On Teaching, Mentoring and Stewardship

What is a preceptor, exactly?

Of the various definitions found in the dictionary, the one most applicable to us would be, “an expert or specialist, such as a physician, who gives practical experience and training to a student, especially of medicine or nursing.”

That definition fits as well as any, I suppose, but the role of a preceptor cannot be distilled into a one-sentence definition. Much like the Supreme Court’s opinion on pornography, it’s hard to describe, but we know it when we see it.

When a preceptor passes on that “practical experience and training,” there are volumes of tradition, science, art, wisdom and bullshit encompassed in those four little words. The good preceptor passes on the collective wisdom – and sometimes, inadvertently, the bullshit – of our profession to the next generation, and I mean all of it; what EMS was, what EMS is, and what EMS should be.

I’d say “what EMS will be,” but so much of that depends upon how well that preceptor does his job.

If you want to know what a preceptor really does, you have to go back to the root word:

Precept: [pree-sept] -noun

1. a commandment or direction given as a rule of action or conduct.
2. an injunction as to moral conduct; maxim.
3. a procedural directive or rule, as for the performance of some technical operation.
4. a law.

All four definitions are important. All four have direct bearing on our practice as EMTs. They encompass our traditions, our attitudes, and our expectations of proper behavior. They are our professional ethos. The role of the preceptor is to be a steward of our profession, and in so doing, prepare the next generation of EMT’s to be stewards of the profession as well.

So why is it that many preceptors only pay attention to #3?

I suppose it’s only natural that, in a profession dominated by action-oriented, Type A personalities, that many of us feel uncomfortable teaching, for lack of a better word, the “soft skills.” As a long-time member of Louisiana’s training cadre for new EMS instructor candidates, I saw this firsthand.

The vast majority of new EMS instructors feel most comfortable teaching only in the psychomotor domain.

A few gregarious, creative types find themselves well-suited for teaching in the cognitive domain. A few more of the psychomotor types, after gaining confidence in their knowledge and skill set, add the cognitive domain to their repertoire.

But damned few, if any, have any clue how to teach the material most vital to preceptors: the affective domain.

EMT instructors can teach the knowledge and skills, but the preceptor instills the attitude, and we all know that, of all the traits necessary for success in a given profession, a positive attitude is one of the most important.

This is not a failing unique to EMS instructors and preceptors. Academics in all disciplines struggle with teaching attitudes and behavior, and few succeed at it. Those that do are easy to spot. Chances are, you’ve seen them yourself. If you think back on all the teachers you’ve had in your life, I’ll bet you could pick out one or two that had the most positive influence.

In your moments of greatest stress and indecision, whose advice do you crave? Who do you first think of when you want to share the elation of a professional triumph? When you feel beaten and discouraged, whose voice whispers your mental pep talk? Who plants the metaphorical foot in your ass when you need the motivation?

Right now, you’re probably smiling, thinking of just such a person.

Your mentor.

When it comes right down to it, any idiot can earn an EMT card. But there is a big difference between holding a card, and being an EMT. Regulatory agencies and all-too-many EMS systems don’t recognize the difference, but your patients and fellow providers do. Unfortunately, the patients usually only encounter us once. If the crew they encounter is a pair of card holders instead of real EMT’s, guess who is now the representative sample of your profession in that patient’s eyes?

So what was it that helped your mentor mold you from a mere card-holder into an EMT? What magic did they possess, and how might you learn that magic when your turn comes to be a steward of our profession?

Luckily, by learning a few simple principles -  precepts, if you will – of mentoring, you can develop your own technique in molding a card-holder into an EMT. Like watching Penn Gillette explain one of his tricks, you realize it wasn’t really magic after all. The real magic is in how skillfully those techniques are applied:

Be the EMT you expect them to be.

The first rule of teaching in the affective domain is simply to model the proper behavior. Be an example.

Be exemplary.

It’s harder than it sounds. We all have days when we aren’t at our best, when fatigue and frustration whisper in your ear that it really isn’t that important to come to work with your boots shined and your pants pressed. But when you feel it necessary to counsel your trainee that patients don’t trust a paramedic who looks like a friggin’ hobo, it really boosts your credibility not to look like one yourself.

“Do as I say, not as I do,” only works with toddlers, and it doesn’t work that well on them, either. It’s a parent’s way of saying, “My attitude isn’t as important as your obedience,” and don’t think for a second that the toddler – and your trainee – won’t eventually be perceptive enough to make the translation.

Likewise, your attitude toward others is going to have some effect on your trainee. Either they’ll adopt it – wrong or right – or they’ll spot it for the bad attitude it is, and vow never to treat others the way you do.

Congratulations, you’ve become an example. A bad one. Instead of a mentor, you’ve become a cautionary tale.

Every experienced medic has a hundred nursing home horror stories, and most are willing to regale you with them at the drop of a hat. Within each of those stories is a kernel of truth, that nursing home care does leave a lot to be desired, and that’s what makes them so toxic.

It’s easy to belittle a nursing home nurse, because you’ve heard the clueless reports, and you’ve seen the shoddy care with your own eyes. You’ve smelled the aroma of poop, urine and bleach that permeates the halls.

What’s harder is respecting them for the job they do, and how hard it is. Until you’ve walked a mile in their shoes, you might want to rein in the condescension a bit, and teach your trainee instead how to assess and treat his patient under challenging circumstances, with very little information to go on.

You know, like we do every single day outside the nursing home, without bitching and belittling the people who called 911.

And on those days when you aren’t at your best, man up (or woman, as the case may be) and admit it. No one expects their mentor to be perfect, but they should be worthy of respect. Earning that respect means being willing to admit when you’re wrong.

Which reminds me: Hey, Peter Griffin? Next long distance transport is on me, man. Or one Genevieve transport, whichever.

Teach more, evaluate less.

I notice an interesting phenomenon among some of my preceptor colleagues. Some of the most talented medics I know, people who will tirelessly coach, critique and encourage a paramedic student, shift gears into Evaluation Mode whenever they’re precepting a newly certified paramedic. It’s as if they expect the new medic to prove his mettle, the attitude almost, “Show me what ya got, kid.”

The question is, what have they got? What have they proven, other than the ability to successfully negotiate a standardized test designed to weed the minimally competent from the outright dangerous? What do they know this week that they didn’t know last week?

Formal education can give a student the pieces to the patient care puzzle, but it takes a talented preceptor to show them how to put it together. What the new EMT-Basic has taken from the sum total of their classroom and clinical education is a set of instructions along the lines of, “Draw a square, with a triangle on top. Now, in the big square, draw two smaller squares, and a rectangle. On the rectangle, draw a little circle.”

Luckily, he drives better than he draws.

A preceptor translates those instructions into, “Draw me a house.”

None of the shapes change. The skill set is no different. The artist doesn’t need you to draw it for him. He only needs you, his muse mentor, to show him what the picture is supposed to look like.

What he doesn’t need is for his mentor to systematically deconstruct everything he learned in the classroom. None of this, “Well, that may work in the classroom, but this is the way it works on the street,” bullshit. You’re supposed to provide confidence and clarity, not contradiction and character assassination.

The picture isn’t any clearer when the trainee is a newly minted paramedic. Bryan Bledsoe delivered a lecture once on critical thinking, and in it, there was one slide defining the levels of practitioners that really stood out:

Novice practitioner:

*Rigid adherence to taught rules or plans
*Little situational perception (symptom management only)
*No discretionary judgment
Competent practitioner:
*Able to cope with pressure
*Sees actions partly in terms of long-term goals and broader conceptual framework
(disease management)
*Follows standardized and routine procedures
Expert practitioner:
*No longer relies on rules, guidelines or maxims
*Intuitive grasp of situations
*Uses analytic approaches only in novel situations or when problems occur

One might think that paramedic school is what changes a novice practitioner like an EMT-B into an expert, but is that really the case? Does paramedic school actually teach you to think critically, or does it just produce another novice practitioner with a broader skill set?

Actually, rather than teach critical thinking skills, most formal EMS educational programs do just the opposite.

They systematically – either by accident or by design – suppress any innate critical thinking skills the student may have had. What emerges is a practitioner who has faithfully memorized the ACLS algorithms, can recall drug dosages, indications and contraindications at will, and can recite system protocols verbatim. They learn to pass a multiple choice exam, when real life is more on the order of an essay question. They’ve memorized all the rules.

What they don’t know, is how to apply them, or more importantly, when they shouldn’t. Teaching that sort of nuanced thinking is the role of the preceptor. It’s your job to turn them from novices into experts, or at the least, competent practitioners.

More teaching, less evaluating.

Know your trainee.

Past street experience can be both blessing and curse for both the trainee and the preceptor.

Experience is hard to quantify, and the plain truth is, not all experience is good. Every EMT filters a patient presentation through a prism of his past experiences. If they’ve been good experiences, that prism can refract a muddy clinical presentation into a clear diagnostic picture.

If they’ve been bad experiences, well… even the clearest set of symptoms can be hopelessly distorted when seen through the eyes of a trainee who has learned all the wrong things on the street.

When I trained retrievers for a living, I described it as a mental photo album. When your retriever steps to the line in a field trial or duck blind, he’s flipping through a mental photo album of all the past retrieves he’s catalogued, until he finds a picture that matches the scene in front of him. As a handler, it was my job to make sure my retriever was looking at the right picture. The only way to do that is to know the retriever. You have to know his personality, his mannerisms, be able to read his body language.

As a preceptor, it’s an easier task, because your trainee can talk.

And that’s what they should do; talk, talk, talk, and then talk some more. Have them plan possible scenarios on the way to the call. Let them speak first in the post-call critique. Encourage them to ask questions. Let them gather most of the patient history, and only speak when you feel they’re missing something important.

The more they talk, the easier it is to learn their weaknesses and strengths, learn what motivates them, learn what they fear, learn how they process their thoughts. But while they’re talking, keep one thing in mind:

Communicate clearly.

While they’re doing all that talking, don’t sit there silently like the Sphinx. Use Socratic dialogue to guide the conversation. Ask rhetorical questions that begin with “why?” or “why not?” Parse your words carefully, and allow your trainee to arrive at the conclusion on his own. Play devil’s advocate occasionally.

But never, ever just assume that your trainee understands why you do things a certain way. For you, it may be intuitively obvious, a shorthand you’ve worked out through years of experience. For your trainee, it may be incomprehensible, or even worse, wrongly ascribed to a different motivation entirely.

Case in point: My trainee and I treated an elderly patient in the nursing home who had fallen and injured her hip. By the time we had arrived, the staff had already picked her up and put her back in bed. They were busy turning her this way and that, cleaning her where she had soiled herself, changing her diaper, putting her in a fresh gown…

… and I chose not to immobilize her. Despite her medical issues, including early Alzheimer’s, she was a fairly reliable patient. She didn’t know what day it was, but she could clearly relate the circumstances of her fall, and the pain wasn’t so distracting that she couldn’t participate in her own NEXUS exam. She followed all commands appropriately, and focused clearly on my instructions.

Now, rigid adherence to our protocols would necessitate immobilizing this lady. But I’ve spent three years in this system, and I have enough experience with our medical director and the people who QA our reports to know that they are not prone to judge harshly, provided our documentation paints a clear picture of why certain steps were omitted.

To the trainee, the medical director is GOD, perhaps even an unmerciful one, and our protocols may as well be written on stone tablets.

So rather than allow my trainee to attend the patient and document the run, I took over. I had my reasons for doing this, but they weren’t clear to the trainee.

He said as much during the post-call critique, insulted that I didn’t trust him to run a simple hip fracture. Instead of replying, I simply asked him, “Why do you think I didn’t immobilize that lady?”

“Because it’d be a major pain in the ass,” he answered. “The bed was against the wall, you couldn’t get to her to log-roll her properly or hold C-spine alignment…”

Wrong.

I didn’t immobilize her because I judged that the procedure was 1) unnecessary, based on my examination, and b) likely to substantially increase my patient’s pain and discomfort, and c) perhaps even cause harmful sequelae like decubitus ulcers or respiratory decompensation.

I went on to explain to my trainee the difference between experience and expedience. Experience tells you when to omit certain things because it’s easier on your patient. Expedience means you omitted those steps because it’s easier on you, and that is never acceptable.

I also explained to him that, since I made a judgment call that differed with protocol, I chose to shield my trainee from scrutiny by handling the entire call myself.

When I document such a run, it’s an experienced medic using his clinical judgment. Were he the one to submit the electronic report, he’d be seen as a raw rookie making a mistake. Even now, when my judgment is sometimes questioned, I have the knowledge and experience to defend my decisions. My trainee has less ammunition.

View mistakes as teachable moments.

It is human nature to learn more from our mistakes than our successes. As the saying goes, “good judgment comes from experience, and experience comes from bad judgment.”

It’s the preceptor’s job to transform those mistakes into learning opportunities, while still ensuring good patient care. Some mistakes -the ones that negatively impact patient care or reinforce bad habits – must be corrected immediately, while others can be identified in the post-call critique. Simply by asking, “What would you have done differently?”you’ll discover that your trainee has often realized his mistake without you having to point it out.

For your example, if your trainee has chosen an IV catheter far too large for the vein he’s identified, you might want to intervene, and have him choose a smaller catheter rather than risk a blown IV and sticking the patient again unnecessarily.

On the other hand, if his venipuncture technique is sound, but you notice that he has placed all of his supplies on his non-dominant side, or out of reach…

… it might be a more valuable lesson to let him futilely try to occlude the vein while he scrambles to hook up the line. Nothing like a good blood stain on your pants leg to teach you to lay out everything within easy reach, is there?

And afterward, while your trainee is changing into a clean uniform, you can smile tolerantly and ask, “So what would you have done differently?” You might even make it another teachable moment, and tell him how to use peroxide and elbow grease to get those blood stains out of his pants.

It’s orientation, not indoctrination.

Part of your job as a preceptor is to familiarize your trainee with your agency’s organizational culture. Every agency has its own way of doing things, and there’s nothing wrong with that. As a preceptor, no doubt you have your own personal style, too.

But just because your trainee does things differently, doesn’t mean they’re wrong. Keep an open mind, and your trainee just may show you a better way of doing things. You’re trying to create a competent practitioner, not a clone of yourself.

Culture constantly evolves, and organizational culture is no exception. The day an agency, no matter how great, refuses to accept outside influence, is the day that agency starts the downhill slide toward mediocrity. As a preceptor, your responsibility to the agency is to consider whether your trainee’s method might have merit, and make suggestions to management accordingly.

If such suggestions are unwelcome, then you’re not orienting, you’re indoctrinating. Cults indoctrinate people, and they do not tolerate independent thought.

As a teacher, a mentor, and a steward of your profession, do you want a cult of protocol monkeys, or would you rather have thinking medics?

Your choice.

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Kelly Grayson

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