In many specialities, it is common to have more than one learner working with you at any given time. These are very challenging days/shifts, because you have to juggle so many cognitive priorities. Personally, I find these to be the most exhausting shifts that I work, regardless of what part of the department I am working in that day. This post looks to serve as a toolbox to help provide you with a few extra skills to make those shifts a bit (cognitively) easier, enjoyable, while still being fruitful for the learners working with you.
Heading in
Sorry learners, but working with more than just one of you is going to be a harder shift for us, so anticipating that this is happening (by looking at your schedule in advance) can be helpful to set the right mindset going into the shift (some would argue that this would cause undue stress, and that is reasonable – its the same reason I don’t look at the department before going into work). But I tend to look at who I am working with on any given shift for a variety of reasons – and when I do see that I have two learners (especially when there are two junior trainees), I prepare for my shift a little bit differently:
- I try and make sure I have a bit of time to myself at some point in the day. Having a bit of cognitive quiet time can help on busy days.
- Personally, I practice some mindfulness before coming into work.
- Extra emphasis on being appropriately caffeinated; not over, not under.
- Eat a good meal pre shift/on shift.
- Driving into the hospital I put on an upbeat playlist, and I try and turn my brain off.
While it conceptually seems trivial, these are important steps for me to set the ‘tone’ for the shift. I often find that my mood and approach going into a shift will often dictate how the shift ends up going – perspective is a valuable tool. How you set up your day going into your shift is going to be different for all of us.
Starting
Your team is going to feed off your energy; so how you start the shift really matters. When you meet your learners, you want to demonstrate enthusiasm, have an understanding for their objectives, set expectations and prime them to how the shift is going to run. Setting the tone and expectations early is going to dictate the entire rest of your day.
Because it is your cognitive load that is going to be challenged on this shift, it is great idea to prime your learners to particular cases, or how you want them to flow through the shift. If 3 of us are picking up a case each at the start of a shift (I may be grabbing 2) – I will often triage those cases in a way that is helpful for the trainee, allows me to prime them to the scope of the case, and this subsequently makes reviewing cases easier for me. The goal here is to minimize the amount of work duplication you will need to do. For example; having the medical student see the chest pain is high yield, a resident to see an abdominal pain, and I take the generalized weakness, or social case.
Use the ‘Food Chain’
If you have more than one trainee, try and maximize the impact of your teaching by teaching all your learners at the same time. This can be accomplished by calling one over when you’re providing a teaching point, having a senior learner teach a junior trainee, while you watch (and then provide feedback on teaching, how meta).
Another option is to ‘run the board’ and provide teaching around the cases for both trainees as you discuss them, while providing insights into what is happening with your patients (excellent teaching tool for senior learners to help learn about practice variation).
Delegate
For the most part, learners are happy to have ownership of their patients. As the trainees are an extension of yourself on shift, ensure that you are appropriately delegating tasks, in an effort to minimize your cognitive or task load to free you up for other things. Prime your learners on providing discharge instructions, or following up on test results with actionable tasks (i.e.: if the D-Dimer is positive, order the CT-PE). Assigning task delegation is essential to maximize productivity on shift. Additionally, having your trainees complete tasks that do not require supervision is very important when there are multiple learners, to minimize the amount of time that you need to spend reviewing information. Once again, enforcing the idea that your cognitive load is the most important factor on these shifts.
Time your Charting
Deferring all your charting to the end of a shift is going to result in you often staying late to finish. Ideally, you want to complete as many as your charts as possible (I normally like to chart on 6 at at time, but on a multiple learner shift I sometimes have to pair this down to 3). Try to chart on your trainees charts as soon as possible (i.e.: we have dispositioned a patient and they are done with their chart), in order to offload this to ensure you are not stuck doing a lot of charting later. On a very busy shift, you may not have the opportunity for this, but make sure you try and build in the time to have the residents wrap up their charting early, so that you can tackle their charts prior to the end of your shift.
Breaks
Make sure everyone takes a break at some point. It is important to cognitively offload and refuel, even in the midst of a very busy shift, if you are mindful of the need to take a break, you will find time to squeeze it in. It makes things better for you, and your patients. When you take your break, don’t chart, or think about cases, use this as an opportunity to cognitively reset. Doing anything for an extended period of time is exhausting, and you still have half a shift to go!
Know when you free yourself up
It is important to view your team of learners as an extension of your shift productivity, so you want to ensure that you are maximizing their efficiency, and at times – this means knowing that they are ready to review a case, and to free up time to review with them. Triaging when they review cases can also be helpful for you to triage the tasks you need to do (i.e.: needing to review 2 cases, see a new patient and reassess another patient).
Especially on night shifts, I try to free myself up in the last two hours of my shift to be available to help the residents wrap up on time; because this is often my limiting factor to leaving on time (a good rule a mentor once taught me was to never leave until your resident leaves). So being free from my own tasks towards the end of the shifts, helps to ensure that my team can clean up on time.
Know when you just need to Survive (rather than Thrive)
It is important to provide educational value to trainees when they are working with us. But, at times, when there are multiple learners, it is reasonable to shift the focus to your needs on shift – less teaching than usual, less flow than usual, because the cognitive load on these shifts can be immense, and so it is quite reasonable to re-evaluate your typical shift priorities, because on these shifts, managing your cognitive load is the most important variable to thrive on the shift. It is important to note that we all have tough days, or stretches of shifts – and so sometimes, it is ok to just survive, and being honest with your trainees about this can help make it an easier shift for everyone.
Evaluations/Wrapping up
A really important core component of my wellness is leaving shifts on time. I ensure that I have done my job for the day, and working hard on shift lets me prioritize leaving on time. In order to a accomplish this with two trainees, I will often do evaluations at some point in the last hour of shift, and will often try to send one of them home 20-30 minutes early, in order to facilitate me completing my charting/other end of shift tasks. It is important in your shift intro to prime your trainees not to pick anything up towards the end of the shift that will add unnecessary late shift complexity.
Conclusions
If you had to draw the two greatest pearls from this post, I would say that the key to thriving on the double learner shift is to ensure you are starting with the right mindset, and you have to plan your moves throughout the shift to anticipate your own future needs. I have often talked about this with flow, but you can set your shift up to flow in a way that is best for you – you just have to think about it in advance, the same holds true for managing multiple learners.
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