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optimizing learner training while prioritizing patient care

It’s a common refrain in academic EDs: sometimes, it feels like there are learners everywhere! A senior resident here, a junior resident there, a few medical students of varying levels—and some off-service rotators to keep things interesting. How do you make sure patients are receiving optimal care while addressing the educational needs of all these people? The simplest approach is organize your team using the RIME paradigm:


For reporters (learners who are capable of or learning to perform and present an H&P), choose bread and butter cases and patients with low communication barriers. Ask them to obtain complete information. Give feedback on interview skills, physical exam skills, documentation, and presentations. Expect these learners to need help devising differential diagnoses and management plans.


Interpreters should be more facile with manipulation of the data to develop a ranked differential and explain how different results would affect the diagnosis. These learners should be offered cases with more acute and complex presentations. Give feedback on their ability to prioritize problems, develop differentials, and interpret clinical data. Encourage task follow-through and patient re-evaluations. 


Managers know not just what data means but what should be done about it. They should be asked to create and implement plans, be the primary managers of their patients, and work to coordinate the medical team. Feedback should be directed at these attributes.


As learners develop, they will often take on the role of educator, sharing their knowledge and skill with their patients and other learners. Ask them to explain concepts and supervise junior leaners. Click here for more information on helping educators improve or helping managers transition to educators.


We often have little control over the types of patients we see in the ED. If the “right” patient isn’t available for a reporter, choose a level of involvement that is commensurate with their readiness. Your medical student might be overwhelmed taking a full H&P on the complex patient with communication difficulty. Asking them to do an appropriately challenging but do-able task on such a patient (reporting the findings of a complete neurologic or cardiovascular exam, for example) may be both empowering and instructive. The key here is tailoring your expectations to the right role and providing the experiences that help the learner “level up.” Misalignment of expectations can put learners at risk for bad experiences and patients at risk for suboptimal care, not to mention drive you crazy. The next time you feel like clinical teaching isn’t going to plan, a mental RIME check may be in order.

Ander DS, Wallenstein J, Abramson JL, Click L, Shayne P. Reporter-Interpreter-Manager-Educator (RIME) descriptive ratings as an evaluation tool in an emergency medicine clerkship. Journal of Emergency Medicine 2012;43(4):720–7.
Chen HC, O’Sullivan P, Teherani A, Fogh S, Kobashi B, Cate ten O. Sequencing learning experiences to engage different level learners in the workplace: An interview study with excellent clinical teachers. Medical Teacher 2015;37(12):1090–7. 

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