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Look, listen, go!
A fast and accurate diagnosis can make the difference between life and death in A&E. But trainees need to learn more than clinical skills to succeed and save lives, says Clinical Professor Goh Siang Hiong, Senior Consultant, Emergency Medicine, Changi General Hospital and Chair of SingHealth Duke-NUS Emergency Medicine Academic Clinical Programme. 

What field of emergency Medicine do you specialise in and teach?
I specialise in trauma and injuries but I teach all areas of emergency medicine. Our residents need to know how to handle any medical or surgical emergency that comes through our doors – one minute they can be diagnosing a heart attack in an elderly person and the next minute they can be providing life-saving support to a young motorcycle accident victim with massive trauma injuries. We also train medical students and residents from Internal Medicine, Family Medicine and Orthopaedic Surgery, who rotate through the Accident and Emergency Department (A&E) during their specialist training. 

What are the challenges of teaching emergency medicine?
The A&E is a high-pressure environment where patients need to be diagnosed quickly and accurately. It takes dedicated training and experience to develop the necessary skills and knowledge. About 60% of patients arrive with no referral from a primary care practitioner. While blood test results and scans help, the best information to obtain often lies with patients and their caregivers. Knowing a patient’s medical history, description of their symptoms, and what medications they have or haven’t being taking, are important for diagnosis and treatment. Doctors need to know how to gather such facts. However, dementia, unconsciousness and language barriers can make it challenging for patients to share such information, so training in the A&E focuses on communication and listening skills in addition to clinical knowledge and procedural skills.  

How has teaching changed during your medical career?
Teaching and mentoring are an integral part of medicine – it is ingrained in us to pass on our knowledge to our juniors. I experienced this as a medical student more than 35 years ago and it continues today. Bedside teaching, learning from good mentors and role models are the best ways to teach empathy, communication skills, and values.

However, technology is changing the way people learn and we need to adapt our teaching styles to keep pace. Teacher training is vital at all levels, so we can improve and retire outdated techniques. 

Quality online learning platforms are a great way for healthcare professionals to learn clinical facts in the comfort of their home. There is potential to expand such learning so we can free up more teaching time to discuss how clinical knowledge is interpreted and how treatment should be applied within the A&E for patients, and also to mentor staff. 

Today’s medical students and junior doctors have grown up with mobile phones and Google, which they are quick to use when considering symptoms and diagnoses. This gives them access to a wealth of research studies that include both well-controlled trials with validated results, as well as those with novel findings that – on closer inspection – are questionable due to poor data analysis or design. Teaching and mentoring junior staff so they can filter this information and identify the good from the bad is important to ensure that they apply evidence-based research that is relevant to our patient population. That aside, when doctors spend more time looking at mobile phones or computer screens, they may miss visual signs and symptoms as well as body language that may convey a patient’s anxieties, and run the risk of damaging the patient’s trust. I often have to remind juniors to put their phones away and to focus fully on their patients and the information that they are sharing.

Do you have any memorable teaching moments?
When residents from other specialties rotate through the A&E, they come with different strengths. For example, Orthopaedics residents have a very good understanding of the musculoskeletal system, read limb x-rays well and are usually good at managing trauma patients. However, they need more help with medical conditions such as pneumonia and knowing how to read ECG tracings from patients with chest pain.  I remember having taught a medical officer how to recognise the ‘tombstone’ sign in diagnosing a heart attack on an ECG. A few years later, when he had become an orthopedic consultant, he diagnosed a heart attack in his patient from the ECG readout. It was satisfying to know that the skills he had learnt in the A&E had made him a more holistic doctor and enabled him to save his patient’s life.