Page 37 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

6 PART 1: An Overview of the Approach to and Organization of Critical Care

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teaching faculty. The critical care syllabus outlined earlier gives the TEACH CRITICAL CARE IN THE CURRICULA OF MEDICAL
opportunity for fellows to observe faculty teaching during their first SCHOOLS AND RESIDENCY PROGRAMS
rotation through the unit and during subsequent months to organize
and present selected topics from the syllabus with the help of their In many academic institutions, critical care faculty are well known
faculty preceptor. Our target is that our fellows have mastery of the among medical students and house staff as outstanding teachers.
complete syllabus by the time they complete their fellowship, an exer- This can allow diverse outlets for teaching scholarship in the medical
cise that confers confidence and credibility on their teaching skills and school curriculum and in residency training programs. In our medical
undoubtedly enhances their learning of the concepts they teach. Just school, freshmen students learn the physiology of the cardiovascular
as bench researchers go elsewhere and establish their laboratories, our and respiratory systems during the winter quarter and have time for
clinical scholars have created the same learning programs elsewhere, elective courses during the spring quarter. This created the opportunity
exporting this approach and content rather than evolving it over years. for critical care faculty to participate in teaching both basic physiology
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A second forum is our daily morning report, where three to five new and an elective course describing the pathophysiology of critical illness
pulmonary and critical care patients are presented in a half-hour con- putting freshman basic science in perspective. Students are stimulated
ference. One fellow provides a brief analysis and solution to each clini- by finding that their hard work in learning physiology has practical
cal problem, and suggestions or affirmations of the analysis by faculty applications in treating critically ill patients, and are enthusiastic to
and other fellows help develop the skill of processing and presenting apply this new knowledge of pathophysiology during preceptored visits
complex patients. to patients with respiratory failure or hypoperfusion states. Utilizing
clinically real teaching aids like a ventilator-lung model and simulators
■ LEARN AND USE A QUESTIONING APPROACH provides freshmen students with a vision of patient care at an early
stage in their clinical exposure. During sophomore year, focused topics
Another important forum for encouraging active learning of critical care related to critical care are taught during our clinical pathophysiology
is the daily teaching round led by the intensive care faculty and critical course, including asthma and acute respiratory distress syndrome.
care fellows. The format we have found most useful is to encourage the In the junior year, students rotate twice through the ICU for 2-hour
most junior member of the team responsible for the patient to provide a preceptored visits to patients illustrating manifestations of respiratory
complete, systematic review of the patient, concluding with a differential failure or hypoperfusion states. As described earlier, most senior medi-
diagnosis and treatment plan, while the attending faculty member pro- cal students in our school spend a month as members of the critical care
vides an active listening presence. When the presentation is complete, teams in our medical or surgical ICU.
the faculty member questions or confirms directly the essential points In the medical ICU, medical residents and interns rotate for at least
from the history, physical examination, and laboratory results, and three 1-month periods during their 3-year residency program. To
provides any clarification helpful to the rest of the team on generic or refresh and maintain the knowledge base acquired during these rota-
specific teaching issues, integrating the input of more senior members tions, our critical care faculty leads two medicine morning reports per
of the team to encourage participation in the bedside decision making month, during which they review a syllabus of critical care meant to
as a learning exercise. allow residents not on the ICU to utilize their critical care knowledge
Often the case discussions can be led to formulate questions not to process cases representing a specific aspect of critical care. Our fac-
yet answered concerning the patient’s problems. It is less important ulty members are also regular participants in the house staff teaching
to provide answers to the questions formed than to point the students conferences conducted by the departments of anesthesia and critical
of critical care in the direction of how to find the answers, beginning care, pediatrics, obstetrics and gynecology, and surgery, and this inter-
with their reading of appropriate topics in a critical care text available action fosters a collegial approach to critically ill patients among these
in the ICU. This continues to the appropriate use of medical infor- different departments. Finally, the participation of academic critical
matics to search the critical care literature electronically for answers care faculty in city, regional, national, and international critical care
expected in a short interval. Whenever the answer is not available, it conferences helps fine-tune and update teaching approaches that can
is the teaching responsibility of the faculty and critical care fellows to then enhance the scholarship of teaching critical care at one’s home
help students of critical care formulate the clinical investigation that institution.
could answer the question. In this way, the rounds in the ICU become
intellectually charged, and active participation of all members of ■ INVESTIGATE MECHANISMS AND MANAGEMENT OF CRITICAL ILLNESS
the team is encouraged. A spin-off of this questioning approach to
active learning in the ICU is much more informed cross-coverage Clinical investigation of critical illness is essential for the continued
between critical care teams. In units with active clinical investigation growth of effective critical care. Indeed, one of the hallmarks of critical
programs, this questioning approach stimulates interaction between care in the last decade has been the large number of high-quality clinical
the personnel delivering care and those conducting the research, and studies leading to better care. Yet the practice of critical care is often so
there is evidence that cross coverage, rather than detracting from demanding that the intensivist’s time is consumed with providing state-
continuity of patient care, may provide a “second set of eyes” on the of-the-art care. Accordingly, clinical investigation in the ICU requires
patient yielding improved outcomes. 19 an organized program that is parallel to and integrated with the prac-
tice and teaching of exemplary critical care. Such a program allows an
■ AFFIRM LEARNING outlet for the creative formulation of hypotheses arising at the bedside
of critically ill patients. It also enhances the morale of the critical care
Students of critical care learn in a charged environment where some physician-nurse- respiratory therapist-pharmacist-physiotherapist team
patients do not improve or actually deteriorate despite thoughtful, by developing shared confidence that new concepts are being regularly
focused, and timely care. Teachers of critical care can diffuse the angst learned during delivery of critical care.
among students by appropriate, well-placed affirmation of the care An effective critical care research team consists of a research director,
being delivered. For example, exemplary case presentations, thought- critical care nurse research coordinator, and several critical care fellows.
ful and complete differential diagnoses, focused and insightful treat- Regular scheduled communications about ongoing research protocols,
ment plans, and well-formulated questions appropriately researched their significance, and their need for patient recruitment need to be
in the available literature are all targets for faculty approbation. When maintained between the research team and the critical care team. The
praised appropriately and without flattery, students of critical care research team needs to meet on a regular basis to interpret and update
respond with energy and enthusiasm, allowing them to learn to the data in each of its protocols and to consider and discuss new hypotheses
limit of their potential. for testing. Ideally, the clinical investigation of critical illness should

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