ADDIE system

The ADDIE system (Analysis, Design, Development, Implementation, and Evaluation) is a system that can be used for teaching in the Emergency Department. Originally developed by the U.S. military, it is a well-defined instructional design system that has been re-purposed for patient safety protocols, curriculum development, and product design.

• The emergency department is a rich environment for medical teaching, with its breadth of pathology and volume of first-presentation cases.
  • Particularly in academic institutions, where junior residents and students are learning, teaching is one of the main responsibilities of faculty and senior staff.
  • However, the high volume, quick-evolving situations, critical care, proximity of patient interaction and general hectic environment compete with teaching time for educators.
    • Beginning learners have been shown to decrease efficiency in the ED[1].
• Effective education is one of the most important functions of the emergency physician.
  • for residents/students for their future effectiveness as physicians
  • for nurses/techs for their effectiveness in their roles in the team
  • for patients/families for their primary role in their continued care
• An ADDIE-based system has been re-purposed for ED teaching. [2]
  • well-designed and structured
  • concise, focused instruction well-suited to the ED environment

1. Assessing the learner: Evaluate the learner's existing knowledge base.
   • Ask a case-based question to assess the learner's level of knowledge.
     • e.g. "What do you know about acute cholecystitis?"
   • Determine general learning goals at beginning of shift.
     • e.g. "What are you looking to get out of this shift today?"
   • Determine general strengths and weaknesses..
     • e.g. "What rotations have you had so far?"
   • Determine depth of learner's clinical progress
     • e.g. "So you saw the guy in 8. He has chest pain?"
     • Learner's answer can show level of clinicianship.
       • e.g. "Yeah, it looks pretty serious. He's had a heart attack before and his pain is really bothering him." vs. "He's got a legit CAD history with an old NSTEMI, but his pain is nonexertional, nonradiating, and reproducible on physical exam with no other anginal equivalents. It started when he ran out of his percocet yesterday. His ECG is unchanged so if his troponin is normal his HEART score should be low risk and maybe he can follow up as an outpatient."
2. Determining the instructional content: Determine gaps in learner understanding.
   • Probe to find limits of the learner's understanding: "constructive pimping".
   • e.g. "How do you want to use the ultrasound? What probe are you using? What are you looking for? What else are you worried about that you can't see on ultrasound?"
   • Can be chosen from five general areas:
     • knowledge (e.g. pathophysiology, diagnosis, treatment of a disease, differential diagnosis)
     • communication (e.g. patient presentation)
     • procedural skills (e.g. laceration repair)
     • attitudes (e.g. coping with an emotional family)
     • behaviors (e.g. staying on top of ED flow)
3. Determining the instructional method: Choose an appropriate method for delivering the information.
   • Find an appropriate way to fill in the determined gaps in knowledge.
     • Didactic: teacher centered, with a speaker and a recipient.
       • explanation of clinical reasoning
       • minilectures/videos
       • Board Rounds
       • how to use clinical decision tools
     • Socratic: question and answer, leading learner toward right path. Frequently preferable for adult learners [3]
       • start with foundational knowledge such as facts
       • progress to questions that assess synthesis, application of concepts
       • allow adequate pauses of several seconds
       • determine learner's level of comfort based on content and prosody of response, body language [4]
     • Demonstrative
       • dependent on acuity of situation
       • ideally conceptualized first, then verbalized by learner
       • simulation is an important field in this
   • Instructional Level must be based on learner level, type of lesson to be taught, acuity of case.
     • e.g. high likelihood of cholecystitis→ perform RUQ US together: have learner use probe
     • e.g. low likelihood of cholecystitis, department is busy→ find Youtube videos of normal RUQ US and of the signs of cholecystitis
     • e.g. department is empty→ mini-lecture: "Let's go through the differential diagnosis of epigastric pain and nausea/vomiting."
4. Determining the effectiveness of instruction: Assess the success of the educational intervention.
   • direct questioning (facts)
     • "So remind me, what are the four major criteria of acute cholecystitis on ultrasound?"
   • direct application
     • "Show me the gallbladder in A5. Tell me if you think it's cholecystitis."
   • hypothetical case (synthesis, application)
     • "How might our differential change if this patient has jaundice and altered mental status? What about an elevated lipase? What else would we test for? How does treatment and disposition change?"

Residency: Basic Skills

Life in the Fast Lane:Guide to Clinical Teaching