See One, Do One, TEACH ONE

See One, Do One, TEACH ONE

Welcome to the new blog titled See One, Do One, TEACH ONE with obvious emphasis on TEACH ONE!

At Kings County Emergency Medicine residency, we are taught to believe in the power of the clinical monster. Majority of us can recall from interview day the excitement and promise of becoming a clinical monster. This promise becomes reality as we progress from medical student to intern to senior resident and ultimately, to the final stage of clinical monster.

I believe however a clinical monster is not complete until they themselves can pass on the message and become a good teacher, evaluator, and mentor. Even attendings working in the community still have to learn how to teach. This is a competency that needs to be developed, whether you work with medical students, junior residents, senior residents, faculty, or professionals in other disciplines. My goal in this blog is to discuss important components within the fields of teaching, evaluation, and mentoring. I hope to create discussion around these important points that can help our residents become the ultimate clinical monster out there.

Background

For the first blog entry, I want to talk about an effective evaluation process called RIME developed in 1999 by Pangaro. Not only is the name catchy, but it also makes intuitive sense. RIME stands for R – reporter; I – interpreter; M – manager; E – educator / expert. It’s perfect for residents who want to evaluate medical students in a meaningful and nonjudgemental way that is also quick and useful. It can provide structure that is more valuable than saying, “you were awesome today”. This tool is based upon developmental vocabulary, classical psychology, and Bloom’s taxonomies. Because the tool uses observed behaviors, it allows for the evaluator (you!) the ability to grade based upon what you see. It also provides a benchmark for medical students to strive for to improve their performance.

I personally like using RIME is as a way to give direct feedback about the quality of the medical student case presentations. An educator / expert is more skilled than manager, who is more skilled than interpreter, who is more skilled than reporter. After I am done giving feedback, RIME allows me to highlight to the medical student ways in which they can also improve for the future. (Better than saying “read more”.)

What is RIME

A reporter (R) is a medical student who saw a patient and then regurgitated a bunch of facts right back at you. Word vomit, if you will. For example: “this is a 45 year old woman coming to the ER with chest pain, shortness of breath, and lower leg swelling for 2 days. She has been fully vaccinated. Her surgical history includes tonsillectomy. She smokes and has two cats. She currently doesn’t work…. etc etc.. Sometimes the medical students are fantastic reporters and their presentations are sheer poetry. Sometimes the students get the wrong facts; sometimes they get too little facts; sometimes they get too many facts about something that is trivial.

An interpreter (I) is a medical student who saw the patient, gave you a history and physical exam presentation, and is now able to say to you, “I think XYZ is going on in the patient”. Essentially, an interpreter can synthesize the information that was gathered and reported, and subsequently gives you their thoughts. Developing a differential diagnosis is a good example of interpretation. In the above example, the student could say to you, “I think that the patient could be suffering from CHF exacerbation, COPD exacerbation, a pulmonary embolus, a myocardial infarction, etc.” Sometimes their differentials are completely off the way, “I think this patient has allergic rhinitis”.

The next category is a manager (M). This is a medical student who can discuss the management and treatment plan for the patient. In the above example, the medical student would say, “I would like to order an EKG, a chest xray, and blood work such as CBC, CMP, and cardiac markers.” Sometimes the medical students are really off such as saying, “I want to get a stat trans-esophageal echo.” Not happening in the ER.

The final category, and the category that requires the highest competency is educator / expert (E). An educator and expert is someone who can report information gathered accurately and succinctly, can infer and interpret meaningfully, can develop a management plan, and finally can discuss evidence and debate important clinical concepts. They are also able to share the knowledge that they also have. For example, this would be the medical student who can discuss if the PERC rule and Wells criteria could effectively rule out a pulmonary embolus in this patient. Perhaps they don’t know all aspects of the debate, but they are insightful enough to allow for meaningful discussion.

When using RIME, one has to be aware that different levels of learners will be in different categories. For example, you would not expect a first year medical student observing in the ER to be at the level of educator / expert, let alone reporter. At the same time, a good stand out candidate for future intern could be that fourth year rotator who is knowledgable about the contraindications of beta-blockers in acute MI. Additionally, it is important to realize that not all learners will be at the same level for every competency. For example, the medical students at our home institution are adept at placing IVs. You may see them teaching other rotating medical students how to place IVs. This is great, they are at the educator level for IVs. However, this medical student may fumble when you try to discuss with them management of ectopic pregnancies.

Using RIME

The next step of using RIME is to use what you learned about the medical student from your encounter and nudge them into a higher competency level. RIME will let you know prodding questions to ask the medical student. For example, a student who is a reporter may be asked to interpret the information given. A student who is a manager may be asked to consider how the Wells criteria can change the management plan. This is a way to challenge the medical student and allows you an easy way to teach the medical student something that is appropriate for the level that they are currently sitting.

Conclusion

This system is very easy to use and remember. Try it the next time you listen to a medical student’s presentation and you will quickly see the categories stand out. Use it to guide your feedback and evaluation. This will make you a more efficient teacher and evaluator. Additionally, this tool works well with any learner type such as resident and junior faculty. I would love to hear your thoughts on RIME. Thank you for reading!

References:

Bloomfield L, Magney A, Segelov E. Reasons to try ‘RIME’. Med Educ. 2007. Nov;41(11):1104. PubMed PMID: 17883381.

DeWitt D, Carline J, Paauw D, Pangaro L. Pilot study of a “RIME”-based tool for giving feedback in a multi-specialty longitudinal clerkship. Med Educ. 2008. Dec;42(12):1205-9.

Pangaro L. A new vocabulary and other innovations for improving descriptive in-training evaluations. Acad Med. 1999. Nov;74(11):1203-7. PubMed PMID: 10587681.

Sepdham D, Julka M, Hofmann L, Dobbie A. Using the RIME model for learner assessment and feedback. Fam Med. 2007. Mar;39(3):161-3. PubMed PMID: 17323203.