The Hospitalist as Teacher

Teach versus Coach

Jeffery G. Wiese, MD, associate professor of medicine at Tulane University in New Orleans, has thought a lot about what makes a great teacher and the differences between teaching information and teaching skills. To him it is the difference between teaching and coaching.

Dr. Wiese, who is on SHM’s board of directors, believes medical education is less about the dissemination of knowledge and more about how to apply that knowledge.

“Dissemination of knowledge is requisite but not sufficient,” says Dr. Wiese. “Clinical education is about performance because ultimately it doesn’t matter if the student knows a lot if he or she can’t put it in act for the benefit of their patient. And when you change that paradigm, then you move from being a good teacher to being a great coach.”

Dr. Wiese, who is also director of the Internal Medicine Residency Program and the chief of medicine at Tulane, presented a workshop at the SHM’s annual meeting in May, titled “Great Hospitalist to Great Teacher: Clinical Coaching.”

The five main points of the presentation are represented by the mnemonic VACUM: visualization, anticipation, choosing content that has utility, and motivation.

Visualization

Great teachers empower trainees to visualize how they will use the skill or knowledge for the benefit of the patient. The average lecture on hypotension, for example, disseminates the causes of hypotension and the treatment for each. The great coaching session, however, begins with getting the student to visualize using the skill. “Picture this: You are awakened from sleep on call to see a hypotensive patient,” Dr. Wiese says. “Do you see yourself in the room? Do you see the panic, the fear of those around you? Now visualize feeling the warmth of the patient’s extremities to exclude causes of low vascular resistance. Now imagine feeling the pulse to exclude bradycardia. Are you there? Now see yourself lowering the head of the bed and starting the IV to increase his preload.” The vision makes the content stick in the student’s memory.

Anticipation

“It’s not enough to teach a trainee how to do the skill,” says Dr. Wiese. “You have to anticipate where the trainee is going to get it confused and where the pitfalls are going to be in performing that skill down the road.”

This concept is analogous to that of someone giving directions to their house. Merely giving the student the destination (i.e., what they need to know) is not sufficient. Providing a heads up on where they might take a wrong turn ensures that they arrive at the destination.

In teaching hyperosmolar nonketotic coma (HONKC), for example, a great coach will begin with the warning: “Listen, this is where you could get confused. You might be tempted to ascribe a patient’s delirium to the osmotic effects of the high glucose, and while this can happen, it does not happen with a serum osmolarity of less than 340. You could forget that the cortisol surge that comes from infection is the leading cause of HONKC. Do you see yourself in the emergency department with that patient with HONKC? OK, when it happens, make sure you check the osmolarity; if it’s less than 340, do the lumbar puncture. Meningitis may just be the cause of the delirium and the infection that has caused the HONKC.”