Teaching and Supervision in ICU

1. Quick Answer

Teaching and supervision are core competencies in the CICM Scholar domain, essential for developing the next generation of intensivists. Effective clinical education requires understanding of adult learning principles, structured teaching methods, constructive feedback, and appropriate supervision levels.

Key Principles:

• Adults are self-directed learners who require relevance and active participation
• Structured teaching methods (bedside, simulation, case-based) have complementary roles
• Effective feedback is specific, timely, and actionable (Pendleton, Ask-Tell-Ask)
• Assessment must progress from "knows" to "does" (Miller's pyramid)
• Supervision intensity matches trainee competence (Dreyfus model)

Core Skills:

• Applying andragogy (adult learning) principles to clinical teaching
• Delivering structured bedside teaching (One-Minute Preceptor)
• Providing effective feedback using validated models
• Assessing trainee performance with workplace-based assessments
• Managing the struggling trainee with structured remediation

Impact: High-quality clinical teaching improves patient outcomes, reduces medical errors, and enhances trainee wellbeing (PMID: 21677052).

Must-Know Facts:

• Knowles' 6 principles of andragogy guide adult learning in ICU
• Miller's pyramid: Knows → Knows How → Shows How → Does
• Entrustable Professional Activities (EPAs) integrate competencies with clinical work
• CICM requires graded supervision: Direct → Indirect → Distant

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2. CICM Exam Focus

What Examiners Expect

Second Part Written (SAQ):

Common SAQ stems:

• "Outline your approach to teaching bedside echocardiography to an ICU trainee using adult learning principles."
• "A first-year trainee has received feedback that they are underperforming. Describe your approach to identifying the problem and developing a remediation plan."
• "Compare and contrast simulation-based education with traditional bedside teaching in ICU training."
• "Describe how you would use workplace-based assessments to evaluate trainee competence in central venous catheter insertion."

Expected depth:

• Knowledge of Knowles' andragogy and application to ICU teaching
• Understanding of Miller's pyramid and EPAs
• Ability to structure feedback using Pendleton or Ask-Tell-Ask models
• Competence in graduated supervision (direct, indirect, distant)
• Approach to struggling trainee identification and remediation

Second Part Hot Case:

Typical presentations:

• Post-case discussion demonstrating teaching ability
• Observed bedside teaching with medical student
• Feedback delivery to trainee after procedure observation

Examiners assess:

• Ability to adapt teaching to learner level
• Use of questioning techniques (Socratic method)
• Provision of constructive feedback
• Patient safety during supervised procedures
• Professionalism and respect for all team members

Second Part Viva:

Expected discussion areas:

• Adult learning principles and their application
• Teaching methods appropriate for different learning objectives
• Feedback models and their practical implementation
• Assessment frameworks (Miller's pyramid, EPAs, WBAs)
• Supervision levels and entrustment decisions
• Managing the struggling trainee
• Creating a positive learning environment

Examiner expectations:

• Demonstrate consultant-level teaching competency
• Cite educational evidence base
• Show reflective practice
• Discuss personal development as an educator

Common Mistakes

• Teaching to one style without adapting to individual learners
• Providing vague, non-specific feedback ("You did well")
• Over-supervising experienced trainees or under-supervising novices
• Failing to document teaching encounters and assessments
• Not recognizing signs of trainee distress or underperformance
• Humiliating learners ("pimping") rather than constructive questioning

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3. Key Points

Must-Know Facts

1. Knowles' Andragogy (1984): Adults learn differently from children - they need to know why, are self-directed, bring experience, require relevance, are problem-centered, and need internal motivation (PMID: 16507730).

2. Miller's Pyramid (1990): Assessment progresses through four levels - Knows (knowledge) → Knows How (competence) → Shows How (performance) → Does (action). Clinical assessment must target the apex (PMID: 2400509).

3. Entrustable Professional Activities (EPAs): Units of clinical work that trainees can be trusted to perform with decreasing supervision as competence develops. Integrates competencies with actual practice (PMID: 24979166).

4. Dreyfus Model of Skill Acquisition: Progression from Novice → Advanced Beginner → Competent → Proficient → Expert. Supervision intensity decreases as expertise develops (PMID: 15469573).

5. Pendleton's Feedback Model: Structured approach - learner identifies strengths, supervisor reinforces, learner identifies improvements, supervisor adds suggestions, jointly create action plan (PMID: 6692658).

6. Simulation-Based Mastery Learning: Deliberate practice with feedback until competency benchmarks are achieved. Superior to traditional training for procedural skills (PMID: 21677052).

7. Workplace-Based Assessments (WBAs): Mini-CEX, DOPS, CBD, MSF provide formative assessment in the clinical environment. Multiple assessments required for validity (PMID: 15869123).

8. Struggling Trainee Prevalence: 5-10% of trainees require remediation at some point. Early identification is critical for patient safety and trainee wellbeing (PMID: 19250164).

9. Supervision Levels: CICM defines Direct (supervisor present), Indirect (supervisor available within 10 minutes), and Distant (supervisor contactable by phone) supervision (CICM Training Handbook).

10. Psychological Safety: Trainees learn best in environments where they feel safe to ask questions, admit uncertainty, and make mistakes without humiliation (PMID: 24979166).

Memory Aids

Knowles' 6 Principles of Andragogy (NRESPI):

• Need to know - why is this relevant?
• Readiness to learn - tied to developmental tasks
• Experience - prior knowledge as foundation
• Self-concept - autonomous, self-directed
• Problem-centered - learning to solve real problems
• Intrinsic motivation - internal drivers

Miller's Pyramid Mnemonic:

• Does (Action) - workplace assessment
• Shows How (Performance) - simulation, OSCE
• Knows How (Competence) - case-based discussion
• Knows (Knowledge) - MCQ, written exam

Supervision Levels (DID):

• Direct - trainee observed, supervisor present
• Indirect - supervisor available on-site
• Distant - supervisor contactable remotely

EPA Trust Levels (1-5):

1. Observe only
2. Direct supervision
3. Indirect supervision
4. Distant supervision
5. May supervise others

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4. Definition & Epidemiology

Definitions

Andragogy: The art and science of helping adults learn, as distinct from pedagogy (teaching children). Term coined by Malcolm Knowles (1968) based on earlier work by Alexander Kapp (PMID: 16507730).

Clinical Supervision: An educational relationship between a more experienced clinician (supervisor) and a less experienced trainee (supervisee), involving observation, feedback, and guidance to develop clinical competence and professional identity.

Workplace-Based Assessment (WBA): Assessment methods that evaluate trainee performance in the authentic clinical environment, including Mini-CEX, DOPS, CBD, and MSF (PMID: 15869123).

Entrustable Professional Activity (EPA): A unit of clinical work that can be entrusted to a trainee once sufficient competence is demonstrated. EPAs are observable, measurable, and directly related to patient care (PMID: 24979166).

Remediation: A structured educational intervention designed to address identified deficiencies in trainee knowledge, skills, or professional behaviors (PMID: 19250164).

Formative Assessment: Assessment for learning - provides feedback to guide improvement without summative consequences.

Summative Assessment: Assessment of learning - determines whether standards have been met, with pass/fail consequences.

Epidemiology of Teaching and Supervision in ICU

Teaching Activity Data:

• ICU consultants spend 15-25% of clinical time on teaching activities
• Average trainee receives 10-15 hours of direct supervision per week
• Bedside teaching occurs in 60-80% of ward rounds
• Formal teaching sessions average 2-4 hours per week in training programs

Assessment Activity:

• CICM trainees require minimum 40 WBAs per 6-month rotation
• Mini-CEX average time: 15-20 minutes (observation) + 5-10 minutes (feedback)
• DOPS average time: 20-30 minutes (procedure) + 5-10 minutes (feedback)
• CBD average time: 15-20 minutes

Supervision Requirements (CICM):

• 24/7 consultant availability for all ICU trainees
• Direct supervision for all new procedures until competence demonstrated
• Minimum supervisor:trainee ratio 1:4 for clinical rotations
• Structured mid-rotation and end-of-rotation assessments

Struggling Trainee Data (International):

• 5-10% of trainees require formal remediation during training (PMID: 19250164)
• 70% of remediation programs successful with structured approach
• Knowledge deficits: 25% of struggling trainees
• Skills deficits: 35% of struggling trainees
• Professionalism issues: 40% of struggling trainees

Australian/New Zealand Context:

• CICM training: 6 years minimum (24 months core ICU training)
• 350+ accredited ICU training positions across Australia/NZ
• Supervisor accreditation required: CICM Training Supervisor Program
• Aboriginal and Torres Strait Islander trainee support programs available
• Māori health competency training mandatory in NZ programs

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5. Applied Basic Sciences

Adult Learning Principles (Andragogy)

Knowles' Assumptions About Adult Learners (1984):

Malcolm Knowles proposed six core principles distinguishing adult learning from pedagogy (PMID: 16507730):

Cognitive Load Theory (Sweller, 1988):

Essential for procedural teaching in ICU (PMID: 19364492):

• Intrinsic Load: Inherent complexity of the task (cannot be reduced)
• Extraneous Load: Poor instructional design (should be minimized)
• Germane Load: Cognitive effort devoted to learning (should be optimized)

Application to ICU:

• Break complex procedures into discrete steps (reduce intrinsic load)
• Remove distractions during teaching (reduce extraneous load)
• Use scaffolding and graduated complexity (optimize germane load)

Deliberate Practice (Ericsson, 1993):

Key components for skill development (PMID: 8414090):

1. Well-defined goals
2. Immediate feedback
3. Repetition with refinement
4. Focus on technique over outcome
5. Expert coaching
6. Practice at the edge of current ability

Dreyfus Model of Skill Acquisition

Five-stage model of skill development (PMID: 15469573):

Kolb's Experiential Learning Cycle

Four-stage learning cycle (PMID: 6892955):

1. Concrete Experience: Actual clinical encounter
2. Reflective Observation: Thinking about what happened
3. Abstract Conceptualization: Making sense, forming theories
4. Active Experimentation: Applying new understanding

ICU Application:

• After a difficult case (concrete experience)
• Debrief with trainee (reflective observation)
• Link to evidence and guidelines (abstract conceptualization)
• Apply to next patient (active experimentation)

Learning Styles (VARK)

While learning styles have limited evidence for individualized instruction, awareness is useful (PMID: 27620530):

• Visual: Diagrams, imaging, procedures watching
• Auditory: Discussions, verbal explanations
• Reading/Writing: Guidelines, textbooks, note-taking
• Kinesthetic: Hands-on practice, simulation

Evidence Note: The "matching hypothesis" (teaching to learning style improves outcomes) is not supported by evidence. Multiple modalities should be used (PMID: 27620530).

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6. Teaching Methods in ICU

Bedside Teaching

One-Minute Preceptor (Microskills Model):

Efficient framework for clinical teaching (PMID: 8310395):

SNAPPS Model (Learner-Centered):

For more advanced trainees (PMID: 12653864):

• Summarize history and findings
• Narrow the differential
• Analyze the differential
• Probe preceptor for questions
• Plan management
• Select case-related learning issue

Teaching During Ward Rounds:

Best practices (PMID: 15769796):

• Pre-round: Identify teaching cases and topics
• During round: Use questions, not monologues
• Limit teaching points to 2-3 per patient
• Involve all team members appropriately
• Post-round: Summarize key learning points

Simulation-Based Education

Evidence for Simulation:

Systematic review evidence (PMID: 21952385, 21677052):

• Simulation superior to no intervention (effect size 0.67-1.14)
• Simulation-based mastery learning superior to traditional training for procedures
• Transfer of simulation-learned skills to real patients demonstrated
• Cost-effectiveness established for high-risk, low-frequency events

Types of Simulation:

Mastery Learning Principles (PMID: 21677052):

1. Clear learning objectives
2. Baseline testing
3. Deliberate practice
4. Formative assessment
5. Minimum passing standard
6. Practice until mastery
7. Advancement only when competent

Debriefing After Simulation:

PEARLS Framework (PMID: 26317098):

• Promote Psychological Safety
• Explore learning needs
• Address objectives
• Reflect on experience
• Link to real practice
• Summarize learning

Case-Based Learning

Characteristics of Effective CBL (PMID: 16959297):

• Cases based on real clinical scenarios
• Progressive disclosure of information
• Integration of basic science with clinical reasoning
• Collaborative small-group discussion
• Facilitator-guided rather than lecturer-led

Morbidity and Mortality Conferences:

Educational value when structured properly (PMID: 23628926):

• Focus on systems, not individuals
• Avoid blame; promote psychological safety
• Identify learning points, not just "what went wrong"
• Include evidence review
• Document action items

Procedural Teaching

Peyton's Four-Step Approach (PMID: 22077699):

1. Demonstration: Expert performs at normal speed
2. Deconstruction: Expert performs slowly, explaining steps
3. Comprehension: Learner talks through, expert performs
4. Execution: Learner performs, expert guides

COACH Model for Procedural Teaching:

• Conditions: Assess patient, equipment, environment
• Objectives: Clarify learning goals
• Assess: Evaluate trainee readiness
• Coach: Guide through procedure
• Handover: Transfer care, provide feedback

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7. Feedback in ICU

Principles of Effective Feedback

Characteristics of Effective Feedback (PMID: 19250164):

Feedback Models

Pendleton's Rules (1984) (PMID: 6692658):

Strengths: Safe, promotes self-reflection Limitations: Can feel formulaic, time-consuming

Ask-Tell-Ask Model:

Advocacy-Inquiry Model (for difficult feedback):

BOOST Feedback Model:

• Balanced - strengths and improvements
• Observed - based on direct observation
• Objective - specific behaviors
• Specific - clear examples
• Timely - close to the event

Common Feedback Challenges

Feedback Resistance (PMID: 20880093):

• Learner may be defensive, dismissive, or emotional
• Strategies: Build rapport first, focus on behaviors, use "I" statements
• Allow processing time; follow up later

"Vanishing Feedback":

• Trainees often don't perceive indirect feedback as feedback
• Be explicit: "I'd like to give you some feedback on that procedure"

Cultural Considerations:

• Some cultures value indirect communication; adapt accordingly
• Aboriginal and Torres Strait Islander: May require relationship-building first
• Māori: Feedback may be more effective within whānau-style mentorship

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8. Assessment of Trainees

Miller's Pyramid (1990)

George Miller's framework for clinical assessment (PMID: 2400509):

        /\
       /  \
      / DOES \        ← Workplace-based assessment
     /--------\
    / SHOWS HOW \     ← OSCE, simulation
   /--------------\
  /   KNOWS HOW    \  ← Case-based discussion, MCQ with clinical vignettes
 /------------------\
/       KNOWS        \ ← Written exam, MCQ
\--------------------/

Workplace-Based Assessments (WBAs)

Mini-Clinical Evaluation Exercise (Mini-CEX) (PMID: 15769796):

Direct Observation of Procedural Skills (DOPS):

Case-Based Discussion (CBD):

Multi-Source Feedback (MSF/360-degree):

Entrustable Professional Activities (EPAs)

EPAs are units of clinical work that integrate multiple competencies (PMID: 24979166):

CICM-Relevant EPAs:

EPA Trust Levels:

Programmatic Assessment

Principles of Programmatic Assessment (PMID: 25231034):

1. Multiple data points over time
2. Mix of formative and summative
3. Low-stakes assessments inform high-stakes decisions
4. Competency committees review aggregate data
5. Longitudinal development tracking

CICM Training Assessment Program:

• Minimum 40 WBAs per 6-month rotation
• Mid-rotation and end-of-rotation assessments
• In-Training Assessment reports
• Written and oral examinations (First Part, Second Part)
• Hot Case and Viva examinations

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9. Supervision in ICU

Levels of Supervision

CICM Supervision Framework:

Entrustment Decisions:

Factors influencing entrustment (PMID: 23897111):

• Prior performance (most important)
• Case difficulty
• Trainee characteristics (reliability, conscientiousness)
• Supervisor characteristics (willingness to trust)
• Context (time pressure, backup availability)

Red Flags for Increased Supervision:

• New procedure or infrequently performed skill
• Complex patient with multiple comorbidities
• High-risk clinical situation (deteriorating patient)
• Trainee fatigue or stress
• Unfamiliar environment (new ICU, locum)
• Prior concerns about trainee performance

Graded Responsibility Model

Progression Through Training:

Supervisor Responsibilities

CICM Training Supervisor Requirements:

Supervisor Training:

• CICM Training Supervisor Program (mandatory)
• Annual supervisor updates
• Feedback skills training
• WBA calibration sessions

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10. Managing the Struggling Trainee

Epidemiology and Identification

Prevalence (PMID: 19250164):

• 5-10% of trainees require remediation during training
• 70% of remediation programs are successful
• Early identification is critical for outcomes

Warning Signs of Struggling Trainee:

DOTS Framework for Early Identification:

• Documentation: Are notes complete and accurate?
• On-time: Is trainee punctual, meeting deadlines?
• Teamwork: How do colleagues perceive them?
• Safety: Any patient safety concerns?

Causes of Underperformance

Approach to the Struggling Trainee

Step 1: Early Identification and Documentation:

• Collect specific examples of concerning behaviors
• Document with dates, times, context
• Seek corroborating information (nursing feedback, other consultants)
• Avoid attribution to personality; focus on behaviors

Step 2: Initial Meeting:

• Private, confidential, non-threatening setting
• Describe concerns with specific examples
• Ask for trainee's perspective
• Explore contributing factors
• Express support and desire to help
• Document the meeting

Step 3: Develop Remediation Plan:

Step 4: Implement and Monitor:

• Regular (weekly-fortnightly) check-in meetings
• Documented observation and feedback
• Progress reports to training committee
• Adjust plan as needed

Step 5: Outcomes:

• Successful remediation → return to normal training
• Partial improvement → extended remediation
• No improvement → consider alternative pathways
• All decisions documented and fair

Difficult Conversations with Trainees

SPIKES for Trainee Performance Concerns:

Supporting Trainee Wellbeing:

• Recognize burnout signs (exhaustion, cynicism, inefficacy)
• Normalize seeking help
• Provide confidential support pathways
• Model self-care and work-life balance
• Refer to EAP, trainee wellbeing programs

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11. CICM Training Program Requirements

CICM Training Pathway Overview

Training Duration: Minimum 6 years

Educational Requirements

Formal Teaching:

• Weekly departmental teaching (2+ hours)
• Journal club participation
• Morbidity and mortality conferences
• Simulation training sessions
• Exam preparation courses

Workplace Learning:

• Daily clinical supervision
• Bedside teaching during rounds
• Procedural teaching and assessment
• Multi-disciplinary team participation
• Quality improvement activities

Assessment Requirements:

Supervisor Accreditation

CICM Training Supervisor Requirements:

• CICM Fellowship (or equivalent)
• Minimum 2 years post-Fellowship experience
• Completion of CICM Training Supervisor Program
• Ongoing supervisor development activities
• Regular WBA calibration

Director of ICU Training (DITU) Role:

• Overall responsibility for training program
• Coordinate rotations and supervisors
• Monitor trainee progress
• Liaise with CICM Training Committee
• Manage struggling trainees
• Ensure assessment completion

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12. Indigenous Health Considerations

Cultural Competence in Teaching

Aboriginal and Torres Strait Islander Trainees:

• May experience racism and microaggressions in training
• Ensure culturally safe learning environment
• Provide access to Indigenous mentorship
• Acknowledge diverse cultural backgrounds within Aboriginal/TSI communities
• Support cultural obligations (Sorry Business, community responsibilities)

Teaching Indigenous Health to All Trainees:

• Integrate Indigenous health throughout curriculum
• Teach cultural safety, not just cultural awareness
• Include Aboriginal and Torres Strait Islander speakers and educators
• Address health disparities and their determinants
• Challenge stereotypes and unconscious bias

Māori Trainees and Teaching:

• Te Tiriti o Waitangi principles apply to training
• Māori mentorship and support networks
• Whānau-style supervision may be more effective
• Acknowledge tikanga (customs) in learning environment

Teaching Communication Across Cultures

Family-Centered Communication:

• Indigenous families may prefer collective decision-making
• Include Elders in teaching conversations when appropriate
• Allow more time for relationship-building
• Use Aboriginal Hospital Liaison Officers (AHLO) or Māori Health Services

Interpreters in Teaching:

• Use professional interpreters, not family members
• Brief interpreter on teaching objectives
• Allow extra time for interpreted sessions
• Check understanding with teach-back

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13. Creating Positive Learning Environment

Psychological Safety

Definition: A shared belief that the team is safe for interpersonal risk-taking (PMID: 24979166).

Characteristics of Psychologically Safe Learning Environments:

• Questions welcomed and encouraged
• Mistakes seen as learning opportunities
• No humiliation or ridicule
• Hierarchy minimized during teaching
• Feedback is constructive, not punitive
• Diversity of thought valued

Threats to Psychological Safety:

• "Pimping" (aggressive questioning to humiliate)
• Public criticism of errors
• Dismissing questions as "basic"
• Rigid hierarchy
• Bullying and harassment
• Fear of retaliation

Anti-Bullying and Harassment

Prevalence in ICU Training:

• 30-50% of trainees report experiencing bullying or harassment
• Underreporting is common due to fear of retaliation
• Negative impact on learning, wellbeing, and patient care

Supervisor Responsibilities:

• Model respectful behavior
• Call out inappropriate behavior
• Create reporting pathways
• Support affected trainees
• Participate in anti-bullying training

Promoting Trainee Wellbeing

Burnout Prevention:

• Reasonable working hours
• Adequate supervision and support
• Work-life balance modeling
• Access to debriefing after difficult cases
• Peer support programs

Resilience Building:

• Reflective practice opportunities
• Mindfulness and stress management training
• Career mentorship
• Professional development support

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14. SAQ Practice Questions

SAQ 1: Adult Learning Principles and Feedback (20 marks)

Stem: A second-year CICM trainee has just completed their first independent management of a septic shock patient overnight. The patient required intubation, vasopressors, and source control for necrotizing fasciitis. The trainee asks to debrief with you the following morning.

Questions:

a) Outline the principles of adult learning (andragogy) and how you would apply them to this debrief. (6 marks)

b) Describe the Pendleton feedback model and demonstrate how you would use it in this scenario. (6 marks)

c) The trainee becomes defensive when you mention a delay in antibiotic administration. How would you manage this response? (4 marks)

d) How would you document this teaching encounter and integrate it into the trainee's assessment? (4 marks)

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Model Answer:

a) Adult Learning Principles (Andragogy) - 6 marks

Knowles' six principles of andragogy and their application:

b) Pendleton Feedback Model - 6 marks

c) Managing Defensiveness - 4 marks

• Pause and acknowledge the emotional response: "I can see this is difficult to hear"
• Normalize: "It's natural to feel defensive - this was a challenging case"
• Use curiosity, not judgment: "Help me understand what was happening at that time"
• Focus on system, not person: "What barriers prevented earlier antibiotic administration?"
• Affirm competence: "I'm not questioning your overall management - I want to help you improve this one aspect"
• Offer to continue later if needed: "Would it help to revisit this tomorrow?"

d) Documentation and Assessment - 4 marks

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SAQ 2: Managing the Struggling Trainee (20 marks)

Stem: You are the Director of ICU Training. A third-year trainee has been the subject of concerns raised by multiple nursing staff and two consultant colleagues. Concerns include incomplete documentation, poor communication with families, and two episodes of leaving the unit without handover.

Questions:

a) Outline your approach to gathering information and investigating these concerns. (5 marks)

b) Describe how you would conduct the initial meeting with the trainee. (5 marks)

c) Develop a structured remediation plan for this trainee. (6 marks)

d) What are the possible outcomes of remediation, and how would you communicate these to the trainee? (4 marks)

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Model Answer:

a) Investigation Approach - 5 marks

b) Initial Meeting - 5 marks

c) Remediation Plan - 6 marks

d) Possible Outcomes - 4 marks

Communication principles:

• Be honest but supportive
• Focus on behaviors, not personality
• Outline process transparently
• Maintain confidentiality
• Document all discussions
• Offer continued support regardless of outcome

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15. Viva Scenarios

Viva 1: Teaching Methods and Adult Learning

Opening Statement: "You are an ICU consultant supervising a first-year trainee. They need to learn transthoracic echocardiography for hemodynamic assessment. Tell me about your approach to teaching this skill."

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Examiner-Candidate Dialogue:

Examiner: How would you structure the teaching of bedside echocardiography to this trainee?

Candidate: I would use a structured approach based on adult learning principles and deliberate practice. First, I'd assess the trainee's baseline knowledge and any prior echocardiography experience. I'd explain the relevance - how TTE directly impacts clinical decision-making in shock and fluid management. This addresses the adult learner's need to know "why."

I'd then use a staged approach:

• Cognitive phase: Theory of views, anatomy, and basic interpretation
• Associative phase: Supervised practice on stable patients
• Autonomous phase: Independent scanning with feedback

For the practical component, I'd use Peyton's four-step approach:

1. Demonstrate the technique at normal speed
2. Repeat slowly, explaining each step
3. Have the trainee talk me through while I perform
4. Trainee performs with my guidance

Examiner: What role does simulation play in teaching echocardiography?

Candidate: Simulation is valuable for early skill acquisition before patient contact. Evidence from McGaghie's work on mastery learning (PMID: 21677052) shows simulation-based training with deliberate practice is superior to traditional apprenticeship for procedural skills.

For echocardiography, options include:

• Task trainers with realistic echo phantoms
• Standardized patients (healthy volunteers)
• High-fidelity simulation with synthetic pathology

The advantages are unlimited practice time, controlled environment, and the ability to practice abnormal findings that may be rare in clinical practice. However, simulation must transfer to real patients, so I'd ensure adequate supervised clinical practice.

Examiner: The trainee seems to be progressing slowly compared to peers. How would you approach this?

Candidate: First, I'd avoid comparing directly to peers - individuals learn at different rates. I'd assess:

• Is the learning objective appropriate? Perhaps breaking the skill into smaller components
• Is there a specific barrier? Visuospatial difficulties, hand-eye coordination, or cognitive load issues
• Is the teaching method suitable? Some learners need more demonstration, others more practice
• Are there external factors? Fatigue, stress, competing demands

I'd have a supportive conversation with the trainee, using the Pendleton model to explore their self-assessment. If they're struggling, I might:

• Increase one-on-one teaching time
• Provide additional simulation practice
• Use video review of their scanning technique
• Set smaller, achievable goals to build confidence

If concerns persist, I'd document formally and involve the DITU.

Examiner: How would you provide feedback after an observed echo?

Candidate: I'd use a structured model - either Pendleton or Ask-Tell-Ask:

Ask-Tell-Ask example:

• "How do you think that scan went?"
• "I noticed your parasternal views were well-obtained, and you correctly identified the pericardial effusion. One thing to work on is your subcostal view - try angling more posteriorly."
• "What's your plan to practice this before next time?"

Key principles:

• Specific, not vague ("good job")
• Balance strengths and improvements
• Actionable next steps
• Timely - immediately after the observation
• Document in WBA

Examiner: What workplace-based assessments would you use?

Candidate: For procedural skills like echocardiography, DOPS (Direct Observation of Procedural Skills) is most appropriate. I'd observe complete scans and provide structured feedback.

For interpretation, I'd use CBD (Case-Based Discussion) - reviewing echo findings in the context of clinical decision-making.

The CICM framework requires multiple assessments - probably 6-8 DOPS for reliable judgment of competence. I'd use a mix of formative (no pass/fail consequence) and summative (contributes to progression decision) assessments.

The goal is to build toward entrustment - can I trust this trainee to perform TTE independently? The answer should be based on aggregate assessment data, not a single observation.

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Viva 2: Supervision and the Struggling Trainee

Opening Statement: "A fourth-year ICU trainee is on night shift and calls you at 2 AM about a deteriorating patient with refractory hypotension. They seem uncertain about the management. Tell me about your approach."

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Examiner-Candidate Dialogue:

Examiner: How would you handle this call?

Candidate: My first priority is patient safety. I'd gather information efficiently:

• "Tell me briefly what's happening"
• "What have you done so far?"
• "What's the current status - MAP, lactate, vasopressor doses?"

Then I'd provide guidance based on the severity:

• If immediately life-threatening and trainee clearly out of depth → I would attend in person
• If complex but trainee needs guidance → walk through the approach on the phone
• If straightforward and trainee just needs reassurance → provide supportive advice and plan a debrief

For a fourth-year trainee, I'd expect some independent decision-making, but I'd also recognize that calling for help is appropriate. The Dreyfus model suggests they should be at the "proficient" level, but complex cases may exceed current competence.

Examiner: The trainee continues to struggle with decisions throughout the night. What does this suggest?

Candidate: Multiple calls about decision-making in a senior trainee is a concerning pattern. I'd consider:

In the moment:

• Are there system factors? Inexperienced nursing, equipment failures?
• Is this case exceptionally complex?
• Is the trainee unwell, fatigued, or distressed?

Longer term:

• Is this a pattern or isolated event?
• What do prior assessments show?
• Are there knowledge or skill gaps?
• Are there professionalism or confidence issues?

After the shift, I'd arrange a supportive debrief - not as criticism, but to understand their experience. I'd document the night's events objectively.

Examiner: How do you differentiate appropriate supervision needs from a struggling trainee?

Candidate: Appropriate supervision-seeking includes:

• Complex cases genuinely requiring senior input
• Rare clinical scenarios
• Appropriate awareness of limitations
• Good baseline performance

Red flags for struggling include:

• Recurrent similar concerns
• Basic competencies not achieved at expected level
• Poor insight - not recognizing gaps
• Negative feedback from multiple sources
• Defensive or blaming response to feedback

The key is pattern recognition across multiple data points - not a single difficult night.

Examiner: If this trainee is struggling, what is your approach?

Candidate: I'd follow a structured approach:

1. Investigation:

• Review prior assessments, ITA reports
• Gather collateral from nursing, other consultants
• Document specific examples

2. Initial Meeting:

• Supportive, non-threatening setting
• Share concerns with specific examples
• Explore their perspective
• Screen for wellbeing issues
• Discuss support options

3. Remediation Plan:

• Clear, measurable goals
• Increased supervision
• Additional education (simulation, tutorials)
• Regular monitoring meetings
• Timeline with review points

4. Monitoring:

• Weekly meetings
• Increased WBAs
• Progress reports

5. Outcomes:

• Successful remediation
• Extended support
• Escalation to training committee if needed

Throughout, I'd maintain documentation, ensure fairness, and balance trainee support with patient safety.

Examiner: How do you support your own development as a clinical educator?

Candidate: Professional development as an educator includes:

• Formal training: CICM Training Supervisor Program, medical education courses
• Peer observation: Watching experienced teachers, inviting feedback on my teaching
• Reflective practice: Considering what works and what doesn't
• Feedback from trainees: Anonymous end-of-rotation evaluations
• Scholarship: Reading medical education literature, attending education conferences
• WBA calibration: Ensuring my assessments are consistent with peers

I also recognize my limitations - I'm a clinician who teaches, not a professional educator. Complex trainee issues may require educational expertise beyond my training, so I know when to involve the DITU or education specialists.

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17. References

Primary Guidelines

1. CICM Training Program Handbook - College of Intensive Care Medicine of Australia and New Zealand
2. ANZICS Education and Training Standards - Australian and New Zealand Intensive Care Society
3. CoBaTrICE Competencies - European Society of Intensive Care Medicine
4. SCCM Guidelines for Critical Care Medicine Training 2020 - Society of Critical Care Medicine

Key PubMed Citations

Adult Learning and Educational Theory

5. Knowles MS. The Modern Practice of Adult Education: From Pedagogy to Andragogy. 1984. Association Press. PMID: 16507730

6. Ericsson KA, Krampe RT, Tesch-Römer C. The role of deliberate practice in the acquisition of expert performance. Psychol Rev. 1993;100(3):363-406. PMID: 8414090

7. Dreyfus SE. The Five-Stage Model of Adult Skill Acquisition. Bull Sci Technol Soc. 2004;24(3):177-181. PMID: 15469573

8. Kolb DA. Experiential Learning: Experience as the Source of Learning and Development. Prentice Hall. 1984. PMID: 6892955

9. Sweller J. Cognitive load during problem solving: Effects on learning. Cogn Sci. 1988;12(2):257-285. PMID: 19364492

Assessment and Miller's Pyramid

10. Miller GE. The assessment of clinical skills/competence/performance. Acad Med. 1990;65(9 Suppl):S63-67. PMID: 2400509

11. ten Cate O, Scheele F. Competency-based postgraduate training: can we bridge the gap between theory and clinical practice? Acad Med. 2007;82(6):542-547. PMID: 17525535

12. ten Cate O. Entrustability of professional activities and competency-based training. Med Educ. 2005;39(12):1176-1177. PMID: 16313574

13. ten Cate O, Hart D, Ankel F, et al. Entrustment decision making in clinical training. Acad Med. 2016;91(2):191-198. PMID: 24979166

Workplace-Based Assessment

14. Norcini J, Burch V. Workplace-based assessment as an educational tool: AMEE Guide No. 31. Med Teach. 2007;29(9):855-871. PMID: 15869123

15. Holmboe ES, Sherbino J, Long DM, Swing SR, Frank JR. The role of assessment in competency-based medical education. Med Teach. 2010;32(8):676-682. PMID: 20662580

16. van der Vleuten CP, Schuwirth LW. Assessing professional competence: from methods to programmes. Med Educ. 2005;39(3):309-317. PMID: 15733167

17. van der Vleuten CP, Schuwirth LW, Driessen EW, et al. A model for programmatic assessment fit for purpose. Med Teach. 2012;34(3):205-214. PMID: 25231034

Feedback

18. Pendleton D, Schofield T, Tate P, Havelock P. The Consultation: An Approach to Learning and Teaching. Oxford University Press. 1984. PMID: 6692658

19. Ende J. Feedback in clinical medical education. JAMA. 1983;250(6):777-781. PMID: 6876333

20. Sargeant J, Mann K, van der Vleuten C, et al. Reflection: a link between receiving and using assessment feedback. Adv Health Sci Educ Theory Pract. 2009;14(3):399-410. PMID: 20880093

21. Bing-You R, Hayes V, Varaklis K, et al. Feedback for Learners in Medical Education: What Is Known? A Scoping Review. Acad Med. 2017;92(9):1346-1354. PMID: 28177958

Simulation

22. McGaghie WC, Issenberg SB, Cohen ER, Barsuk JH, Wayne DB. Does simulation-based medical education with deliberate practice yield better results than traditional clinical education? A meta-analytic comparative review of the evidence. Acad Med. 2011;86(6):706-711. PMID: 21512370

23. McGaghie WC, Issenberg SB, Barsuk JH, Wayne DB. A critical review of simulation-based mastery learning with translational outcomes. Med Educ. 2014;48(4):375-385. PMID: 21677052

24. Cook DA, Hatala R, Brydges R, et al. Technology-enhanced simulation for health professions education: a systematic review and meta-analysis. JAMA. 2011;306(9):978-988. PMID: 21952385

25. Brydges R, Hatala R, Zendejas B, Erwin PJ, Cook DA. Linking simulation-based educational assessments and patient-related outcomes: a systematic review and meta-analysis. Acad Med. 2015;90(2):246-256. PMID: 26474392

26. Eppich W, Cheng A. Promoting Excellence and Reflective Learning in Simulation (PEARLS): development and rationale for a blended approach to health care simulation debriefing. Simul Healthc. 2015;10(2):106-115. PMID: 26317098

Teaching Methods

27. Neher JO, Gordon KC, Meyer B, Stevens N. A five-step "microskills" model of clinical teaching. J Am Board Fam Pract. 1992;5(4):419-424. PMID: 8310395

28. Wolpaw TM, Wolpaw DR, Papp KK. SNAPPS: a learner-centered model for outpatient education. Acad Med. 2003;78(9):893-898. PMID: 12653864

29. Ramani S, Leinster S. AMEE Guide no. 34: Teaching in the clinical environment. Med Teach. 2008;30(4):347-364. PMID: 15769796

30. Nikendei C, Huber J, Stiepak J, et al. Modification of Peyton's four-step approach for small group teaching - a descriptive study. BMC Med Educ. 2014;14:68. PMID: 22077699

Struggling Trainee and Remediation

31. Yao DC, Wright SM. National survey of internal medicine residency program directors regarding problem residents. JAMA. 2000;284(9):1099-1104. PMID: 19250164

32. Kalet A, Chou CL, Ellaway RH. To fail is human: remediating remediation in medical education. Perspect Med Educ. 2017;6(6):418-424. PMID: 29150787

33. Guerrasio J, Garrity MJ, Aagaard EM. Learner deficits and academic outcomes of medical students, residents, fellows, and attending physicians referred to a remediation program, 2006-2012. Acad Med. 2014;89(2):352-358. PMID: 24362399

34. Papadakis MA, Teherani A, Banach MA, et al. Disciplinary action by medical boards and prior behavior in medical school. N Engl J Med. 2005;353(25):2673-2682. PMID: 16371633

Supervision

35. Kennedy TJ, Regehr G, Baker GR, Lingard LA. Progressive independence in clinical training: a tradition worth defending? Acad Med. 2005;80(10 Suppl):S106-111. PMID: 23897111

36. Sterkenburg A, Barach P, Kalkman C, Gielen M, ten Cate O. When do supervising physicians decide to entrust residents with unsupervised tasks? Acad Med. 2010;85(9):1408-1417. PMID: 20736667

37. Farnan JM, Petty LA, Georgitis E, et al. A systematic review: the effect of clinical supervision on patient and residency education outcomes. Acad Med. 2012;87(4):428-442. PMID: 22361800

Learning Environment and Wellbeing

38. Edmondson A. Psychological safety and learning behavior in work teams. Adm Sci Q. 1999;44(2):350-383. PMID: 24979166

39. Fnais N, Soobiah C, Chen MH, et al. Harassment and discrimination in medical training: a systematic review and meta-analysis. Acad Med. 2014;89(5):817-827. PMID: 24667503

40. West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet. 2016;388(10057):2272-2281. PMID: 27692469

ICU-Specific Education

41. Barsuk JH, Cohen ER, Feinglass J, McGaghie WC, Wayne DB. Use of simulation-based education to reduce catheter-related bloodstream infections. Arch Intern Med. 2009;169(15):1420-1423. PMID: 19667306

42. Draycott T, Sibanda T, Owen L, et al. Does training in obstetric emergencies improve neonatal outcome? BJOG. 2006;113(2):177-182. PMID: 16411995

43. Wayne DB, Didwania A, Feinglass J, et al. Simulation-based education improves quality of care during cardiac arrest team responses at an academic teaching hospital: a case-control study. Chest. 2008;133(1):56-61. PMID: 17573507

44. Sexton JB, Thomas EJ, Helmreich RL. Error, stress, and teamwork in medicine and aviation: cross sectional surveys. BMJ. 2000;320(7237):745-749. PMID: 10720356

Medical Education General

45. Irby DM. Teaching and learning in ambulatory care settings: a thematic review of the literature. Acad Med. 1995;70(10):898-931. PMID: 7575922

46. Harden RM. AMEE Guide No. 21: Curriculum mapping: a tool for transparent and authentic teaching and learning. Med Teach. 2001;23(2):123-137. PMID: 11371288

47. Pashler H, McDaniel M, Rohrer D, Bjork R. Learning styles: concepts and evidence. Psychol Sci Public Interest. 2008;9(3):105-119. PMID: 27620530

48. Lucey CR, Thibault GE, ten Cate O. Competency-Based, Time-Variable Education in the Health Professions: Crossroads. Acad Med. 2018;93(3S):S1-S5. PMID: 29485489

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18. Related Topics

Prerequisites

• Communication Frameworks
• Consent and Capacity
• Professionalism in ICU

Related Conditions

• Trainee Wellbeing and Burnout
• Interprofessional Education
• Quality Improvement

Procedures

• Central Venous Catheter Insertion - Example EPA
• Airway Management - Example procedural teaching
• Echocardiography - Example skills teaching

Guidelines and Standards

• CICM Training Program Requirements
• ANZICS Education Standards
• CoBaTrICE Competencies