.^86,89,90

The OMP model depends on the accuracy and completeness of information gathered by the learner. With more experienced learners, such as a senior EM resident, this model may be implemented rapidly in one interaction from start to finish. With more novice learners, modifications may be necessary to allow the instructor the opportunity to assess the patient and gather any missing data. Regardless, the fundamental theme of encouraging learners to commit to a diagnosis and plan is crucial to help shape their critical thinking and decision-making skills.

D. SNAPPS (Summarize, Narrow, Analyze, Probe, Plan, Select)

The SNAPPS model emphasizes active learning by incorporating opportunities for the learners to ask the instructor questions regarding uncertainties and alternative approaches, as well as guiding self-directed, future learning. Although faculty training and ongoing commitment is required, SNAPPS does not require significantly more time than traditional teaching.^91,92 A simple refinement of the SNAPPS technique incorporates the PICO (Patient, Intervention, Comparison, and Outcome) approach to frame clinical questions to guide additional self-directed learning.⁹³

Multiple studies have reported that utilization of the SNAPPS model results in numerous benefits when compared with traditional teaching and the OMP model. These benefits include increases in learner satisfaction, differential diagnosis generation, expression of clinical reasoning, active engagement with teachers, generation of teaching points, opportunities for self-directed learning, and clinical skills development.^91,92,94-98

E. ED STAT (Emergency Department Strategies for Teaching Any Time)

ED STAT is the first tool specifically designed for the complex learning environment of the ED with easy-to-follow steps, allowing incorporation of clinical teaching and feedback into a single model. This model has been shown to increase the confidence in preceptors’ teaching and is designed for educators of all experience levels and backgrounds.⁹⁹ Aside from demonstrating an increased knowledge of teaching strategies specific to the ED, this technique has also been associated with an increased satisfaction and confidence in teaching abilities by the individual.⁹⁹

F. Teaching Scripts

Teaching scripts are quick, specific, previously created teaching talks designed to review common complaints seen in the ED. Having these teaching scripts prepared ahead of time allows for efficient teaching during a busy ED shift.^4,22,100 For example, when a patient presents with possible pulmonary embolism, being able to quickly summarize the diagnostic approach with a figure and references for additional reading can reduce the educator’s workload while ensuring high-quality knowledge dissemination. Instructional content for teaching scripts can include medical knowledge, communication skills, procedural training, and time management strategies. To prevent cognitive overload, instructors should focus on one topic and limit the teaching to a short time period.⁴¹ While some teaching opportunities will present themselves based on a particular patient complaint, others can be created by asking learners about theoretical scenarios.¹⁰⁰

G. Bedside Presentations and Rounds

Although initially a clinical teaching approach used in inpatient medicine, bedside presentations and rounds can be incorporated into the ED environment and may prove beneficial for patient care. During bedside rounds, all team members should be introduced, and the comfort and privacy of the patient should be maintained at all times.¹⁰¹ The patient should be oriented to the goal of the clinical teaching session prior to the interaction and be informed that there may be theoretical discussions (e.g., differential diagnosis development, what-if scenarios) about their illness.^{19,20,30,32,42,102} Of note, some experts believe that hypothetical scenarios are best left for discussion away from the patient’s bedside to avoid confusion.³⁰ Patient-centered communication (both verbal and non-verbal) should be used. As such, a body part should not be referred to as “it.” The patient should be talked to and not about, and there should be mindful physical positioning between the physician, learner, and patient.^22,25,103

With adequate preparation, an instructor can add structure and depth to the teaching session to maximize the learning opportunity, even if presenting patient complaints are limited.¹⁸ Several different models of bedside rounds exist that can be adapted to the ED, including basic science rounds (focus on pathophysiology, signs, and symptoms); problem-oriented rounds (focus on prioritizing and managing the presenting problem list); and clinical skills rounds (focus on history-taking and physical examination skills).¹⁸

There are several benefits to having learners present to the supervising clinician at the patient’s bedside. By moving away from the computer or busy workstation, the focus shifts to the patient.¹⁰² Learners are able to directly observe how experienced clinicians interview, examine, reason, and communicate with patients and their families. In addition, supervising clinicians can immediately clarify presentations and physical examination findings.

However, this approach has potential challenges. Learners may feel increased pressure to present all of the facts and provide a comprehensive management plan while patients may not want more sensitive issues disclosed in group teaching sessions. Residents may also fear that answering questions incorrectly in front of their patients will jeopardize their patient-physician relationship and undermine their ability to care for that patient. To avoid this, the faculty can direct questions to learners not involved in direct care of that specific patient.⁴ Alternatively, instructors can help mitigate this by guiding learners to identify or by demonstrating a particular finding.³⁵

 

BEST PRACTICE RECOMMENDATIONS

 

Use questions to engage students and residents in active learning. Combine the use of low-level questions to assess knowledge and high-level questions to assess problem-solving skills. Make sure to create a supportive, safe learning environment (Level 2b, Grade B).

 

Consider OMP to promote a learner-centered model of instruction. This tool is well-received by both learners and instructors due to its focus on five microskills while incorporating feedback (Level 2b, Grade B).

 

Consider using SNAPPS to promote active participation and engagement for both learners and educators (Level 1b, Grade B).

 

Considering using ED STAT to help foster an environment of learning in the complete ED environment. It is designed for educators of all experience and backgrounds and will increase preceptors’ confidence in teaching. (Level 2b, Grade B)

 

Prepare ahead by having brief, specific, pre-created teaching scripts designed to review common ED complaints to allow for efficient teaching during a busy ED shift (Level 2b, Grade B).

 

For bedside presentations, always orient the patient to expectations prior to the interaction. Use patient-centered communication, while being cautious with hypothetical situations in front of the patient, to facilitate a successful experience (Level 2b, Grade B).

 

INCORPORATING TECHNOLOGY

The use of technology can help promote learning. As clinical teaching continues to evolve, the use of technology and innovative bedside teaching approaches will increase. Learners who are involved in simulation rather than traditional, paper-based learning have been shown to demonstrate better retention skills.¹⁰⁴ However, the use of technology is not just limited to formal didactics and can be used in a variety of formats, including just-in-time training, task trainers, in situ simulation, and telemedicine.

A. Just-in-Time Training

The learning needs and preferences of medical student and resident learners continue to evolve. Digital natives crave immediate information and prefer the integration of technology in the learning process.^105-107 One particular teaching modality, just-in-time training (JITT), incorporates both technology and immediate, high-yield information to satisfy digitally-savvy learners. JITT is a method of training where topic-specific education occurs in a focused, concise manner just prior to performing the task. The literature most commonly focuses on using short, predefined educational content, such as a video with simulation for procedural-based competency.

The advantages of JITT include minimizing training time, the ability to visualize the procedure prior to performing it, and allowing prompt return to clinical duties.¹⁰⁸ As such, this is ideal for a high-volume ED setting. Additionally, JITT has demonstrated positive effects at the learner, patient, and system levels, while also generally being enjoyed by learners.¹⁰⁸ JITT has previously been studied for splint application.^109,110 When compared with reading textbooks, watching a brief JITT instructional video before splinting was shown to yield faster learning times and more successful splint applications.¹¹⁰ Another study assessed JITT for intraosseous needle placement and defibrillator use in a pediatric ED. JITT significantly increased comfort levels and the ability to perform the procedure independently by the trainee. Moreover, the use of a dedicated JITT room in the clinical environment is both feasible, effective, and can lead to improved resident confidence with fewer supervisor-reported procedural interventions.^108,111,112 However, JITT may not be helpful for all types of procedures and training with some research showing conflicting success rate for certain procedures, such as pediatric intubation and infant lumbar puncture.^113,114

Importantly, in the era of mounting technology and easy availability, it is vital to screen the JITT resources for quality and applicability prior to incorporation into clinical practice.^115,116 One study performed a systematic search of YouTube^TM to assess videos focused on teaching ophthalmoscopy.¹¹⁷ Out of more than 7,000 videos, they identified 27 (0.4%) that were suitable for teaching this skill; however, none of them included all of the elements for a thorough education on ophthalmoscopy. Pre-identifying resources and having them ready for learners, rather than having to look them up and evaluate them in real time, can help ameliorate this.

B. Simulation (including Task Trainers and In Situ Simulation)

Clinical procedures have been identified as one core area to improve the efficiency and effectiveness of critical care education, specifically given the need to balance patient safety with opportunities for learners to practice procedures.⁶⁰ Strategies to bridge this gap include learning that uses computers, task trainers, and simulation. The use of simulation to enhance clinical teaching and learning continues to increase rapidly in the form of both in situ simulation and procedural training.

Task trainers can serve as a safe alternative for reinforcing the muscle memory necessary for many of the tasks required of an emergency physician. These can range from phantom limbs for peripheral intravenous line placement to transvenous pacing or pericardiocentesis models. Use of task trainers allows evaluation of procedural competencies, provides a safe environment for learning and fine-tuning skills, and allows for troubleshooting common errors that may occur in these high-stakes procedures without the added pressure of patient and time constraints. The learner can practice placing an ultrasound-guided peripheral line on an ultrasound phantom model prior to performing the procedure on a patient.

In situ simulation refers to simulation performed in the clinical care setting. Simulation offers the benefit of experiential learning in a realistic environment and can be run during any clinical shift. Simulation allows the opportunity for interdisciplinary interactions and communication training. This can range from high fidelity (e.g., mannequins) to low fidelity (e.g., mock cases in an empty patient room).¹¹⁸ Technology can facilitate these simulations by using stored images or videos, as well as a number of simulation smartphone apps.

C. Telemedicine

Wearable platforms enable learners to view how they are perceived by patients and facilitate novel debriefing approaches when attendings are not in the room during the initial patient encounter. Google Glass is a wearable platform with a head-mounted optical display that is lightweight, voice-activated, and provides the opportunity for technology-assisted education.^119,120 This platform allows audiences and learners to visualize what the operator is seeing in real time, thereby allowing multiple learners to experience an educational benefit from a single experience.^104,120 This can also be used by learners to review and engage in self-reflection based on the encounter.¹²¹ Many of the features that clinical learners deem as important to clinical education can be accomplished using this model.^122,123 However, it is important to be conscious of patient privacy and the Health Insurance Portability and Accountability Act. Moving forward, it is imperative that medical educators keep abreast of emerging educational technologies including personalized learning, mobile technologies, and learning analytics. Such technology has the potential to enhance learning and clinical competence within the clinical environment.⁶⁰

 

BEST PRACTICE RECOMMENDATIONS

 

Use just-in-time training instructional videos to facilitate asynchronous teaching and procedural skills (Level 1b, Grade B).

 

Incorporate a variety of stimuli (eg, imaging, electrocardiograms, ultrasound videos) into clinical shifts to enhance teaching and engagement of the learner (Level 2b, Grade B).

 

Consider employing in situ simulation as an effective educational strategy when teaching in the clinical environment (Level 2b, Grade B).

 

Consider incorporating telemedicine and wearable platforms such as Google Glass to enhance teaching and feedback during clinical encounters (Level 2a, Grade B).

 

LIMITATIONS

This review has several important limitations to consider. First, while our search methodology was comprehensive, some articles may nevertheless have been missed in the current review. We minimized the risk by reviewing all related studies in the bibliographies of included articles, reaching out to content and topic experts, undergoing pre-submission review and approval by the CORD community, and placing several calls via social media for further resources. Another limitation is the dearth of experimental studies specifically within the ED setting. When robust, ED-specific educational outcomes data were not available, we used studies from other fields and expert opinions. Thus, some proposed interventions may not be as effective in the ED setting and further studies are needed to establish their efficacy in our learning environment.

CONCLUSION

Because clinical teaching is a critical tool in the education and development of all physician trainees, it is vital to have a strong foundation of the available techniques and methods for clinical teaching. Our work provides a critical review of the literature on clinical teaching for residency education with a focus on EM. Recommendations were given for instructor teaching considerations, clinical teaching strategies, and options for incorporating technology into clinical practice. We hope this manuscript will inform readers on strategies and techniques for successful clinical teaching.

Footnotes

Section Editor: Tehreem Rehman, MD

Full text available through open access at http://escholarship.org/uc/uciem_westjem

CORD Best Practice Committee 2019-2020

Address for Correspondence: Sreeja Natesan, MD, Duke University, Division of Emergency Medicine, 1320 Erwin Road, PO Box 3096, Durham, NC 27710. Email: sreeja.natesan.md@gmail.com. 7 / 2020; 21:985 – 998

Submission history: Revision received December 3, 2019; Submitted March 30, 2020; Accepted April 9, 2020

Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. No author has professional or financial relationships with any companies that are relevant to this study. There are no conflicts of interest or sources of funding to declare.

REFERENCES

1. Cooke M, Irby DM, Sullivan W, et al. American medical education 100 years after the Flexner Report. N Engl J Med. 2006;355(13):1339-44.

2. Sheng AY, Sullivan R, Kleber K, et al. Fantastic learning moments and where to find them. West J Emerg Med. 2018;19(1):59-65.

3. Buckley C, Natesan S, Breslin A, Gottlieb M. Finessing feedback: recommendations for effective feedback in the emergency department. Ann Emerg Med. 2020;75(3):445-51.

4. Aldeen AZ, Gisondi MA. Bedside teaching in the emergency department. Acad Emerg Med. 2006;13(8):860-6.

5. Crumlish CM, Yialamas MA, McMahon GT. Quantification of bedside teaching by an academic hospitalist group. J Hosp Med. 2009;4:304-7.

6. Rousseau M, Könings KD, Touchie C. Overcoming the barriers of teaching physical examination at the bedside: more than just curriculum design. BMC Med Educ. 2018;18(1):302.

7. Green GM, Chen EH. Top 10 ideas to improve your bedside teaching in a busy emergency department. Emerg Med J. 2015;32:76-7.

8. Penciner R. Clinical teaching in a busy emergency department: strategies for success. CJEM. 2002;4(4):286-8.

9. Ramani S. Twelve tips to improve bedside teaching. Med Teach. 2003;25(2):112-5.

10. Ramani S, Orlander JD, Strunin L, Barber TW. Whither bedside teaching? A focus-group study of clinical teachers. Acad Med. 2003;78(4):384-90.

11. Chinai SA, Guth T, Lovell E, Epter M. Taking advantage of the teachable moment: a review of learner-centered clinical teaching models. West J Emerg Med. 2018;29(1):28-34.

12. McNeil C, Muck A, McHugh P, Bebarta V, Adams B. Bedside rounds versus board rounds in an emergency department. Clin Teach. 2015;12(2):94-8.

13. Gonzalo JD, Masters PA, Simons RJ, Chuang CH. Attending rounds and bedside case presentations: medical student and medicine resident experiences and attitudes. Teach Learn Med. 2009;21(2):105-10.

14. Young L, Orlandi A, Galichet B, Heussler H. Effective teaching and learning on the wards: easier said than done?. Med Educ. 2009;43:808-17.

15. Gottlieb M, King A, Byyny R, Parsons M, Bailitz J. Journal club in residency education: an evidence-based guide to best practices from the Council of Emergency Medicine Residency Directors. West J Emerg Med. 2018;19(4):746-55.

16. Parsons M, Bailitz J, Chung AS, Mannix A, Battaglioli N, Clinton M, Gottlieb M. Wellness in resident education: an evidence-based guide to best practices from the Council of Emergency Medicine Residency Directors. West J Emerg Med. 2020;21(2):299-309.

17. Estes M, Gopal P, Siegelman JN, Bailitz J, Gottlieb M. Individualized interactive instruction: an evidence-based guide to best practices from the Council of Emergency Medicine Residency Directors. West J Emerg Med. 2019;20(2):363-8.

18. Phillips R, Ball C, Sackett D, et al. Oxford Centre for Evidence-based Medicine – Levels of Evidence. 2009. Available at: https://www.cebm.net/2009/06/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/. Accessed March 26, 2020.

19. McLeod PJ, Harden RM. Clinical teaching strategies for physicians. Med Teach. 1985;7(2):173-89.

20. Ramani S, Orlander JD, Strunin L, et al. Whither bedside teaching? A focus-group study of clinical teachers. Acad Med. 2003;78:384-90.

21. LaCombe MA. On bedside teaching. Ann Intern Med. 1997;126:217-20.

22. Gonzalo JD, Heist BS, Duffy BL, et al. The art of bedside rounds: a multi-center qualitative study of strategies used by experienced bedside teachers. J Gen Intern Med. 2013;28(3):412-20.

23. Lang VJ, O’Connor AB, Blatt A, Gracey C. Collaborative development of teaching scripts: an efficient faculty development approach for a busy clinical teaching unit. J Hosp Med. 2012;7(8):644-8.

24. Ruesseler M, Obertacke U. Teaching in daily clinical practice: how to teach in a clinical setting. Eur J Trauma Emerg Surg. 2011;37:313-6.

25. Jenkins C, Hewamana S, Brigley S. Techniques for effective teaching. British J of Hosp Med. 2007;68(9):M150-153.

26. Lichstein PR, Atkinson HH. Patient-centered bedside rounds and the clinical examination. Med Clin North Am. 2018;102(3):509-19.

27. Rajput V. Ten rituals that may help to make bedside teaching rounds more patient centered. Ind J Med Spec. 2014;5(1):1.

28. Ramani S, Leinster S. AMEE Guide no. 34: Teaching in the clinical environment. Med Teach. 2008;30(4):347-64.

29. Handfield-Jones R, Nasmith L, Steinert Y, Lawn N. Creativity in medical education: the use of innovative techniques in clinical teaching. Med Teach. 1993;15(1):3-10.

30. Burgess A, Oates K, Goulston K, et al. First year clinical tutorials: students’ learning experience. Adv Med Educ Pract. 2014;5:451-6.

31. Carlos WG, Kritek PA, Clay AS, Luks AM, Thomson CC. Teaching at the bedside. Maximal impact in minimal time. Ann Am Thorac Soc. 2016;13(4):545-8.

32. Clare CA, Yeh J. Faculty development and other strategies for clinical teaching. Curr Wom Health Rev. 2015;11:131-6.

33. Wald DA. Teaching techniques in the clinical setting: the emergency medicine perspective. Acad Emerg Med. 2004;11(10):1028.e1-e8.

34. Gierk B, Harendza S. Patient selection for bedside teaching: inclusion and exclusion criteria used by teachers. Med Educ. 2012;46:228-33.

35. Garout M, Nuqali A, Alhazmi A, et al. Bedside teaching: an underutilized tool in medical education. Int J Med Educ. 2016;7:261-2.

36. Kroenke K, Omori DM, Landry FJ, et al. Bedside teaching. South Med J. 2016;90(11):1069-74.

37. Kisiel JB, Bundrick JB, Beckman TJ. Resident physicians’ perspectives on effective outpatient teaching: a qualitative study. Adv in Health Sci Educ. 2010;15:357-68.

38. Beckman TJ, Lee MC. Proposal for a collaborative approach to clinical teaching. Mayo Clin Proc. 2009;84(4):339-44.

39. Skeff KM. Enhancing teaching effectiveness and vitality in the ambulatory setting. J Gen Intern Med. 1988;3(2 Suppl):S26-33.

40. Vytgotsky LS. Mind in the society: the development of higher psychological processes. 1978.

41. Haydar B, Charnin J, Voepel-Lewis T, Baker K. Resident characterization of better-than- and worse-than-average clinical teaching. Anesthesiology. 2014;120(1):120-8.

42. Houghland JE, Druck J. Effective clinical teaching by residents in emergency medicine. Ann Emerg Med. 2010;55(5):434-9.

43. Beckman TJ. Lessons learned from a peer review of bedside teaching. Acad Med. 2004;79(4):343-6.

44. Goertzen J, Stewart M, Weston W. Effective teaching behaviours of rural family medicine preceptors. CMAJ. 1995;153(2):161-8.

45. Certain LK, Guarino AJ, Greenwald JL. Effective multilevel teaching techniques on attending rounds: a pilot survey and systematic review of the literature. Med Teach. 2011;33(12):e644-50.

46. Loftus TH, McLeod PJ, Snell LS. Faculty perceptions of effective ambulatory care teaching. J Gen Intern Med. 1993;8(10):575-7.

47. Thurgur L, Bandiera G, Lee S, Tiberius R. What do emergency medicine learners want from their teachers? A multicenter focus group analysis. Acad Emerg Med. 2005;12(9):856-61.

48. Mallory R, O’Malley P, Jackson J, et al. Characteristics of top rated attendings. J Gen Intern Med. 2010:S237.

49. Sutkin G, Wagner E, Harris I, Schiffer R. What makes a good clinical teacher in medicine? A review of the literature. Acad Med. 2008;83(5):452-66.

50. Sweller J. Cognitive load during problem solving: effects on learning. Cogn Sci. 1988;12(2):257-85.

51. Gooding HC, Mann K, Armstrong E. Twelve tips for applying the science of learning to health professions education. Med Teach. 2017;39(1):26-31.

52. Young JQ, Merrienboer JV, Durning S, Cate OT. Cognitive load theory: implications for medical education: AMEE Guide No. 86. Med Teach. 2014;36(5):371-84.

53. Sewell J, Maggio L, Cate OT, et al. Cognitive load theory for training health professionals in the workplace: A BEME review of studies among diverse professions: BEME Guide No. 53. Med Teach. 2018;41(3):256-70.

54. Van Mierrenboer JJ, Sweller J. Cognitive load theory in health professional education: design principles and strategies. Med Educ. 2010;44(1):85-93.

55. Weinstein Y, Madan C, Sumeracki M. Teaching the science of learning. Cogn Res Princ Implic. 2018;3(2):1-17.

56. Kang S. Spaced repetition promotes efficient and effective learning policy implications for instruction. Policy Insights Behav Brain Sci. 2016;3(1):12-9.

57. Rowe MB. Wait Time: Slowing down may be a way of speeding up!. J Teach Educ. 1986;37(1):43-50.

58. Wilen WW, Clegg AA. Effective questions and questioning: a research review. Theory Res Soc Educ. 1986;14(2):153-61.

59. Farrell SE, Hopson LR, Wolff M, Hemphill RR, Santen SA. What’s the evidence: a review of the One-Minute Preceptor Model of clinical teaching and implications for teaching in the emergency department. J Emerg Med. 2016;51(3):278-83.

60. Sidhu NS, Edwards M. Deliberate teaching tools for clinical teaching encounters: a critical scoping review and thematic analysis to establish definitional clarity. Med Teach. 2018;41(3):282-96.

61. Joyce MF, Berg S, Bittner EA. Practical strategies for increasing efficiency and effectiveness in critical care education. World J Crit Care Med. 2017;6(1):1-12.

62. Young L, Orlandi A, Galichet B, et al. Effective teaching and learning on the wards: easier said than done?. Med Educ. 2009;43(8):808-17.

63. Williams KN, Ramani S, Fraser B, et al. Improving bedside teaching: findings from a focus group study of learners. Acad Med. 2008;83(3):257-64.

64. Celenza A, Rogers IR. Qualitative evaluation of a formal bedside clinical teaching programme in an emergency department. Emerg Med J. 2006;23:769-73.

65. Sisterhen LL, Blaszak RT, Woods MB, et al. Defining family-centered rounds. Teach Learn Med. 2007;19(3):319-22.

66. Huang KT, Minahan J, Brita-Rossi P, et al. All together now: impact of a regionalization and bedside rounding initiative on the efficiency and inclusiveness of clinical rounds. J Hosp Med. 2017;12(3):150-6.

67. Grall KH, Harris IB, Simpson D, Gelula M, Butler J, Callahan EP. Excellent emergency medicine educators adapt teaching methods to learner experience level and patient acuity. Int J Med Educ. 2013;4:101-6.

68. Brancati FL. The art of pimping. JAMA. 1989;262(1):89-90.

69. Stoddard HA, O’Dell DV. Would Socrates have actually used the “Socratic method” for clinical teaching?. J Gen Intern Med. 2016;31(9):1092-6.

70. Brancati FL. The art of pimping. JAMA. 1989;262(1):89-90.

71. Wear D, Kokinova M, Keck-McNulty C, Aultman J. Pimping: perspectives of 4th year medical students. Teach Learn Med. 2005;17(2):184-91.

72. Kost A, Chen FM. Socrates was not a pimp: changing the paradigm of questioning in medical education. Acad Med. 2015;90(1):20-4.

73. Chen DR, Priest KC. Pimping: a tradition of gendered disempowerment. BMC Med Educ. 2019;19(1):345.

74. Tozer J, Layng T, Wolff M, Santen SA. Strategic questioning in emergency medicine training. AEM Educ Train. 2018;2(4):336-8.

75. Dunlowsky J, Rawson K, Marsh E, Nathan M, Willingham D. Improving students’ learning with effective learning techniques: promising directions from cognitive and educational psychology. Psychol Sci Public Interest. 2013;14(1):4-58.

76. Brown PC, Roediger HL, McDaniel MA. Make it stick: the science of successful learning. 2014.

77. Jessee SA, O’Neill PN, Dosch RO. Matching student personality types and learning preferences to teaching methodologies. J Dent Educ. 2005;70(6):644-51.

78. Detsky AS. The art of pimping. JAMA. 2009;301(13):1379-81.

79. Byrne R, Barbas B, baumann BM, Patel SN. Medical student perception of resident versus attending contributions to education on co-supervised shifts during the emergency medicine clerkship. AEM Educ Train. 2018;2:82-5.

80. Cunningham AS, Blatt SD, Fuller PG, Weinberger HL. The art of precepting Socrates or Aunt Minnie?. Arch Pediatr Adolesc Med. 1999;153(2):114-6.

81. Kahneman D. Thinking, fast and slow. 2015.

82. Cayley WE. Effective clinical education: strategies for teaching medical students and residents in the office. WMJ. 2011;110(4):178-81.

83. Hess BJ, Lipner RS, Thompson V, Holmboe ES, Graber ML. Blink or think: can further reflection improve initial diagnostic impressions?. Acad Med. 2015;90(1):112-8.

84. Tay SW, Ryan P, Ryan CA. Systems 1 and 2 thinking processes and cognitive reflection testing in medical students. Can Med Educ J. 2016;7(2):e97-e103.

85. Neher JO, Stevens NG. A five-step “microskills” model of clinical teaching. J Am Board Fam Pract. 1992;5(4):419-24.

86. Neher JO, Stevens NG. The One-Minute Preceptor: shaping the teaching conversation. Fam Med. 2003;35(6):391-3.

87. Teherani A, O’Sullivan P, Aagaard EM, Morrison EH, Irby DM. Student perceptions of the One Minute Preceptor and traditional preceptor models. Med Teach. 2007;29(4):323-7.

88. Seki M, Otaki J, Breugelmans R, Komoda T, Nagata-Kobayashi S, Akaishi Y, Hiramoto J, Ohno I, Harada Y, Hirayama Y, Izumi M. How do case presentation teaching methods affect learning outcomes?–SNAPPS and the One-Minute preceptor. BMC Med Educ. 2016;16:12.

89. Ferenchick G, Simpson D, Blackman J, DaRosa D, Dunnington G. Strategies for efficient and effective teaching in the ambulatory care setting. Acad Med. 1997;72(4):277-80.

90. Aagaard E, Teherani A, Irby DM. Effectiveness of the One-Minute Preceptor model for diagnosing the patient and the learner: proof of concept. Acad Med. 2004;79(1):42-9.

91. Furney SL, Orsini AN, Orsetti KE, Stern DT, Gruppen LD, Irby DM. Teaching the One-Minute Preceptor. a randomized controlled trial. J Gen Intern Med. 2001;16(9):620-4.

92. Jain V, Waghmare L, Shrivastav T, Mahakalkar C. SNAPPS facilitates clinical reasoning in outpatient settings. Educ Health. 2018;31(1):59-60.

93. Pascoe JM, Nixon J, Lang VJ. Maximizing teaching on the wards: review and application of the One-Minute Preceptor and SNAPPS models. J Hosp Med. 2015;10(2):125-30.

94. Nixon J, Wolpaw T, Schwartz A, Duffy B, Menk J, Bordage G. SNAPPS-Plus: an educational prescription for students to facilitate formulating and answering clinical questions. Acad Med. 2014;89(8):1174-9.

95. Wolpaw TM, Wolpaw DR, Papp KK. SNAPPS: a learner-centered model for outpatient education. Acad Med. 2003;78(9):893-8.

96. Wolpaw T, Papp KK, Bordage G. Using SNAPPS to facilitate the expression of clinical reasoning and uncertainties: a randomized comparison group trial. Acad Med. 2009;84(4):517-24.

97. Wolpaw T, Côté L, Papp KK, Bordage G. Student uncertainties drive teaching during case presentations: more so with SNAPPS. Acad Med. 2012;87(9):1210-7.

98. Barangard H, Afshari P, Abedi P. The effect of the SNAPPS (summarize, narrow, analyze, probe, plan, and select) method versus teacher-centered education on the clinical gynecology skills of midwifery students in Iran. J Educ Eval Health Prof. 2016;13:41.

99. Kapoor A, Kapoor A, Kalraiya A, Longia S. Use of SNAPPS model for pediatric outpatient education. Indian Pediatr. 2017;54(4):288-90.

100. Sherbino J, Frank J, Lee C, Bandiera G. Evaluating “ED STAT”: a novel and effective faculty development program to improve emergency department teaching. Acad Emerg Med. 2006;13:1062-9.

101. McGee S. A piece of my mind. Bedside teaching rounds reconsidered. JAMA. 2014;311(19):1971-2.

102. Alweshahi Y, Harley D, Cook DA. Students’ perception of the characteristics of effective bedside teachers. Med Teach. 2007;29:204-9.

103. Janicik RW, Fletcher KE. Teaching at the bedside: a new model. Med Teach. 2003;25(2):127-30.

104. Elsey C, Challinor A, Monrouxe LV. Patients embodied and as-a-body within bedside teaching encounters: a video ethnographic study. Adv in Health Sci Educ. 2017;22:123-46.

105. Chaballout B, Molloy M, Vaughn J, Brisson R, Shaw R. Feasibility of augmented reality in clinical simulations: using Google Glass with manikins. JMIR Med Educ. 2016;2(1):e2.

106. Knowles MS, Swanson RA, Holton EF. The Adult Learner: The Definitive Classic. Adult Education And Human Resource Development. 2015.

107. Prensky M. Digital natives,digital immigrants Part 1. On the Horizon. 2001;9(5):1-6.

108. Prensky M. Digital natives, digital immigrants Part 2: Do they really think differently?. On the Horizon. 2001;9(6):1-6.

109. Itoh T, Lee-Jayaram J, Fang R, Hong T, Berg B. Just-in-time training for intraosseous needle placement and defibrillator use in a pediatric emergency department. Pediatr Emer Care. 2019;35(10):712-15.

110. Wang V, Cheng YT, Liu D. Improving education: just-in-time splinting video. Clin Teach. 2016;13:183-6.

111. Cheng YT, Liu DR, Wang VJ. Teaching splinting techniques using a just-in-time training instructional video. Pediatr Emer Care. 2017;33(3):166-70.

112. Mangum R, Lazar J, Rose MJ, Mahan JD, Reed S. Exploring the value of just-in-time teaching as a supplemental tool to traditional resident education on a busy inpatient pediatrics rotation. Acad Pediatr. 2017;17(6):589-92.

113. Thomas AA, Uspal NG, Oron AP, Klein EJ. Perceptions of the impact of a just-in-time room on trainees and supervising physicians in a pediatric emergency department. J Grad Med Educ. 2016;8(5):754-8.

114. Nishisaki A, Donoghue AJ, Colburn S, et al. Effect of just-in-time simulation training on tracheal intubation procedure safety in the pediatric intensive care unit. Anesthesiology. 2010;113(1):214223.

115. Kessler D, Pusic M, Chang TP, et al. Impact of just-in-time and just-in-place simulation on intern success with infant lumbar puncture. Pediatrics. 2015;135(5):e1237-e1246.

116. Patocka C, Lin M, Voros J, Chan T. Point-of-care resource use in the emergency department: a developmental model. AEM Educ Train. 2018;2:221-8.

117. Campbell J, Umapathysivam K, Xue Y, Lockwood C. Evidence based practice point-of-care resources: a quantitative evaluation of quality, rigor, and content. Worldviews Evid Based Nurs. 2015;12(6):313-27.

118. Borgerson NJ, Vuokko Henriksen MJ, Konge L, et al. Direct ophthalmoscopy on YouTube: analysis of instructional YouTube videos’ content and approach to visualization. Clin Ophthalmol. 2016;10:1535-41.

119. Patterson MD, Geis GL, Falcone RA, LeMaster T, Wears RL. In situ simulation: detection of safety threats and teamwork training in a high risk emergency department. BMJ Qual Saf. 2013;22:468-77.

120. Mishra S. Google Glass in medicine: the man with a computer on face. Indian Heart J. 2016;68(4):586-7.

121. Dougherty B, Badawy SM. Using Google Glass in nonsurgical medical settings: systematic review. JMIR Mhealth Uhealth. 2017;5(10):e159.

122. Sandars J. The use of reflection in medical education: AMEE Guide No. 44. Med Teach. 2009;31(8):685-95.

123. Adams RJ. Tele-attending can emulate and even improve bedside teaching and learning. Med Teach. 2018;40(10):1067-8.