Advanced Teaching Skills for the

Fast-paced OR: How to Educate

Successfully When Faced With High
Clinical Workload, Lack of Protected Time,
and Limited Funding
Marek Brzezinski, MD, PhD and John D. Mitchell, MD
Department of Anesthesia and Perioperative Care
University of California
San Francisco, California

Department of Anesthesia, Critical Care, and Pain Medicine

Beth Israel Deaconess Medical Center
Harvard Medical School
Boston, Massachusetts

 Explain the impact of milestones on resident

Learning Objectives:
education
As a result of completing this activity, the participant
will be able to: Author Disclosure Information:
 Describe the current and relevant teaching theo- Dr. Brzezinski has disclosed that he receives hono-
ries, including the adult learning theory and the raria from Grifols Inc. Dr. Mitchell has disclosed that
Dreyfus and Dreyfus model he has no financial interests in or significant relation-
 Explain the development of clinical decision- ship with any commercial companies pertaining to
making by residents this educational activity.
 Identify potential obstacles to teaching in the fast-
paced, high-pressure environment of the operating
eaching in the fast-paced, high-pressure operating
room
 Describe simple approaches to optimize the cur-
riculum, as well as effective techniques to improve
teaching, while not compromising quality of care
T room (OR) is demanding. High clinical workload, lack
of protected time, and limited funding represent major
obstacles to education1–7 (Supplemental Digital Content 1,
http://links.lww.com/ASA/A586). Moreover, the motivation
for many anesthesiologists when they entered medical school
was to become a doctor, not an educator. The talents and
Supplemental Digital Content is available for this article. Direct URL skills involved in teaching are quite different than those
citations appear in the printed text and are available in both the HTML
and PDF versions of this article. Links to the digital files are provided in involved in clinical care—and many are not intuitive. Thus,
the HTML and PDF text of this article on the Journal’s Web site the educator-anesthesiologist must learn teaching strategies
(www.asa-refresher.com). that are effective, time-efficient, and simple.
49
Copyright r 2015 American Society of Anesthesiologists. All rights reserved.
50 Brzezinski and Mitchell

In this chapter, we provide an overview of relevant and therapeutic plan. The Educator researches the evidence
teaching theories, highlight potential obstacles to teaching, behind clinical practice with the goal of improving manage-
and provide effective and time-efficient techniques to im- ment. Although not developed for anesthesiology, RIME aids
prove teaching while not compromising quality of care. in assessing the learner’s progress.
Example: A resident who provides all the data without any
prioritization by ‘‘just reading’’ the preoperative note (pre-
CURRENT AND RELEVANT EDUCATIONAL pared by someone else), and without integrating the data, is a
MODELS ‘‘reporter.’’ To facilitate development to the next level, it is
Four educational models are particularly relevant to the edu- essential to encourage the resident to focus on data relevant to
cator-anesthesiologist: Adult Learning Theory, the RIME the particular patient’s anesthetic management in a mean-
framework, the Dreyfus and Dreyfus model, and Milestones. ingful and cohesive way, emphasizing clinical judgment.

Adult Learning Theory Dreyfus and Dreyfus Model

Adult Learning Theory, introduced by Malcolm Knowles in the The Dreyfus and Dreyfus model describes the progression from
1950s,8 promotes and defines concepts of andragogy: self-di- novice learner to master. In this model, the development of ex-
rection in learning and adult education.8,9 The central premise pertise is not a linear process, but a progression through a series
of Adult Learning Theory is that as individuals mature, they of increasingly complex stages: Novice, Advanced Beginner,
develop a drive and desire to learn as well as an inner respon- Competent, Proficient, Expert, and Master (Table 1).5,12
sibility for their own training. Thus, although educators sup- Novices approach a skill with a rule-based and context-
port and facilitate training, the energy and motivation has to free mindset. The exposure to clinical work facilitates four
come from the learner. Consequently, the educator should: major changes5,6,12:

 Direct the learner to embrace independent learning.  The learner’s presentations become more focused and
Example: Rather than just lecture, the educator should condensed, that is, only pertinent data are presented.
provide educational materials and encouragement to  The learner recognizes that many clinical presentations are
read independently. ‘‘copies’’ of those of previous patients and can be diagnosed
 Utilize the learner’s interest in knowledge with practical and treated quickly, efficiently, and safely without consult-
relevance. Example: Concentrate on information rele- ing textbooks, simply by using pattern recognition.
vant to current patient care, demonstrating the practi-  The learner develops his/her own idiosyncratic techniques on
cality of such knowledge. how individual diseases present, are diagnosed, and are
 Create a respectful learning environment and treat the treated (i.e., ‘‘own anesthesia techniques’’ or ‘‘illness scripts’’).
adult learner as a colleague. Example: Solicit learner  The learner develops the ability to prioritize and see the
opinions based on acquired knowledge and experience, ‘‘big picture.’’
and integrate them into the care plan when appropriate.
Using the analogy of a dancer, the beginner consciously
The essence of Adult Learning Theory could be summa- repeats a pattern of ‘‘left foot, right foot, left foot’’ based
rized in one sentence: ‘‘There will be no teaching today—just on a ‘‘textbook,’’ whereas an intermediate dancer begins to
learning!’’ It is less important how much teaching took place monitor only the more difficult steps, and an experienced
(duration of teaching) and more important how much was dancer can dance for hours on a sort of intuitive, subcon-
actually learned (‘‘productivity’’ of teaching). scious ‘‘autopilot.’’ Ultimately, each dancer uses his/her
own moves when it comes to expressing the music.

The essence of Adult Learning Theory could be Milestones

A shortcoming of the Dreyfus and Dreyfus model applied
summarized in one sentence: ‘‘There will be no
clinically is that it describes a general development of
teaching today—just learning!’’ skills, but lacks specifics. The Milestones project took the
Dreyfus and Dreyfus model and applied it to the six do-
mains of competencies identified by the Accreditation
Council for Graduate Medical Education and the American
RIME Framework Board of Medical Specialties: patient care, medical knowl-
The RIME framework provides terminology describing the edge, practice-based learning and improvement, inter-
level and progress of the learner: Reporter, Interpreter, Man- personal and communication skills, professionalism, and
ager, and Educator (Supplemental Digital Content 2, http:// systems-based practice.13 This approach allowed ‘‘trans-
links.lww.com/ASA/A587).10,11 The Reporter gathers clinical lation’’ of the competencies into separate developmental
information. The Interpreter uses clinical data to identify and stages (level 1 to level 5), facilitating assessment of each
prioritize problems and to establish a differential diagnosis. learner’s level of competence (Table 2). By helping the ed-
The Manager formulates a diagnosis and develops a diagnostic ucator and learner alike to better define the progression

Copyright r 2015 American Society of Anesthesiologists. All rights reserved.

Advanced Teaching Skills for the Fast-paced OR 51

Table 1. Dreyfus and Dreyfus Model: Stages of By helping the educator and learner alike to
Learning Development
better define the progression from novice
Training
Stage Development Issues Level learner to master, Milestones facilitate
Novice May not see the ‘‘big picture’’ Intern or monitoring of a learner’s progress.
Difficulty prioritizing clinical information medical
student
Uses the analytical, textbook approach
All current educational models agree on the importance of
Advanced Recognizes recurrent clinical Junior encouraging the learner to focus on clinical judgment
beginner presentations resident
rather than on repeating ‘‘the facts’’ (as commonly happens
Recognizes that clinical presentations can during the daily preoperative presentation).2,15,16 To op-
be managed without ‘‘textbook’’
timize the educational experience in the time-limited OR
Starts to use pattern-recognition
approach
environment, the educator should1,2,15–19:
Learns to prioritize, develop own clinical
preferences
 Identify the level of the learner, for example, by asking
the resident to reason about the case and gaining insight
Competent Develops illness transcripts and relies on Senior
pattern recognition (most cases) resident into his/her knowledge level.
 Assist the learner’s transition from gatherer of data (e.g.,
Understands and acknowledges personal
responsibility for clinical decision- a resident who is ‘‘just reading’’ the preoperative
making anesthesia note) to interpreter and decision-maker
May desire to stay longer and follow up on (e.g., encouraging the resident to focus on clinical
the patient’s progress judgment, with simple questions such as: ‘‘What is the
Proficient Strong intuitive sense Fellow or ASA classification?’’ ‘‘Why does the patient need the
Capable of handling evolving situations Junior operation at this time?’’ ‘‘Does the patient have a
attending
Learning limitations and when to call for difficult airway—yes or no?’’)
help  Encourage reading, promoting conceptualization over
Expert Uses pattern recognition for most cases Midlevel memorization.
learner Is able to identify cases that require attending  Provide learners with opportunities to share knowledge
further analysis to assess their breadth of understanding (e.g., by asking:
Easily falls into ‘‘autopilot’’ ‘‘So, what did you do yesterday? Last month?’’)
Master Reflects on individual patient cases Senior
 Facilitate the change from analytical to intuitive (pattern
learner attending recognition) (e.g., by consciously reducing the time for
Determines how to better the overall
clinical practice of the field ‘‘analytical thinking’’ and only allowing time for
Clinical exposure to patients forces the novice to progress through stages intuitive decisions).
wherein s/he begins to understand situational aspects, learns to recognize  Promote reevaluation of clinical decision-making and
clinical patterns, and develops an approach based on experience-based pattern
recognition that is intuitive and uses idiosyncratic ‘‘my-own-anesthesia’’ self-reflection.
techniques. This flexible and intuitive approach ultimately replaces the originally
inflexible, analytical, textbook-based and rule-based approach.5,6,12 Adapted
from Bhave and Brzezinski.2

EFFECTIVE AND TIME-EFFICIENT TEACHING

from novice learner to master, Milestones facilitate mon-
TECHNIQUES FOR THE OR
itoring of a learner’s progress.4,14 The key to time-efficient education in the OR is to spend
the time effectively. Rather than teaching comprehensively,
Summary of Learning Theories teach productively. This is best accomplished with an es-
tablished three-step approach20–22:
 The progression to expert clinician is a nonlinear process
that happens in stages. The steps driving this process are: Step 1: Identify the learning needs of the particular
familiarity with recurrent clinical presentations, priori- resident
tization, and development of a fast, intuitive, pattern- Step 2: Focus teaching on identified needs only (e.g.,
recognition approach to clinical situations.5,6,12,15 limited and rapid teaching)
 The driving force behind learning is the mature adult Step 3: Finish with feedback to ensure that identified
learner.8,9 needs have been met and reinforced
 The RIME, Dreyfus and Dreyfus, and Milestones
frameworks allow assessment of the learner’s prog- This ‘‘target an educational need, teach only that need, and
ress.4,13,14 then make sure you got your message across’’ approach ac-

Copyright r 2015 American Society of Anesthesiologists. All rights reserved.

52 Brzezinski and Mitchell

Table 2. Example of Anesthesiology Milestones Used to Assess a Resident’s Progress

Level 1 Level 2 Level 3 Level 4 Level 5

Performs patient assessments Performs postanesthetic assessment Identifies and manages Identifies and Independently
and identifies complications to identify complications of perianesthetic complications manages all identifies and
associated with patient care; anesthetic care; begins initial unique to subspecialty or medically perianesthetic manages all
begins initial management of management of perianesthetic complex patients, and requests complications with perianesthetic
complications with direct complications with direct appropriate consultations with conditional complications
supervision supervision indirect supervision independence
Example of Anesthesiology Milestones (ACGME report worksheet) for Patient Care 4: ‘‘Management of Perianesthetic Complications.’’ The milestones demonstrate the
increasing level of competence (learner’s progress).13
From Schartel SA, Kuhn C, Culley DJ, Wood M, Cohen N. Development of the anesthesiology educational milestones. J Grad Med Educ 2014; 6(suppl 1):12–14. Reproduced
with permission. Copyright Journal of Graduate Medical Education.13 (Italics added.)

complishes two goals.20–22 First, it reduces the time required doing this, the teacher will ultimately pinpoint sound,
for OR teaching, as a significant amount of time is frequently reasonable, and achievable learning goals.
spent on unintentionally teaching what the learner already
knows or is not ready for, or what the faculty likes to teach
independent of the case at hand. Second, it increases teaching Step 2: Teach Only the Identified Needs
productivity by focusing the limited OR teaching time on Once the specific learner’s needs have been identified,
deficits only. We will review strategies for each step. teaching should address those needs only. There are five
well-established, time-efficient, and effective teaching
Step 1: Identify the Learning Needs of the Particular methods that promote high-value skills essential for
Resident
Two time-tested tools effectively identify learning needs:
asking questions and observing the learner. Asking ques- Table 3. Examples of Questions Assessing the
Learning Needs of a Resident
tions is a quick and effective way to assess learning needs
and identify where deficiencies exist (Table 3). Observation What Is the Resident’s: Suggested Approach/Questions
can be performed efficiently anywhere and anytime. It ef-
fectively identifies needs across all domains, including in- Level of experience with the The goal is to establish whether the
particular procedure? resident understands the two or three
terpersonal interactions, knowledge, and technical skills. crucial aspects of the particular
Most faculty members unconsciously use both tech- procedure to provide safe anesthesia
niques already, but do not identify that this is vital to the Has the learner done this surgery
educational process. If the learner is not included and is before? Will the resident be able to
unaware that these techniques are part of the teaching set up the room? Is s/he familiar
with diluting and dosing particular
process, however, he/she could perceive questions and ob- medications?
servation in a negative way.2 For example,
Level of knowledge? Simple, uncomplicated questions can
be a powerful tool to identify what
 Simple observation by the attending could have a should be taught:
counterproductive effect by making the resident think How does heparin work?
‘‘Is my attending going to take the procedure away from
Why ACT and not PTT?
me?’’ or ‘‘I must be doing something wrong! Why is he
What are the key aspects of PFT?
watching me?’’ Similarly,
 Well-meant questions, like ‘‘Did you give the patient the How do you calculate SVR?
entire 250 micrograms of fentanyl?’’ can be perceived Level of clinical skills? How many times have you done this
procedure before?
negatively by the learner. He/she may begin wondering,
‘‘Did I do something wrong? Wasn’t I supposed to do it? Who was your staff and what was your
approach? (Given that we all are
Why is she micromanaging me?’’ idiosyncratic, clarifying the
difference between your and other
In the examples, ‘‘undisclosed’’ teaching and ‘‘unsolicited’’ attending’s preferences might
feedback create dissonance. Questions and observations prevent negative interactions later.)
should instead be ‘‘disclosed’’ as an educational activity.2 Clinical judgment? What are the issues we should focus
on in this patient?
Building on this critical foundation, the educator needs
to determine the learning goals: (1) identify the one to three How can we induce this patient with
aortic valve stenosis safely?
‘‘clinical pearls’’ of the procedure at hand; (2) compare
ACT ¼ activated clotting time; PFT ¼ pulmonary function test; PTT ¼ partial
them with the identified learning needs; and (3) distill out thromboplastin time; SVR ¼ systemic vascular resistance.
what teaching is feasible during that particular case. By

Copyright r 2015 American Society of Anesthesiologists. All rights reserved.

Advanced Teaching Skills for the Fast-paced OR 53

development of medical expertise: the One-Minute Pre-

ceptor (1-MP) model, the Think Aloud approach, ‘‘Acti- Table 4. Four Steps of the One-Minute Preceptor
Model
vated’’ Demonstration, the Aunt Minnie model, and the
Focused ‘‘Teach General Principle’’ model. Step 1 ‘‘What do you think is going on?’’
Step 2 ‘‘What led you to this conclusion?’’
One-Minute Preceptor Model. The 1-MP model is ‘‘What would you like to do now for this patient?’’
one of the best-established teaching methods in the edu- Step 3 Teach a general principle relevant to that particular situation
cational literature, reflecting its simplicity and effective- Step 4 Provide brief feedback
ness23–27 (Table 4). The 1-MP promotes clinical judgment The secret of the One-Minute Preceptor model’s popularity has been its
and prioritization. It includes four steps: simplicity and brevity.23–27

(1) Try to obtain a commitment from the learner on a

clinical problem. For example: The resident calls you
to the OR because of hypotension. On arrival, you ask ports aloud to the learner what s/he was thinking when
the resident, ‘‘What do you think is going on?’’ making a particular clinical decision. This teaching meth-
Frequently, the learner tries to avoid a clear diagnostic od is a powerful tool to teach clinical reasoning. Typically,
commitment out of fear of being wrong, and instead it requires the attending to take a few minutes to review,
provides a long list of possibilities: ‘‘Well, it could be step by step, what was going on in his/her mind during the
this, this, or thaty’’ Thus, it is crucial that the teacher decision-making process. For example:
insists on a commitment to just one choice, since it Resident: ‘‘I didn’t understand why you placed the pa-
provides insight into the learner’s reasoning. (Other tient in the reverse Trendelenburg position during the code
simple questions could be: ‘‘What do you think is the blue earlier today. It helped, but I don’t understand why.’’
diagnosis?’’ ‘‘What tests should we get?’’) Attending: ‘‘When I arrived at the code, the patient was
(2) Probe for supporting evidence with the focus on the in a Trendelenburg position and receiving chest com-
learner’s clinical reasoning, for example, ‘‘What led you to pressions. She converted twice to sinus rhythm—but only
that conclusion?’’ ‘‘Why would you choose that particular briefly, returning rapidly to V-fib. Something was keeping
test?’’ ‘‘What would you like to do now for this patient?’’ her from staying in the sinus rhythm. The history indicated
(3) Teach a general principle, based on the learner’s that the patient had a history of severe pulmonary hyper-
identified strengths and needs. tension and her end-tidal CO2 just before the code was
(4) 1-MP concludes with a brief feedback (Step 4). 70 mmHg. One of my big concerns was acute right heart
failure secondary to hypercapnia and respiratory acidosis.
Example: The anesthesia attending, Dr. Notime, to- Acute right-sided heart problems fit the clinical picture. I
gether with her resident, Dr. Workhand, provides care to a placed her into reverse Trendelenburg position to unload
73-year-old man who needs a knee replacement. There is a her right heart. Following this maneuver, she stayed in si-
sudden drop in blood pressure, and the resident asks the nus rhythm after the next defibrillation, and ultimately
attending to return to the OR. stabilized.’’

 On arrival, the attending resists the temptation to tell the ‘‘Activated’’ Demonstration Model. This model ef-
resident what she believes is going on. Instead, Dr. fectively addresses deficits in technical skills identified
Notime asks the resident: ‘‘What do you think is going during observation. In the ‘‘Activated’’ Demonstration
on?’’ and obtains a clear commitment (Step 1). model,22 the learner observes the master clinician. A few
 She then follows up with few additional questions, like critical steps make it an effective teaching tool:
‘‘What led you to this conclusion?’’ ‘‘What would you
like to do for the patient?’’ (Step 2). (1) The educator has to make it clear that this is an
 Dr. Notime then takes 1 or 2 minutes to teach a general educational activity. No procedure will be taken away
principle, such as ‘‘This looks like pulmonary embolism. from the learner.
The classic features of PE arey’’ (Step 3). (2) The expert has to tell the learner what to focus on. This
 Dr. Notime concludes with a brief feedback (Step 4). is a key step!
(3) Following the demonstration, the teacher has to
The Think Aloud Approach. Sometimes the resident ‘‘activate’’ the learner by asking her/him to clearly
does not fully understand clinical decisions made ‘‘in the heat describe what s/he has observed in order to verify that
of battle.’’ There is often limited time to discuss decisions in s/he ‘‘got the teaching point.’’
the OR. Sometimes, intuitive decisions may be explained by (4) Subsequently, if time permits, the resident is offered an
saying: ‘‘It just seems like the right thing to do.’’ Un- opportunity to repeat the just demonstrated activity to
fortunately, this is not enlightening for the resident. reemphasize the teaching point.
The Think Aloud approach28,29 turns this deficit into a (5) Brief feedback concludes the ‘‘Activated’’ demonstra-
meaningful educational experience. Here, the expert re- tion.

Copyright r 2015 American Society of Anesthesiologists. All rights reserved.

54 Brzezinski and Mitchell

Example: Dr. Notime has identified a problem with Dr. discussion. Although most clinician-educators use this tech-
Workhard’s mask ventilation. So, Dr. Notime: nique with regularity, there are ways to make it more time-
efficient and maximize learning productivity.2
 Explains to the learner, before the next mask ventilation,
that she will demonstrate one potential technique that (1) The first step is to divide the deficits into urgent or
could optimize Dr. Workhard’s approach to mask nonurgent:
ventilation (i.e., she is putting this activity in an  Urgent needs refer to deficits that, if not corrected,
educational context). could lead to endangering patients. Lack of
 She then asks the resident to focus only on how she experience is a typical example of an urgent
positions the patient’s head and holds the mask. learning need.
 Following a 1- to 2-minute demonstration, Dr. Notime Example: The attending, Dr. Notime, is manag-
‘‘activates’’ the resident by asking him to describe what ing a case in which the surgeon is going to inject
he observed in order to verify that he ‘‘got the teaching epinephrine nasally, and the resident has only a
point.’’ rudimentary understanding of potential compli-
 Following this, Dr. Notime offers the resident an cations. Therefore, correcting this deficit is
opportunity to perform mask ventilation and incorpo- urgent—she needs to talk to the resident
rate the new technique. ASAP.
 Finally, at a later time point after the intubation (when Dr. Notime: ‘‘The ENT surgeon is going to
things have quieted down), Dr. Notime provides brief, inject epinephrine nasally. Let’s review
constructive feedback. potential complications and manage-
ment.’’
Notably, ‘‘activated’’ demonstration can also be used to  There are many nonurgent needs, including knowl-
teach difficult conversations, such as end of life, DNR, edge needs. For example, it is unlikely that the
death, medical error, or communication with other col- patient’s care will be impacted if the resident does
leagues. not know about the molecular effect of epinephrine.
Thus, this learning need can be covered at any time,
The Aunt Minnie Model. This technique effectively especially when things have calmed down in the
teaches pattern recognition. If developed today, it would be case.
called ‘‘Snap Judgment’’ or ‘‘Blink’’—but it was established in Dr. Notime: ‘‘You mentioned earlier that
the 1940s by a radiologist at the University of Cincinnati and you would like to learn more about how
is called the Aunt Minnie model. The model uses the premise epinephrine works at the molecular level.
‘‘A case with radiologic findings so specific and compelling Would this be a good time to go over that
that no realistic differential diagnosis exists’’ to establish the topic or should we do it later?’’
principle that if someone walks like Aunt Minnie, talks like (2) Get buy-in from the learner, that is, disclose that this
Aunt Minnie, and looks like Aunt Minnie, then it’s Aunt activity has educational value.
Minnie!30–32 Although not developed specifically for (3) Secure the learner’s undivided attention. One well-
anesthesiology, the model promotes rapid pattern recognition. established way to do this is by taking over the case
Example 1. Attending: ‘‘What is this?’’ (and saying this out loud) so that the learner can focus
fully on learning.
(4) Focus on ‘‘clinical pearls’’ in the context of the current
patient.
(5) Limit teaching to the learner’s needs only; also, limit
teaching time to 10 to 15 minutes per ‘‘episode.’’
Limiting teaching time during clinical care will
enable the learner to remain engaged in care of the
patient, an activity that is of prime interest for the
resident.

Summary of Teaching Methods. The five teaching

Example 2. The Aunt Minnie model can also be applied to methods discussed in this section are current and evidence-
rapid pattern recognition of clinical scenarios, for example: based, effective and time-efficient (high teaching pro-
Attending: ‘‘This patient developed a sudden drop in blood ductivity), easy to remember, simple to use and implement
pressure and an elevation in pulmonary artery pressure fol- in any clinical setting, modifiable to fit individual needs,
lowing administration of protamine. What happened?’’ and focused on promoting high-value skills that are
essential for the development of medical expertise (Sup-
Focused ‘‘Teach General Principle’’ Model. This is a plemental Digital Content 3, http://links.lww.com/ASA/
wonderful way to correct deficits identified during preoperative A588).

Copyright r 2015 American Society of Anesthesiologists. All rights reserved.

Advanced Teaching Skills for the Fast-paced OR 55

The effectiveness of these five techniques can be further

increased by adjusting teaching to the level of the resident The motto for recommending literature in the
(milestones).2 In the beginning of the training (CA-1) as beginning of a rotation is ‘‘Less is more.’’
well as the start of every new rotation (CA-2), the learner is
focused on obtaining ‘‘textbook’’ knowledge as it relates to
pathophysiology and has a primarily analytical approach
to clinical problems. The learner has little ability to filter
Step 3: Finish Strong With Feedback to Ensure That
and prioritize clinical information. The big picture is elu-
the Identified Learning Needs Have Been Achieved
sive. The learner favors rules and checklists, as they typi-
Providing meaningful feedback is a critical, but difficult
cally provide a ‘‘textbook-standardized approach’’ to care.
skill.38–42 The old-fashioned ‘‘feedback sandwich,’’ that is,
In a sense, such a learner is a ‘‘one-trick-pony’’ when it
constructive criticism ‘‘sandwiched’’ between two positive
comes to anesthesiology training. To ‘‘speak the same
comments, is so widespread that learners are aware of it.
language’’ as the learner and better address the learning
While teachers are pointing out the positive things they
needs at this stage, the teacher should use ‘‘textbook lan-
observed, learners are not paying much attention—they
guage’’ and offer simple rules and protocols (i.e., limit the
are waiting for the ‘‘meat’’ of the feedback. Thus, it is
number of techniques to one or two) in order to avoid
useful to consider a new sandwich: ‘‘Ask–Tell–Ask’’43,44:
cognitive overload, confusion, and frustration. Hearing a
resident say: ‘‘Every attending is using a different techni-
 Ask: Start by asking the resident general questions, like
que. It’s so frustrating! Why don’t they agree on one simple
‘‘What do you think about today? How did you do?’’
approach?’’ could be an indication that the resident is still
Residents are introspective, recognize their mistakes,
stuck at a beginner-level mindset.
and verbalize them during this part of the feedback
At more advanced levels (experienced CA-2, CA-3, fel-
session.
low), the learner is invested in expanding the skills of in-
 Tell: During the ‘‘tell’’ part, the teacher—instead of being
tuitive decision-making, filtering and prioritizing clinical
negative and pointing out mistakes—gets the opportu-
information, seeing the ‘‘big picture,’’ and developing an nity to be positive, agree with resident assessment (‘‘You
extensive portfolio of techniques. Thus, the teaching
are correct, this was not a great intubation’’), and
should focus more on these advanced skills; the teacher
encourage the resident (‘‘I think your intubation was
should challenge and advance the learner’s clinical judg-
better than you described—remember, his neck was stiff
ment (judgment over facts), teach a variety of approaches,
and he had limited mouth opening. As a matter of fact, I
and foster development of trust in the learner’s clinical
would have had similar problems. You did well.’’).
judgment and skills. Overall, the thrust of the teaching
 Ask: In the final ‘‘ask’’ part, the educator focuses on
should be on taking the resident beyond the ‘‘comfort
future aspects: ‘‘So, what are you going to do differently
zone.’’ next time?’’
The educational process is further improved by
optimizing the curriculum. For this to work, any curricu-
Overall, the new Ask–Tell–Ask sandwich is more inter-
lum should define expectations. This should be done
active and supportive, and less confrontational (Supple-
within the written curriculum provided to the learner. The
mental Digital Content 4, http://links.lww.com/ASA/A589).
curriculum should also offer dedicated face-to-face time to
better understand the learner (e.g., level of training,
past experiences, rotational goals) and to remove any
unrealistic expectations—on both sides: faculty and
CONCLUSIONS
resident.33–37 The four main components of advanced teaching skills are:
The teacher should also recommend appropriate
reading materials. Avoid recommending major textbooks (1) Ensuring that learners know you are helping them to
as the introductory books to a new rotation. Reading learn.
big, thick, comprehensive (and expensive) books as the (2) Identifying specific learning needs (questions and
primary source can be overwhelming and lead to frus- observation).
tration. Typically, such books have only low educational (3) Practicing productivity-oriented teaching with less
impact in the beginning of a new rotation. However, focus on the duration of teaching or the number of
major textbooks are excellent for a more experienced topics covered and more on ensured learning. While
learner. teaching, focus on the following: promoting high-value
The motto for recommending literature in the beginning skills (clinical context)45; quality, not quantity; not
of a rotation is ‘‘Less is more.’’ Consider books that are not overwhelming the learner46,47; adjusting to the level of
only readable, but are feasible to complete in a day or two. the learner (e.g., using Milestones)2; and being out-
Such books will introduce key concepts while providing come-oriented (feedback loop at the end of teaching to
immediate satisfaction and motivate the resident to read ensure the resident ‘‘got it’’). Note that taking the
more, so have a second book ready for recommendation. learner ‘‘out of his/her comfort zone’’ can be perceived

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56 Brzezinski and Mitchell

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Copyright r 2015 American Society of Anesthesiologists. All rights reserved.