The Effects of Clinical Workload on Teaching in the Emergency Department

Background: Academic emergency physicians have expressed concern that increased clinical workload and overcrowding adversely affect clinical teaching. Objectives: To evaluate the influence of clinical workload and attending physicians' teaching characteristics on clinical teaching in the emergency department (ED). Methods: This was a prospective observational study using learner satisfaction assessment tools to evaluate bedside teaching. On days when a research assistant was available, all ED residents and attending physicians were queried. A total of 335 resident surveys were administered over nine months (89% response). Clinical workload was measured by perception and patient volume. Teaching quality and characteristics were rated on ten‐point scales. A linear mixed‐effects model was used to obtain adjusted impact estimates of clinical workload and teaching attributes on teaching scores while controlling for individual attending physicians' teaching ability and residents' grading tendencies. Results: No clinical workload parameter had a significant effect on teaching scores: residents' workload perception (β estimate, 0.024; p = 0.55), attending physicians' workload perception (β estimate, ?0.05; p = 0.28), patient volume in patients per hour (β estimate, ?0.010; p = 0.36), and shift type (β estimate, ?0.19; p = 0.28). The individual attending physician effect was significant (p < 0.001) and adjusted in each case. In another model, the attending physicians' learning environment established (β estimate, 0.12; p = 0.005), clinical teaching skills (β estimate, 0.36; p < 0.001), willingness to teach (β estimate, 0.25; p < 0.001), and interpersonal skills (β estimate, 0.19; p < 0.001) affected teaching scores, but the attending physicians' availability to teach had no significant effect (β estimate, 0.007; p = 0.35). Conclusions: Clinical workload and attending physicians' availability had little effect on teaching scores. Attending physicians' clinical teaching skills, willingness to teach, interpersonal skills, and learning environment established were the important determinants of overall scores. Skilled instructors received higher scores, regardless of how busy they were.     

8 The Observed Teaching Encounter: Providing Residents Feedback on Their Teaching Skills

Introduction:  Emergency medicine residents spend a significant portion of their time teaching junior residents and medical students in the clinical setting. Feedback is an integral component of any teaching curriculum, and therefore, feedback on residents' skill in teaching abilities is an essential part of their learning to teach. We have developed a structured method of providing feedback to senior residents on their teaching competence.
Methods:  Upcoming senior residents receive an 8-hour course on clinical teaching during their useful conference time. In our ED, attending faculty and senior "teaching" residents are matched with medical student learners. The Observed Teaching Encounter (OTE) is used during usual clinical ED shifts to reinforce concepts in teaching. During the OTE, the teaching resident is directly observed by a faculty physician while teaching a student learner. A checklist is completed by both the faculty member and the student learner in order to provide feedback to the teaching resident. Assessed skills correlate with teaching theory provided to residents in their didactic curriculum. Written formative comments are provided to the resident from faculty, as well.
Results:  Attending faculty, senior residents, and student learners have all provided positive feedback on the OTE. Assessment of residents' retention of knowledge on methodology of teaching is presently in progress as a tool to evaluate the efficacy of the OTE.     

Collective actions by physicians that do not endanger patients

Exploitation of resident physicians still occurs and can result in working conditions so unfavorable that patients are endangered. Because residents are vulnerable to exploitation, and because they are not fully accountable for patient care or for fully developed professionalism until they have completed their training, for just ends it is morally acceptable for residents to strike. Given that the ultimate responsibility for every patient rests not with the residents but with the attending and staff physicians, in the event of a resident strike the attending and staff physician supervisors should cover patient care, at least with respect to essential services. It is not morally acceptable for attending or staff physicians who are employees to strike. Attending and staff physicians should make every effort to resolve concerns about patient care without the use of confrontation. However, it may be necessary to consider collective actions to secure certain professional interests, including an interest in patient care. For such ends, patient endangerment is an unacceptable means and contrary to the professional virtue of altruism. The strategy for a just collective action is to identify the things that physicians normally do for their employer and collectively to withhold all of them, with the single exception of patient care.     

Identifying Bioethics Learning Needs: A Survey of Canadian Emergency Medicine Residents

Objectives: Emergency medicine (EM) postgraduate training programs must prepare residents for the ethical challenges of clinical practice. Bioethics curricula have been developed for EM residents, but they are based on expert opinion rather than resident learning needs. Educational interventions based on identified learning needs are more effective at changing practice than interventions that are not. The goal of this study was to identify the bioethics learning needs of Canadian EM residents. Methods: A survey‐based needs assessment of Canadian EM residents was performed between July 2000 and June 2001. Residents were asked to identify their learning needs by rating bioethics topics and by relating their clinical experiences. Physicians and nurses who work with residents were surveyed in a similar manner and also asked to identify the residents' bioethics learning needs. Results: A total of 129 EM residents (77% of eligible residents), 94 physicians, and 87 nurses responded. Residents, physicians, and nurses all identified issues in end‐of‐life care as the greatest bioethics learning needs of the residents. Other areas identified as learning needs included negotiating consent, capacity assessment, truth telling, and breaking bad news. A learning need identified by nurses, but not residents, was the manner in which residents interact with patients and colleagues. Conclusions: This needs assessment provides valuable information about the ethical challenges EM residents encounter and the ethical issues they believe they have not been prepared to face. This information should be used to direct and shape ethics education interventions for EM residents.     

Comparison of clinical teaching by residents and attending physicians in inpatient and lecture settings

We examined the differences between the clinical teaching of 21 residents and 19 attending physicians in one of two settings. Participants completed self‐assessments and were videotaped in either inpatient rounds or lectures. The videotapes were rated using the Clinical Teaching Observational Rating Scale. Teacher (Resident, Attending Physician) x Setting (Inpatient, Lecture) between‐subjects analyses of variance of videotape ratings showed that (a) attending physicians and residents generally received similar ratings; (b) when ratings were significantly different, faculty ratings were higher than residents’ ratings; and (c) setting was a significant source of variance for five of seven educational categories. There were no significant differences between residents’ and attending physicians’ self‐assessments of their clinical teaching. We concluded that (a) teaching improvement methods should acknowledge the influence of teaching experience and setting on teaching performance, and (b) residents and faculty could expand their repertoire of teaching behaviors.     

Comparing physicians and experienced advanced practice practitioners on the interpretation of electrocardiograms in the emergency department

BackgroundMany patients present to emergency departments (ED) in U.S. for evaluation of acute coronary syndrome, and a rapid electrocardiogram (ECG) and interpretation are imperative for initial triage. A growing number of advanced practice practitioners (APP) (e.g. physician assistants, nurse practitioners) are assisting patient care in the ED.PurposeThis study aims to compare the interpretation of ECGs by experienced APPs, each having 10 or more years of experience, with resident physicians and attending physicians.Patients and methods99 ED providers were stratified into attendings, residents at varying levels, and APPs were tested to interpret 36 ECGs from a database of ECGs initially interpreted to be ST elevation myocardial infarctions, of which 24 were determined to have a culprit lesion by coronary intervention.ResultsAttending physicians were the most sensitive (0.86, 95% CI of 0.80 to 0.92) and specific (0.69, 95% Cl of 0.60 to 0.79) at interpreting ECGs, but APPs and physicians in their first year of practice out of residency were almost equally as sensitive [(0.82, 95% CI of 0.76 to 0.88) and (0.82, 95% CI of 0.76 to 0.88)] and specific [(0.62, 95% cl of 0.52 to 0.73) and (0.65, 95% Cl of 0.56 to 0.75)].ConclusionThis study suggests the possibility of changing ED workflow where experienced APPs can be responsible for initial screening of an ECG, thus allowing fewer interruptions for ED physicians.     

Musculoskeletal education in physical medicine and rehabilitation residency programs: graduating resident perspective

OBJECTIVES: To characterize graduating physical medicine and rehabilitation (PM&R) residents physicians' perceptions of their current musculoskeletal (MSK) training, to identify barriers perceived by resident physicians to improving MSK education experiences, and to compare the views of resident physicians with those of PM&R residency program directors. DESIGN: Fourth-year PM&R residents graduating in 2004 whose program directors attended the 2004 Association of Academic Physiatrists annual meeting were asked to complete an MSK education survey developed by the authors. Data were compared with a previous MSK education survey that had been completed by PM&R residency program directors. RESULTS: Ninety-three of 156 (61%) fourth-year PM&R residents responded after multiple contacts. According to residents, the most frequently used MSK education formats during residency were MSK lecture series, MSK journal clubs, and MSK workshops. Potential barriers to improved MSK education during residency included staff, money, and time. If given unlimited resources, most residents would greatly increase the use of visiting lecturers, MSK workshops, and MSK lecture series. CONCLUSION: Graduating PM&R residents as well as residency program directors indicated a strong interest in expanding resident MSK education through the use of visiting lecturers. Differences were noted with respect to the use of hands-on learning (i.e., MSK workshops [residents]) vs. passive learning (i.e., CD ROMS/DVDs and videos [program directors]). Both groups described how limited resources including staff, money, and time are barriers to resident MSK education.     

Attending Rounds and Bedside Case Presentations: Medical Student and Medicine Resident Experiences and Attitudes

Background: Attending rounds have transitioned away from the patient's bedside toward the hallway and conference rooms. This transition has brought into question how to best teach on medicine services. Purpose: The purpose is to describe learner experiences and attitudes regarding bedside attending rounds at an academic medical institution. Method: Cross-sectional Web-based survey of 102 medical students and 51 internal medicine residents (75% response rate). Results: The mean time spent at the bedside during attending rounds was 27.7% (SD = 20.1%). During 73% of the rotations, case presentations occurred at the bedside 25% of the time or less. Learners experiencing bedside case presentations were more likely to prefer bedside case presentations. Despite their stated concerns, learners believe bedside rounds are important for learning core clinical skills. Conclusions: Time spent at the bedside is waning despite learners' beliefs that bedside learning is important for professional development. Our findings suggest the necessity to re-examine our current teaching methods on internal medicine services.     

Effect of an Integrated Public Health Curriculum in an Emergency Medicine Residency

Background: Emergency departments (EDs) serve as a central point of interaction between the public and the medical system. Emergency physicians need education in public health in order to optimize their clinical care and their ability to evaluate potential public health interventions in the ED. Methods: As part of the Centers for Disease Control and Prevention (CDC) and the Association of American Medical College's (AAMC) national initiative for "Regional Medicine-Public Health Education Centers-Graduate Medical Education", we designed and implemented a new public health curriculum for the emergency medicine residents. Over four sessions during regular didactic time, we used a modular approach to link a basic public health principle, such as environmental hazard assessment, to a relevant clinical topic, such as violent patients and ED safety. Each session emphasized resident involvement, including small group work and role-plays. Journal clubs and quality assurance projects supplemented the curriculum. We sought resident feedback through focus groups and anonymous online pre- and post-tests for each session. Assessment: Both before and after the curriculum, 76% of responders felt it was important for physicians to receive training in public health. The program appeared to have a positive effect on residents' comfort level with various public health topics, and felt the residency program had taught them the skills necessary to implement public health principles in clinical practice (23.8%, versus 11.5% before; p<0.05). Conclusions: Integration of public health principles into existing clinical curricula in emergency medicine may increase resident interest and knowledge. Combining public health and emergency medicine topics in regular didactic conferences facilitates public health education for residents.     

Predictors of Success in Emergency Medicine Ultrasound Education

OBJECTIVES: To compare emergency medicine resident performance on an ultrasound-oriented, American Board of Emergency Medicine-styled written examination with the following variables in resident education: number of ultrasound scans performed, presence of a formal, structured ultrasound rotation, presence of a mandatory ultrasound rotation, number of hours of didactic ultrasound education, and percentage of ultrasound education taught by emergency physicians. METHODS: This was a prospective cohort study involving 14 residency programs. A 60-question multiple-choice test was completed by individual residents and returned for scoring. RESULTS: 262 residents completed the study. Average score was 39.1/60 +/- 6.5 (65%). Scores improved as residency year increased (year 1: 36.6, year 2: 39.3, year 3: 42.6) (p < 0.005). Scores improved as number of scans performed increased from 34.3 (57%) for those residents who had performed 0-10 scans to 45.4 (76%) for those with >150 scans (p < 0.005). The presence of an ultrasound rotation at an emergency medicine residency program also produced a statistically significant increase in test score (OR 1.82; 95% CI = 1.29 to 2.55). Residents at programs spending the least time (6 to 15 hours) on didactic education throughout the residency predicted examination failure (OR 0.60; 95% CI = 0.39 to 0.93). Increasing the amount of resident ultrasound teaching by emergency physicians improved the score, but this did not reach significance (p = 0.357). CONCLUSIONS: Improved resident performance on an ultrasound written examination was associated with increasing resident year, number of scans performed, and the presence of an ultrasound rotation at the residency program. Increasing the number of didactic hours spent on ultrasound each year beyond 15 hours showed no improvement in resident performance.     

A deep learning-based framework for segmenting invisible clinical target volumes with estimated uncertainties for post-operative prostate cancer radiotherapy

In post-operative radiotherapy for prostate cancer, precisely contouring the clinical target volume (CTV) to be irradiated is challenging, because the cancerous prostate gland has been surgically removed, so the CTV encompasses the microscopic spread of tumor cells, which cannot be visualized in clinical images like computed tomography or magnetic resonance imaging. In current clinical practice, physicians’ segment CTVs manually based on their relationship with nearby organs and other clinical information, but this allows large inter-physician variability. Automating post-operative prostate CTV segmentation with traditional image segmentation methods has yielded suboptimal results. We propose using deep learning to accurately segment post-operative prostate CTVs. The model proposed is trained using labels that were clinically approved and used for patient treatment. To segment the CTV, we segment nearby organs first, then use their relationship with the CTV to assist CTV segmentation. To ease the encoding of distance-based features, which are important for learning both the CTV contours’ overlap with the surrounding OARs and the distance from their borders, we add distance prediction as an auxiliary task to the CTV network. To make the DL model practical for clinical use, we use Monte Carlo dropout (MCDO) to estimate model uncertainty. Using MCDO, we estimate and visualize the 95% upper and lower confidence bounds for each prediction which informs the physicians of areas that might require correction. The model proposed achieves an average Dice similarity coefficient (DSC) of 0.87 on a holdout test dataset, much better than established methods, such as atlas-based methods (DSC<0.7). The predicted contours agree with physician contours better than medical resident contours do. A reader study showed that the clinical acceptability of the automatically segmented CTV contours is equal to that of approved clinical contours manually drawn by physicians. Our deep learning model can accurately segment CTVs with the help of surrounding organ masks. Because the DL framework can outperform residents, it can be implemented practically in a clinical workflow to generate initial CTV contours or to guide residents in generating these contours for physicians to review and revise. Providing physicians with the 95% confidence bounds could streamline the review process for an efficient clinical workflow as this would enable physicians to concentrate their inspecting and editing efforts on the large uncertain areas.     

Intensive care decisions about level of aggressiveness of care

Questionnaires were used to assess (a) the factors intensive care unit resident physicians (N = 33) and nurses (N = 57) perceived as influential in making decisions about level of aggressiveness of patient care (LAC), (b) who residents and nurses believed should be involved versus who was involved in decision making, and (c) the amount of collaboration they perceived in their practices. Questionnaires then were used to assess decision making about 314 patients. All providers agreed that patient request influenced their LAC decisions, with possibility of benefit and diagnosis ranked second and third. Although both nurses and residents believed capable patients should be making LAC decisions, providers identified attending physicians as the most common participants in decision making for specific patients. Residents were more satisfied with the decision making process than nurses, t = 2.05 (88), p =.04. There was no relationship between perceptions of nurse–resident collaboration and providers' inclusion of others in the LAC decision process. ©1995 John Wiley & Sons, Inc.     

When Professors Don't Return Essays

Issue: Students devote hundreds of hours to writing notes during medical school clerkships but receive very limited feedback on that work. Medical student notes are like college essays—both are persuasive compositions. But attending physicians rarely scrutinize student notes like college professors analyze essays. This is a missed opportunity to teach clinical reasoning. Evidence: A survey at our institution showed that only 16% of students received written feedback and 31% received oral feedback on their notes from more than 3 attending physicians during the first 8 months of 3rd-year clerkships. Many studies have reported a paucity of feedback across multiple domains and a sense among students that clinical reasoning is not being adequately taught during clerkships. Meanwhile, college professors teach written composition and reasoning through interactive methods that help students to develop structured, well-reasoned arguments. A recent study showed that 85% of Oxford undergraduates favored these demanding and time-intensive tutorials. Implications: Attending physicians who adopt a tutorial-based approach toward their students' notes would have a forum to teach clinical reasoning and emphasize the importance of written composition in medical practice.     

Assessing clinical competence in physical medicine & rehabilitation residency programs

OBJECTIVE: Evaluation of resident clinical competence is a complex task. A multimodal approach is necessary to capture all of the dimensions of competence. Recent guidelines from the Accreditation Council for Graduate Medical Education delineate six general competencies that physicians should posses. Application of these guidelines presents challenges to residency program directors in defining educational experiences and evaluation methods. DESIGN: We surveyed 81 physical medicine and rehabilitation program directors regarding assessment tools used in their programs. Seventy-five percent responded. The most frequently used assessment tools included: In-training self-assessment examinations, faculty evaluations, direct observation, and conference participation. Program directors assigned the highest values to direct observation, faculty evaluations, self-assessment examinations, and oral examinations. RESULTS: Of the general competencies, more than 90% of program directors believed they did an adequate job rating dimensions of patient care, medical knowledge, professionalism, and communication skills. Approximately one-third, however, thought they did a less than fair job rating practice-based learning and improvement and systems-based practice. The majority of programs reported that they were able to identify a resident with difficulties during the first year of training, 44% within the first 6 months. Program directors reported that their residents spend a significant amount of their time with nurses and therapists during their inpatient rotations; however, this was not reflected in their evaluation practices, in which only one-fourth of programs reported the use of nurses and therapists in evaluating residents. CONCLUSIONS: Survey results indicate that physical medicine and rehabilitation program directors apply a variety of assessment tools in evaluating resident clinical competence. Although perceptions about the relative value of these tools vary, most programs report a high value to direct observation of residents by faculty. Of the six general competencies, program directors struggle the most with their evaluation of practice-based learning and improvement and systems-based practice.     

Barriers to low tidal volume ventilation in acute respiratory distress syndrome: survey development, validation, and results

OBJECTIVE: To evaluate perceived attitudes, knowledge, and behaviors regarding the use of low tidal volume ventilation in acute respiratory distress syndrome among physicians, nurses, and respiratory therapists in intensive care units. DESIGN: Cross-sectional, self-administered survey. SETTING: Large Acute Respiratory Distress Syndrome Network teaching hospital in Baltimore, MD. PARTICIPANTS: Attending, fellow, and resident physicians; staff nurses; and respiratory therapists in three intensive care units. INTERVENTIONS: A survey was designed to assess barriers related to clinicians' perceived attitudes, knowledge, and behaviors related to low tidal volume ventilation in acute respiratory distress syndrome and intensive care unit organization-related barriers. Survey development was guided by a published framework of barriers to clinician adherence to practice guidelines; individual items were derived through literature review and refined through pilot testing. Content validity, face validity, and ease of use were verified by local clinicians. Psychometric properties were assessed and regression analyses were conducted to examine differences in perceptions and knowledge level by provider discipline and training level. MEASUREMENTS AND MAIN RESULTS: There were 291 completed surveys with a response rate of 84%. Validity and acceptable psychometric properties were demonstrated. Barriers related to clinician attitudes, behaviors, and intensive care unit organization were significantly higher among nurses and respiratory therapists vs. physicians. Knowledge-related barriers also were significantly higher among nurses vs. physicians and respiratory therapists. Barriers were lower and knowledge test scores higher among fellows and attending physicians vs. residents. Similarly, barriers were lower and knowledge test scores higher among nurses with >10 yrs of experience vs. <10 yrs of experience. CONCLUSIONS: Important organizational and clinician barriers, including knowledge deficits, regarding low tidal volume ventilation were reported, particularly among nurses and resident physicians. Addressing these barriers may be important for increasing implementation of low tidal volume ventilation.     

Length of Attending-Student and Resident-Student Interactions in the Inpatient Medicine Clerkship

Phenomenon: Changes in the medical education milieu have led away from the apprenticeship model resulting in shorter physician–student interactions. Faculty and student feedback suggests that supervisor/student interactions may now be more cursory with increasing numbers of supervisors per student, and shorter duration of interaction. This may affect both education and student assessment. Approach: We compared inpatient attending and resident daily schedules with those of 3rd- and 4th-year medical students rotating on medicine clerkships at Brigham and Women's Hospital during academic years 2009–11 to determine the number of days of overlap. We used evaluation forms to determine the extent of evaluator's self-reported knowledge of the student. Findings: We correlated the daily schedules of 199 students and 204 resident and 187 attending physicians, which resulted in 558 resident–student pairings and 680 attending–student pairings over 2 years. During a 4-week block, students averaged 3.7 attending physicians (M = 4, range = 2–7), with 49.7% supervised by 4 or more. Attending-student overlap averaged 9 days (M = 9, range = 2–23), though 40% were 7 days or less. Students overlapped with an average 3.4 residents (M = 3, range = 1–6). Resident-student overlap averaged 12 days (M = 11, range = 3–26). There were 824 student assessment forms analyzed. Resident and attending physician supervisors describing knowledge of their student as “good/average” overlapped with students for 14 and 11 days respectively compared to resident and physician supervisors who described their knowledge as “poor” (11 days, p < .01; 6 days, p < .01). Insights: On the inpatient medicine clerkship, students have multiple supervising physicians with wide variability in the period of overlap. This leads to a disrupted apprenticeship model with fragmentation of supervision and concomitant effects on assessment, feedback, role modeling, and clerkship education.     

Pilot Study: Concordance of Disposition for Hypothetical Medical Patients in the Emergency Department

Objectives: Emergency physicians (EPs) make dispositions for every patient in the emergency department (ED) and often require agreement from inpatient services to admit medical patients to the hospital. Sometimes disagreements arise. The authors sought to determine in their institution disposition concordance between EPs and admitting medical services of hypothetical ED patients. A second objective was to describe additional information requested by each service. Methods: Within a two‐week period, physicians from emergency medicine (EM), family practice (FP), and internal medicine (IM) voluntarily completed anonymous questionnaires asking them to disposition hypothetical ED patients. Eleven case scenarios were followed by three disposition choices (admit, discharge, or cannot tell) from given information (followed by a free‐text area). Results: A total of 105 questionnaires were returned: 42 from EM (12 attending physicians/30 residents), 33 from FP (14 attending physicians/19 residents), and 30 from IM (4 attending physicians/26 residents). Admission rates were statistically different for EM (68% attending physicians/65% residents/66% total) when compared with FP (42% attending physicians/54% residents/49% total) (p < 0.01) and IM (36% attending physicians/53% residents/51% total) (p < 0.01). Discharge rates were also statistically different for EM (8% attending physicians/19% residents/16% total) versus FP (29% attending physicians/29% residents/28% total) (p < 0.01) and IM (27% attending physicians/28% residents/28% total) (p < 0.01). “Cannot tell” rates were not significantly different between groups (p > 0.05) for EM (23% attending physicians/16% residents/18% total) versus FP (25% attending physicians/14% residents/19% total) and IM (36% attending physicians/16% residents/18% total). The proportion of additional tests requested in the “cannot tell” disposition by attending EPs was about half that of the other groups. Dispositions between FP and IM were not different at any level (p > 0.05). Conclusions: In the authors' institution, when presented with identical hypothetical ED patients, EPs would admit more, discharge less, and ask for fewer additional tests than FP or IM physicians. The FP and IM physicians surveyed disposition patients in a similar manner.     

Social Workers as Workplace-Based Instructors of Alcohol and Drug Screening,Brief Intervention,and Referral to Treatment (SBIRT) for Emergency Medicine Residents

Problem: Residency education is challenged by a shortage of personnel and time, particularly for teaching behavioral interventions such as screening, brief intervention, and referral to treatment (SBIRT) to reduce hazardous drinking and drug use. However, social workers may be well placed to teach SBIRT in clinical training settings. Intervention: We describe a curriculum with social workers as SBIRT trainers of emergency medicine (EM) residents during actual clinical shifts in an EM residency training program. The curriculum required 1 EM faculty member working with social workers and 1 additional hour of formal residency conference teaching time. Context: We implemented the curriculum at both a university tertiary care hospital emergency department and a county trauma center. We trained 8 social workers at both sites as SBIRT superusers to teach and assess EM resident SBIRT performance with actual patients. We measured the length and number of sessions to attain SBIRT competence, residents' satisfaction, and resident comments (coded by authors). Outcome: Five of the 8 social workers trained residents between June 2013 and May 2014, 31 EM residents trained to a level indicating SBIRT competence with 114 patients. Each patient interaction averaged 8.8 minutes and residents averaged 3.13 patients. Twenty-four (77%) residents gave ratings of 1.58 (SD = .58) for the quality of teaching, 2.33 (SD = .87) for recommending the training to a colleague, 1.38 (SD = .49) for superusers' knowledge, 1.88 (SD = .95) for usefulness of instruction, 1.54 (SD = .72) for workplace learning, and 1.58 (SD = .78) for valuing learning from social workers (on a scale of 1 [very satisfied/strongly agree] to 5 [very dissatisfied/strongly disagree]). Residents preferred learning SBIRT during the 1st and 2nd training years and in the workplace. Lessons Learned: Social work colleagues can be effective in teaching SBIRT to residents in the workplace, and our residents highly valued learning from social workers, who all had prior training in motivational interviewing. In the implementation of this curriculum, the clinical demands of residents must be taken into account when teaching occurs, and having multiple social worker instructors was instrumental.