The Key to Teaching & Learning Procedures as a Resident

March 13, 2023
From contending with burnout to struggling with managing your finances, residency is a difficult stage in any medical professional’s journey. But perhaps one of the biggest stressors of all is “learning on the job.”
Whether you’re a chief resident teaching juniors or it’s the other way around, it’s important to foster a rich educational environment for residents. This ensures that they fully understand the procedures they’ll one day have to perform. Read on for best practices to better learn (or teach!) during residency. 

My Learning Experience As a Resident

Another disaster coming to the OR from the emergency department: a septic patient with an empyema, the kind of chest infection that can quickly become lethal. Already on pressors. And much to our dismay, the high-dose pressors are going in through a measly 22 gauge IV that may or may not be in a vein.

As an eager junior resident, I was excited by the challenges ahead.

“Dr. Radvansky,” one of my favorite mentors asked me, “What is your plan for [IV] access?” His name was Dr. O. He was brilliant—all business.

I wasn’t exactly sure, but I knew we had to improve the situation. And I feared that the surgeons scrubbing on this pad of pus in the pleura would mobilize some of those nasty cytokines into the vasculature.

“I think we’re gonna need a central line. But I’ve never done one.

“Go scrub. I’ll talk you through it.”

I had rotated through the ICU by this point, so I knew some of the basic tenets of the procedure, but the finer points of it would be all new to me.

Despite this happening almost 10 years ago, the explanation of how to do the procedure was so fantastic that I remember it as one of the shining moments of residency. 

Dr. O threw on some gloves and cleared his voice.

“First, I need your full attention. I’ll watch the vitals. Your full focus, here,” he said as tapped on the kit. “It begins with nomenclature. This is ‘the wire.’ This is ‘the dilator.’ This is ‘the catheter.’ This is ‘the needle.’”

These were all things that I already knew. But explicitly naming each intricate piece in the kit almost personified the materials, as though I had known them all of my life. 

Time to begin.

“Grab the ultrasound probe with your left hand. Hold it completely orthogonal to the floor. Apply the gentlest pressure necessary to obtain a picture, with the distal part of the probe just touching the clavicle. Anchor your left hand with your pinky and 4th finger.” 

I see the vessel. A little too much compression, and it shrinks before my eyes.

“You are pushing too hard with your left hand. Lighten up while maintaining gentle contact with the skin.”

It’s back into view. 

“Hold the syringe exactly like this, with your right thumb and first three fingers. Give a staccato jab ‘this hard’ through the skin he says,” as he prods my own clavicle sterilely to demonstrate the right amount of pressure.

“Now hold your right hand against his head, and WITHOUT MOVING IT AT ALL, take your left hand and slide the catheter off of the needle.”

As you recall, this was my first central line. But other than the trepidation I was experiencing, it had felt like my 50th.

Why had things gone so smoothly? What did Dr. O do to make this experience glow? And perhaps more importantly, what steps can you take to maximize learning during residency?

How to Teach a Procedure

1. Indicate a demarcation to indicate the new phase of learning starts now. 

We stopped everything else we were doing, there was no peripheral chatter about the procedure. It was clear to me that we were transitioning from the induction/intubation phase of the case to the central line. 

2. Demand explicit focus.

When Dr. O reeled me in to focus on nothing but the procedure in front of me, it kept any thoughts of tiredness, other cases, and worry about the procedure completely at bay. I knew to direct the totality of my attention to his every word at this moment.

3. Establish the nomenclature.

This step is crucial and often falls by the wayside, especially with new learners. We assume, after having done a procedure 100 times, that everyone knows what every piece is called. Then when you deliver a simple command to “keep wire and dilator still while sliding the catheter down the wire/dilator complex,” your student stares at you dumbfounded and overwhelmed. 

No matter the size of the procedure, naming the pieces is essential! Even for something as simple as placing an IV, the learner has to know that the “catheter” slides over the “needle” by “advancing the tab with your index finger.”

4. Be explicitly explicit in every description.

Dr. O left no ambiguity in his directions. There was no “grab that piece over there.” It was “gently control the plunger of the syringe with the middle finger and thumb of your right hand.” As you give a command, make sure to be so precise that no doubts or questions can exist in your learner’s mind.

How to Learn a Procedure

So, what if you find yourself on the other side of this? You are that resident or medical student trying their hands at a procedure for the first time, and your teacher hasn’t yet read this blog post. Ask them to take you through it in this fashion before and during the procedure. 

“Can we go over the parts of the kit? What’s this called? How do I hold the probe?”

And, if given directions that you don’t know exactly how to follow, ask for clarification before moving forward.

“Do I do that with my left or right hand? Advance gently or aggressively? Throw the stitch toward my body or away from me?”

In the old name of “see one, do one, teach one,” think about how you would teach the procedure, and see if you can tease that kind of direction from whoever is teaching you. While there is no substitute for doing a procedure hundreds of times in order to build confidence and fluidity, excellent instruction can surely make the difference between successful and failed attempts. 

Don’t be afraid to pose questions to chief residents or program leadership. By going the extra mile, and explaining (or interrogating) with tact and resolve, you will spare your patients from missed attempts and enhance their overall care.

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By Brian Radvansky, MD

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