Section J

Housestaff as Educators

Gwendolyn Wright, M.D.
Nancy Kaufman, M.D.

Students learn a tremendous amount from housestaff.The interaction is generally more of an apprenticeship situation than formal education.Students will spend most of their time with interns and residents who tend to be stressed by the demands and responsibilities of their position.This may influence their ability to teach students.Yet house officers are in aunique position to model essential skills.They are the most available and least intimidating source of information for students.

Orientation to clinical services:
Orientation is usually provided by house officers.Every hospital, and sometimes every service, has its own complex organization and rules.Interns' survival and function depend upon knowing this information, and they can orient students to the hospital.They teach students where to find vital information about the care of their patients in charts, nurses' notes and in the computer.Interns teach students how to performpractical tasks, such as writing admission orders, progress notes medication orders, lab and radiology requests, and discharge orders.In the outpatient setting, residents can show students how to find supplies and are a great source on the usual pattern of activity, e.g. "the nurses weighs the patient, puts him in a room,charts are put in the door, and you write on this form."House officers may show students how to make appointments and referrals, where to call for information, and how to interpret information from old hospital records.

History and physical examination skills:
These skills have been taught to the students by the faculty.However, the housestaff have a unique opportunity to supervise, evaluate, and critique the students' skills on a daily basis.They can emphasize areas of the history and physical examination that are unique and different at different ages.

Data management and interpretation:
Organizing and interpreting information is essential to the care of patients.In the hospital students are barraged by large amounts of information.They are frequently asked for results of lab tests and other procedures.Learning to organize this data is an essential skill not only for becoming a house officer, but for becoming a physician.Interns can show students how they organize patient data on cards and flow-sheets.They can help students learn which data are essential and worth presenting on rounds, and how to organize complex patients by systems.Interns serve as models for the students of how to present patients during rounds.Interpretation of data is an essential skill to learn during third year.Housestaff and attendings teach students how to read x-rays and interpret lab values, identifying when results warrant immediate attention, should be repeated, or suggest further testing.In pediatrics, students must learn how to assess the normal values of lab tests for various ages.

Prioritization:
Prioritizing the different aspects of a patient's care is an essential skill taught by attendings and modeled by housestaff.The student must learn which of the patient's problems must be addressed first, and which tests should be performed first.Not all things can be performed at once, and the student must learn which are of the highest priority and must be pursued.

Time management:
This is a life-long skill modeled by the housestaff.Interns can show students when during the day to get work done, such as when to "pre-round", write progress notes and orders.Housestaff teach students how to use time wisely and accomplish their work efficiently.

Traditional and unspoken rules:
These are passed from the interns to the students.A few examples include:

• Trust the parents
• Listen to the nurses
• When you call a consult, have a specific question to ask
• If you really want something done, find the patient's nurse and explain why
• At all costs, don't offend the nurses or ward clerk
• Call the private physician when you see his/her patient in the clinic or emergency room or admit the patient

House officers also model for students the nuances of appropriate house officer decision making, i.e.,decisions that should be made with the attending's advice, or should be made independently.

Procedures:
House officers teach, demonstrate, and supervise procedures.These vary from minor procedures, such as phlebotomy, ear cleaning, and IV starts, to more invasive procedures such as lumbar punctures and other line placements.Students learn not only the procedure, but where to find supplies, how to set them up, how to prepare the patient and family, including obtaining consent and what to do with the samples obtained.

Patient and family interactions:
Housestaffare models of these skills for the students.Although attendings are present for some discussions with families, particularly involving important diagnoses and procedures,students need to learn how to deliver daily news to family, and how to respond to and calm their worries.In pediatrics, students can learn a lot from housestaff on how to charm, soothe and distract patients of various ages.

Attitudes:
Attitudes are learned in the hospital under pressure.It is essential that house officers serve as a modelfor open-minded, sensitive understanding of the needs of the patients and families.They are in a position to give students feedback on their interactions with patients, family members and other members of the staff.They also convey their attitudes about subspecialists and generalists in the department and the community.

Self-education:
Self-education is demonstrated by interns and residents when they recognize the limits of their knowledge and seek information from other sources, including textbooks, literature searches and consults.Residents are the best source of information on what books are worth buying, what resources you should carry, and where to read in more detail about a specific issue.Most importantly, residents can help students select patients to follow.Students need guidance on which cases will provide the best learning experience.If the housestaff are familiar with the curriculum, they can guide students toward patients who demonstrate key teaching points.

The role of senior residents:
The senior residents' role is between that of the intern and that of the attending.At times, they may directly supervise students, and thus teach some of the basic patient assessment and management skills discussed above.In general, they are in the best position to review cases with students, teaching them how to apply knowledge of basic science in constructing a differential diagnosis and management plan, as well as giving them clues for how to present patients clearly and effectively.Residents can motivate students to think and learn by asking probing questions which force them to analyze and justify their differential diagnosis and assessment plan They have an opportunity to provide students with feedback on their progress and performance of required tasks.

Academic teaching:
Academic teaching is better provided by senior house officers who are in a position to help students with a patient-centered discussion of pathophysiology, differential diagnosis and interpretation of physical findings.Residents can draw upon their expertise with other patients to discuss the usual work-up or course for a patient with a specific problem.They can use standardized or hypothetical cases to broaden the discussion of differential diagnosis and management issues.

House officer role in student evaluation:
Evaluation of many aspects of the student's performance can be done by the housestaff because of the close and frequent contact.However, the nature of the interaction affects what aspect of the student's performance can best be evaluated.A house officer who actually observes a student's interaction with the patient and family in the performance of the history and physical examination is in the best position to evaluate these skills and attitudes.A resident who reads the written work-up or listens to the case presentation is able to evaluate different skills.Senior residents who lead conference discussions are able to better assess the student's knowledge.Most house officers are capable of evaluating interpersonal and professional skills such as rapport, punctuality, attitude toward patients, response to stress, organization, efficiency and enthusiasm for the work.They can evaluate how quickly students learn new skills, assume responsibility and follow through on assigned tasks.It is important for house officers to evaluate only those areas of the student's performance in which they have had significant interaction.In order to do so effectively, house officers must know the expected level of competency for the students and be as objective as possible, setting aside personal likes and dislikes.

Clerkship director's role promoting house officer teaching:
Clerkship directors can increase the effectiveness of house officers as teachers by providing them with a copy of the goals and objectives and curriculum for the clerkship and working with the housestaff to identify areas which can be taught and evaluated by them.If the housestaff are responsible for teaching certain aspects of the curriculum, these areas should be clearly delineated to the housestaff at the beginning of the year.Interns and residents should be given feedback on their effectiveness as teachers and evaluators, as documented on evaluations performed by the medical students.Residents should have access to the clerkship director to discuss problems which arise over the course of the rotation, particularly when the performance of a student is below the expected level.Residents should be made aware of the profound influence they have, not only on the educational experience of the student, but upon the attitudes they develop toward patient care.Their important contribution should be recognized and rewarded.