Author: Nikki Abela / Codes: SLO9 / Published: 27/02/2017


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Unlike FOAMed, education is not a new thing. That is not to say it is completely understood, but there are many theories behind good and bad education. Two renowned scholars in particular, Abraham Maslow and Alfred Adler gave particularly popular insight in what works and what doesn’t, and their ideas will be covered in this blog.

Maslow theorised that in order for individuals to reach their full potential, a series of needs has to be met. Unless the most basic ones are satisfied, we can not move on to higher levels of fulfilment.

These needs can be depicted in the form of a pyramid (see diagram below), where each layer above needs to be built on a pediment of more “fundamental” needs.


If you had to reflect on these, you will realise that the Emergency Department is a challenging environment for teaching and learning. I know I am not alone in saying that there are shifts where I go without a pee or a drink, and our rotas leave many of us feeling tired, lacking sleep and/or away from our families. For these reasons (and a few others) I think it is safe to say that high levels of burnout exist in those practicing emergency medicine.

If we had to base our departmental education on Maslow’s theory alone, we are doomed: with the most basic physiological learning needs unfulfilled due to departmental pressures, how can supervisors and trainees be expected to reach higher levels of self-actualisation and transcendence?

Yet, many of us know many good ED doctors. So how did they thrive in spite of the challenges faced in their department? The truth is that although the ED may not satisfy some educational needs according to Maslow, it is an educational gem in other areas.

For example, departments full of sick patients  present an ideal environment for problem based learning as large numbers of patients equate to more training opportunities for junior doctors to be exposed to the different problems they present with.

Its 24-hour cover by senior and junior staff and allied health professionals means that many of these departments are able to provide training opportunities to satisfy both the technical and non-technical skills required to make good doctors. More importantly, there is evidence for a “survivor” category of Emergency Medicine practitioners who rise above environments known to bring about high levels of burnout.

Many of us will be familiar with the adrenaline that goes through our veins when we are faced with stressful situations, how we like to rise to the challenge and feel rewarded for it. An example of this is the euphoric feeling many of us feel after a particularly challenging set of nights – we don’t like doing them, but we feel accomplished to have completed them. We walk out of the ED or a difficult resus with pride, like we have proved our self-worth among our peers.

Overcoming ED challenges gives EM physicians an opportunity to feel significant, while its environment allows for a sense of belonging among our peers. This fits in to the Adlerian theory – that all individuals have one goal: to belong and feel significant.

Adler believed, in a nutshell, that learners who feel encouraged, able and appreciated will respond by being cooperative. On the other hand, those who are discouraged may make up for their feelings of inferiority by competing unhealthily or giving up.

Therefore, one could argue that the ED can actually be an ideal place to achieve self-actualisation, but it is up to educators to exploit this by encouraging learners to realise their potential in this environment.

Moreover, the teamwork in the ED is something which physicians will tell you is an attractive part of the specialty as they feel they belong there and the challenging environment is thought to attract personalities which strive under these conditions.

As a trainee, I have always felt happier and more open to learning in departments where I felt appreciated, part of the team and the load is shared among staff.

As educators, being aware of the “survivor mentality” and making sure Maslow’s basic learning needs are satisfied in our learners will allow them to progress through to higher levels of learning.

Don’t know where to start? Alan Grayson has a few ideas you should take up, if you are in a position to. For those of us who are not able to make massive changes to the system we are part of, don’t be discouraged: a little can go a long way. For example, ensure everyone on your shift gets a break if you are in charge, stop the hierarchy gradient by insisting on being called by your first name, dip that urine yourself if the nurses are too busy (many of them are also learning) and make your colleagues feel valued and part of the team.

Winter pressures can leave many learners feeling discouraged by their speciality choice, but if we remember the theories of Maslow and Adler, then even the smallest of changes can make all the difference to the learners on your shift.

Remember that when you are faced with the daily ED disorder, you should stick to the theory of chaos and be the butterfly.


Further reading:

  1. St.Emlyns: Futureproofing EM: Why your trainees deserve it (and your nation needs it)
  2. Adler:Theory and Application
  3. Goldberg, R., et al.(1996).Burnout and Its Correlates in Emergency Physicians: Four Years’ Experience with a Wellness Booth. Academic Emergency Medicine. 3 (12), pp. 1156–1164.
  4. Self-Actualisation and Transcendence in Emergency Medicine
  5. St Emlyns
  6. RCEM FOAMed podcast with Simon Carley