Tag Archives: education

EM Mindset: Reading My Mind

Author: Judith E. Tintinalli, MD MS (Professor of EM / Chair Emeritus, Department of EM, University of North Carolina) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) and Brit Long, MD (@long_brit)

A style of working, teaching, and learning in Emergency Medicine takes time to develop.   We don’t get much opportunity to see how our colleagues operate, except perhaps on change-over rounds, which are always pressed for time, and which don’t allow for discussions about why different attendings do things differently.  I’ve always thought of myself as a middle-of-the roader in our group: middle in terms of times, patients/hr, decisions to admit versus discharge. But I’m pretty good at documentation, work generally on the careful and compassionate side, can work at the speed of light when necessary, and have learned from the past so hopefully current mistakes are few and far between.

So, step into my office and I’ll share with you some of my habits, behaviors, and opinions that I’ve developed over the years.

Supervising Learners

Working in an academic medical center has great rewards.  Being surrounded by shadowers, medical students, and residents of all specialties keeps you on your toes. Medicine has moved from time-lapse to fast-forward, and residents who have recently completed inpatient rotations are terrific sources of changes in specialty practice patterns.  But the growing number of learners you are responsible for on a shift can be intellectually overwhelming and certainly slows down the process of patient care.  A different approach is needed for each level, so that one can loosen (but never eliminate) the level of supervision for the most senior learners.

I start my shifts explaining how to structure presentations. The goal is to get a good mental picture of the patient – ill-appearing, obese, amputee, in pain, blind or deaf, angry, demanding.  Then a concise statement of the triage note and patient’s problem, but with a listing of key meds/conditions that will affect the ED workup.  ‘This is a 65 year old patient with atrial fibrillation on Xarelto with 2 hrs of acute abdominal pain’.  Key meds for me are antithrombotics, immunosuppressives, steroids, insulin.  I’ll never forget a ‘routine’ intern presentation of a 65 year old woman who fell at home, and now had a femur fracture. When I went to evaluate her, I was aghast at not being told she had a heart transplant and had severe COPD requiring home oxygen.  How many times have I been told confidently that vital signs were ‘rock stable’, only to find a pulse rate of 120 or a BP of 230/170.

So, focused and concise presentations help a busy attending prioritize which patients need to be seen as soon as possible. They also teach learners how to present to consultants.

Teaching in the ED

There’s a growing body of EM literature that focuses on clinical teaching in the busy ED.  Each of us has to develop our own style.  I like to ask for the main, and then major differential diagnoses, before the learner spews out the orders, so the learner can demonstrate why each order is needed. I keep trying to minimize laboratory orders, but one of our jobs is to let each learner order stuff, and with experience, to be able to gain confidence in clinical judgement and stop ordering unnecessary labs and imaging. That is a trial and error process. One good tool is to ask the resident ‘If this patient came into your office, would you send them to the ED to get these lab tests or imaging?’

One of the best teaching tools I use is to ask a question that I myself cannot answer.  Like – ‘OK this person with prior DVT and PE is on Xarelto, and now we’re concerned about another PE. What’s the failure rate for Xarelto and does this patient have any risk factors for failure?’  Another tool is to come armed with a recent article you’ve read, ready to whip it out when needed.   For example, our residents like to order stress tests out of the ED for patients with low probability chest pain, because we have a protocol, but ask them ‘why’, ‘how’, or ‘what does it cost the patient’ and you’re met with silence.  So for a while I kept a copy of Long and Koyfman’s article  ‘Current Controversies in the Evaluation of Low Risk Chest Pain (JEM Dec 2016)’ in my doctor bag,  let them see the current data on the topic, and then give the opportunity to re-evaluate their decision.   Another one I kept with me recently was the recent study on single-dose decadron 12 mg po for adults with mild-moderate asthma.  As residents don’t read journals anymore, it gives them the opportunity to at least read a journal abstract.

Procedures and Consultations

In emergency medicine, we’ve structured our residency programs so the majority of learning and teaching is in tertiary care centers.  Consider the disadvantages: where specialty consultants are available 24/7, it can be a lot easier to call ortho to reduce a hip, evaluate a fracture or tap a joint, to call GU to place a difficult Coude catheter, or to have neurology decide who gets tPA for possible stroke.  The community EM practices that most of our residents will select after graduation will typically have a very limited menu of emergency consultants, and I’m not sure we are training them well for these environments.  I always have residents think through their treatment plans before calling the consultant, as this is their future reality.  I remember during the early days of EM training, moonlighting was really frowned upon.  The philosophy was that the only time anybody cared about resident learning was during residency, so every minute should be spent reading, seeing patients, and learning.  The medical environment has changed, and our senior residents get invaluable experience moonlighting that we cannot give them in a tertiary care environment.

Disposition and Follow-Up

This is where I think attendings and residents diverge.  I explain that everyone, learner or attending, has his or her own inherent ability to tolerate uncertainty.  If a resident strongly wants to admit a patient that I feel can be safely discharged, I challenge him or her to present the case to the admitting team. This gives a chance to practice skills needed in a community ED setting.  Another area of divergence is how far to go to exclude specific diagnoses in the ED. In our current medical care system, where so many patients have no insurance, giving them a clean bill of health in the ED means a lot. So ultrasounds, MRIs, and CT scans, and sometimes consultations in the ED to provide a clear follow-up plan, are more and more part of routine management.  Disposition requires a lot of stepped-thinking. Recently I took over a shift where a young Spanish-speaking woman came into the ED with a disc of a head CT identifying a brain tumor. Imaging had been done at an outside community hospital without neurosurgeons, and the patient was told to make an appointment with a neurosurgeon.  Mystified, she came into the ED.  Her discharge had already been written by the previous shift team, and the phone number of neurosurgery clinic was provided.  We held the discharge and consulted neurosurgery.  The CT was reviewed, an MRI was then done, decadron and Keppra were recommended by the neurosurgeon, and a clear follow-up was arranged in 3 days in neurosurgery clinic.  These steps would be very difficult to manage as an outpatient, where waits for an MRI can be weeks; payment is required before testing; the clinic appointment team may or may not speak Spanish; and it can take weeks to get an appointment in an overburdened neurosurgery clinic.  Another important principle I try to teach is ‘we cannot predict the future’.  Residents will sometimes say, oh, why get this specialized imaging; why call the consultant, they won’t do anything; why try for admission – there’s an easy answer.  I cannot predict the future – can you?

Why I love Emergency Medicine

A recent JAMA article reported that emergency medicine has the highest burn-out and fatigue rate of any other specialty.  If that is so, why are medical students flocking to our residency programs? Not every shift is wonderful – some are exhausting, filled with contentious problems or patients. Most times I look forward to a shift, but sometimes it is hard to put one foot in front of the other as I walk to my desk.  But I think all of us would rather be emergency physicians rather than anything else.  We have the unique ability to help patients when they are most vulnerable.  We have to establish rapport within minutes, not weeks or months.  We work in a terrific team environment.  We learn to be flexible, can calm down irritable consultants, and like to make fast decisions.  We can work a lot of shifts or fewer shifts. We don’t carry our patient burdens home with us. Life is good.

EM@3AM – Abdominal Aortic Aneurysm

Author: Erica Simon, DO, MHA (@E_M_Simon, EM Chief Resident, SAUSHEC, USAF) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital) and Brit Long, MD (@long_brit, EM Attending Physician, SAUSHEC, USAF)

Welcome to EM@3AM, an emDOCs series designed to foster your working knowledge by providing an expedited review of clinical basics. We’ll keep it short, while you keep that EM brain sharp.


A 67 year-old patient with a history of smoking, hypertension, and hyperlipidemia presents for the evaluation of sudden onset, severe, right flank pain. ROS is remarkable only for right thigh pain and weakness of two weeks duration. Triage VS: HR 114, BP 101/78, RR 22, SpO2 92% on room air.

What is the patient’s diagnosis? What’s the next step in your evaluation and treatment?


Answer: Abdominal Aortic Aneurysm1-3

  • Risk Factors: smoking, hypertension, family history, atherosclerosis
  • Presentation: sudden onset, severe pain radiating to the back/flank +/- pulsatile abdominal mass, +/- hypotension
  • Unstable or Symptomatic:
    • Emergent vascular/general surgery consult
    • Bedside ultrasound
    • Type and screen 6-10U pRBCs
  • Stable:
    • CT abdomen/pelvis with IV contrast
  • Asymptomatic:
    • Aortic diameter > 3cm: requires follow-up for surveillance
    • Aortic diameter > 5cm (female) or >5 cm (male): surgical candidate
  • Pearls:
    • Consider in patients presenting with femoral neuropathy: indicative of a ruptured aneurysm with enlarging hematoma.2-3
    • Consider in the differential of the elderly syncope patient.

References:

  1. Tintinalli J, Kelen G, Stapczynski J, Ma O, Cline D, et al. Tintinalli’s Emergency Medicine. 8th ed. New York: McGraw-Hill; 2016. Chapter 60, Aneurysmal Disease.
  2. Haddad F, Hatrick N, Shanahan D. An unusual presentation of a ruptured abdominal aortic aneurysm. J Accid Emerg Med. 1995; 12(3): 220-221.
  3. Razzuk M, Linton R, Darling R. Femoral neuropathy secondary to ruptured abdominal aortic aneurysms with false aneurysms. JAMA. 1967; 201(11): 817-820.

The Road to Academic Emergency Medicine

Authors: Brit Long, MD (@long_brit, EM Attending Physician at SAUSHEC), Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital), and Jennifer Robertson, MD, MSEd (Assistant Professor, Emory University, Atlanta GA)

Emergency physicians train to be highly proficient in the resuscitation and management of acutely ill patients.  In addition, all emergency medicine (EM) training programs focus on preparing physicians to care for these patients in community practice settings. While most EM graduates go on to practice in community settings, academic EM is an option for interested physicians.

In general, academic EM was established to provide the teaching, research, and leadership goals of the specialty. For current residents and community doctors, specific pathways for practicing academic EM are now available, which allow new graduates to directly enter academic EM from residency or transition from community to academic EM.

The decision to practice academic or community practice can be a difficult one to make, as there are perks and drawbacks in both settings. This post will evaluate the road to academic emergency medicine, the positives and negatives, and provide tips for success. However, before we start, we need to understand the difference between academic and community EM.

What is academic emergency medicine?

An academic emergency medicine practice is defined by its providers spending the majority of their time in resident education/supervision, along with scholarly activity (academic writing, teaching, or research).1-5 This focus came into existence in order to meet the teaching, research, administrative, and educational aspects of emergency medicine. The majority of academic providers are associated with a teaching hospital, and many have time protected for academic pursuits. Over 40% of current residents are interested in pursuing an academic career, but the road to determining whether an academic or community practice is right for you can be difficult.1

Unfortunately, many graduating residents feel ill prepared to begin a career in academics, and program directors agree. A survey of EM residency directors found that only 29% feel their program graduates are prepared for an academic career involving original research.2 Obstacles include insufficient research training and resident difficulty in finding knowledgeable collaborators and mentors.

What is community practice?

Community EM refers to practices based mostly on clinical medicine. In community EM, providers spend the majority of their time on clinical duties (usually shifts), rather than supervising and educating residents. Providers may have other obligations such as administrative tasks, but their primary focus is direct patient care. However, the actual amount of patient care duties will vary within individual departments, hospitals, and even parts of the country. Pay is often based on the number of shifts and relative value units (RVUs) per shift. However, overall pay can be also be affected by partnerships, bonuses based on productivity, patient satisfaction, and quality measures.

 Why academic EM?

Academic medicine seeks to pursue scholarship, expand knowledge, and pass on that knowledge. This is most commonly done through resident education and supervision. Education and scholarly activity are ultimately the goals, though these can take several forms. Academics provides career diversity, expertise development, formation of educational philosophy and techniques, specialty advancement, networking and formation of relationships, and research development. It can allow physicians to influence hospital and institution practices, and provide a bit of control in his or her schedule. Best of all, academic EM gives physicians the chance to affect and improve the care of many patients through resident education and scholarly activity.

There are several negative factors associated with academic EM. You will likely work more hours combined, make less money, work fewer clinical hours, and experience more pressure to be scholarly productive (we will cover this later), as compared to community practice.

We know the decision is difficult.

Residency rotations in both settings can provide glimpses of both types of practice. Hybrid programs are also in existence, and it is never too late to switch from one to the other.

In the meantime, how should a resident prepare for academic EM? Residency is the time to obtain several important skills.

1) The first is the most fundamental and important: clinical competency. Excellence in patient care is fine-tuned during residency. Every patient encounter, lecture, and time spent studying should focus on learning and enhancing clinical evaluation and management.

2) The next skill is teaching and knowledge dissemination. This is primarily learned via supervising junior residents or medical students at the bedside or by mentorship. In addition, lecture-based learning and teaching are also paramount.

3) Research skills are essential, no matter what environment you will practice in. Experience in reviewing the literature, establishing research questions and study designs, data collection/analysis, and presentation of data is important.  This can be difficult to obtain through journal clubs only, and some form of higher education is often beneficial for developing key research skills.

4) Expressing ideas and disseminating your knowledge are important, not only for abstracts, papers, and grants, but for hospital protocols and committees.

5) Administrative skills are helpful for both community and academic settings.

6) As most physicians (especially in EM) know, “people” skills are essential, not only to your clinical practice but also in forming long-lasting relationships and collaborations. Whether you go into academic or community EM, these skills are critical.

7) Finally, developing a personal learning strategy is important for continued clinical development.

Ok, so academic EM sounds like your thing… Now what?

There are several aspects of career planning that will help you find the best fit and succeed in academic EM. Each of the following components summarize key information for not only academic survival, but also for long term success.

Preparing for Academics

  1. The importance of a mentor – Mentorship is a key component of a healthy career. Forming a healthy mentoring relationship leads to academic success and career satisfaction, especially when formal postgraduate training is not completed.15-19 Look for mentors within the department, your institution, other institutions, prior training places, and from regional/national meetings. Mentors assist in setting and achieving goals, providing feedback on performance, building confidence and moral support, helping you get involved in committee work, introducing mentees to leaders in your field, protecting you and your interests, and keeping you on track. Your mentor is your advocate.   When choosing a mentor, there are several considerations. These include ensuring the mentor has a track record in the area of your interest, has available time and interest, possesses a personality that fits, and does not possess conflicts of interest. More than one mentor can be helpful, and mentors outside of EM can provide a different viewpoint for you.
  1. Setting time goals: 1, 3, 5, 10 years – Short and long term goals are necessary for a successful career, as a resident and faculty member. You have probably been setting goals all of your life, and just like before, it is important to possess concrete and obtainable goals. A career plan should be established, with each year broken down into separate goals that work toward achieving the long term goal. Keep in mind these may need to be revised, and these goals should be used as a guide for feedback/evaluation sessions. These goals should be discussed with your mentor, with regular meetings and feedback sessions to keep you on track.
  1. Finding your niche – Even though EM is a broad specialty, the majority of academic leaders are known for expertise in one or several areas of knowledge. This is essential for those forming a career: determine what interests or excites you and what opportunities are available to focus on these interests. Ask yourself what your passion is and what excites you. Another key is to consider what you do not enjoy. When you recognize what you like and dislike, then seek to get involved in your area of interest, with a goal of academic productivity (through research, lectures, or publishing). Research projects should also focus on this. Because of EM’s broad spectrum, some may want to target what’s currently available at their institution. Others may take too much on, spreading themselves too thin. It can be difficult to focus on one or two areas, but do your best to choose what interests you the most.
  1. Keep an academic portfolio and curriculum vitae – As most know, a curriculum vitae (CV) is a necessity. Even though different formats may be used, all contain the same information. Your mentor and senior department leadership can provide valuable assistance in forming and fine-tuning your CV. A personal academic profile or portfolio should also be maintained, as this summarizes your teaching, compiles your awards and evaluations, and should also contain examples of lectures and other academic achievements. Both are vital for academic success and promotion.
  1. Join an EM organization – Several emergency medicine societies are available, and each can provide significant benefits. Organizations include AAEM, ACEP, SAEM, CORD, NAEMSP, and several others. These organizations provide valuable networking and socializing opportunities for residents and faculty of all levels. Many of these organizations also have committees, which provide opportunities to improve nonclinical educational skills, form relationships with physicians with similar interests, and contribute to EM. If you can, attend meetings that allow open attendance. You will gain valuable skills in learning how to manage meetings and conferences by watching those in charge.
  1. Networking – There are several aspects to networking. Joining a committee or task force can be helpful and provide links to other departments and senior leaders. Speaking with everyone in the department, from interns to department chair, can form relationships that last. Everyone in EM has lessons learned or advice they can offer. Ask senior department members for connections or to introduce you to other leaders.
  1. Remember your colleagues and provide assistance to others – An academic physician with goals will develop and advance. As you begin to grow in your career, seek to help and mentor others. You obtained your success with the assistance of others, including your mentor and family, and you need to extend this same courtesy to others around you. Involve others in your projects and educational goals. By seeking the advancement of other EM colleagues, you form friendships and long-lasting relationships. If you switched programs, remember those back home and acknowledge them in your success.

What about postgraduate training?

Postgraduate training can help through providing focus on future work, as well as training in teaching, writing, research, and funding. Unfortunately, medical school and residency often do not prepare physicians for an academic career. Though not mandatory for an academic position, postgraduate training can facilitate academic training, enhance career satisfaction, and increase chances of academic success. This training also assists mentoring relationships and collaborative relationships. Dedicated postgraduate training may be the only means of obtaining truly protected time to develop academic skills. Interestingly, fellowship or postgraduate-trained physicians are more likely to obtain success and career satisfaction if involved in an academic program. This training provides increased job mastery, leading to less stress, greater certainty, and improved vision of career goals. Fellowships include pediatric EM, toxicology, undersea and hyperbaric medicine, sports medicine, ultrasound, palliative care, EMS, critical care, and several others. However, further training does delay maximum salary potential.

If you are considering a fellowship, look at each program’s expected clinical time, training value, access to mentors, research opportunities, and total experience. The vast majority of EM fellowship programs offer complete, valuable experiences. If interested in education, fellowship training necessity is less defined. This fellowship is growing, but many departments offer formal, structured, multiyear educational training opportunities. For more information on fellowships, please see EMRA’s complete guide at: https://www.emra.org/uploadedfiles/emra/emra_publications/emra_fellowshipguide_v1_0816.pdf

The nuts and bolts for success in academic EM

What roles are there? Academic EM is comprised of many positions, and each institution and program will vary. Research roles include director, clinical trial director, research advisor, and research assistants’ program director. Educational roles can be residency director, associate residency director, medical student director, medical school leadership (dean), rotating resident director, fellowship director, CME director, hospital committee director, and others. There are also specialty roles such as ultrasound, hyperbaric chamber, chest pain, etc. Administrative roles include chief/chair, EMS director, operations director, pediatric ED director, CQI/Risk management director, and others.

Finding the right program – A program that will provide the environment and tools to help you flourish is important. First, characterize the institution, and evaluate what the program rewards (publications, lectures, clinical throughput). Are you just another cog in a vast machine? What would happen if you leave the program? You should ensure true opportunities to advance clinically and professionally exist in the program. Ultimately, look at what the institution and the program can do for you, rather than what you can do for the institution/program.  

Several program types or models possess different attributes. The egalitarian model treats everyone the same, regardless of specific talents or interests. Faculty work similar numbers of shifts, teach a similar number of lectures, carry similar administrate duties, and are expected to have similar productivity. The specialization model demonstrates a more team-based approach. All faculty work clinically, but the department can modify career development to better match faculty member strengths, weaknesses, interests, and dislikes. Shift numbers can vary based on faculty member roles and productivity.

Promotion and tenure – There are progressive ranks with timelines for academic physicians including assistant professor, associate professor, and full professor. Many are based on specific criteria such as publications, grants, regional/national recognition, teaching portfolios, and clinical productivity. An area of focus or niche can be helpful. This should be discussed with your department/program leadership and mentor. A mark of a strong program is a definitive track for career advancement, so you must inquire about this component of the academic program. Many offer workshops or provide further faculty development, which can significantly improve your advancement.

Research – Research is one of the fundamental means of growth for EM. The research environment physicians experience during residency often shapes future interest in research.1,4  At its core, research involves formulating a question, addressing the question with appropriate study design, collection and interpretation of data, and presenting the results in a peer-reviewed journal. This is often a long process, requiring time, effort, and mentorship for residents. Faculty have several goals when it comes to research: conducting research themselves, educating residents on scientific study, and/or how to conduct a study.

A large number of relevant areas of study are in existence. The majority of academic centers will desire their physicians to be “academically productive,” or obtain clinically relevant publications or grants. Research topics can be clinical, basic science, education, policy, or clinical operations. Mentorship and senior physician assistance to residents and new faculty seeking a research track are essential. Properly forming a research question and designing a protocol can be challenging, and thus, the more experience you can obtain, the better.

Teaching – Education is one of the key factors in an academic position. All physicians teach, whether the audience is nurses, technicians, or other physicians. One major component of an academic program is working with residents. Most programs expect academic clinicians to teach on shift as well as present lectures at conferences several times per year. This aspect is often one of the most fulfilling aspects of academic medicine, as you have the opportunity to affect the growth of future EM physicians. You may also work with students and off-service residents, and your relationship with these learners can have significant impact on their education, patient care, and relationships with the emergency department in their future careers.

Residency provides valuable time for honing educational skills. Some programs have dedicated programs for teaching, while others expect those interested in teaching to pick up the skills on their own. Focusing on shift teaching, presentation skills, and creation of lectures are great places to start for residents and new faculty. In emergency medicine, it can be difficult to work on your teaching skills, as there are so many options for teaching and so many different learners. Many adult learners seek information that will directly and positively impact their future careers. Thus, it is important to focus on how individuals learn and how you can make a difference in their learning experiences.

Teaching involves the ability to observe, question, and review trainee performance in actual patient care settings. When developing your own education techniques, look at the educators around you. New faculty and senior residents should pay close attention to those teachers who demonstrate master education skills. At the same time, strongly consider providers who are working on their own deficiencies. You should seek to recognize and understand these deficiencies so you can avoid them. Recognizing these skills and one’s own shortcomings will allow you to grow as an educator.

Scholarly Activity – One major aspect of an academic career is scholarly activity. In the past this included writing, either book chapters, original research, or review articles. The majority of academic programs still rely on clinical research and formal publication in medical journals. The academic environment is evolving, with several other opportunities. Free Open Access Medical Education (FOAMed) is one of these, with a growth of blogs and podcasts. Many academic physicians have now based their career on this avenue. Other options include ACEP’s Critical Decisions in Emergency Medicine, case reports, images, and specialty organization newsletters. Most programs will ask for at least one lecture per academic year, often grand rounds. However, speaking at regional, national, or international meetings is another means of scholarly productivity.

Once you have a project, seek to present the results in multiple settings and formats. Start with presenting an abstract at a conference, then seek publishing in a peer-reviewed journal. A FOAMed blog publication is also an option. Presenting this further at other functions, such as a grand rounds lecture, offers another avenue.  Publication in this format develops writing skills, develops an area of expertise, and advances your career. Remember, most programs still focus productivity on peer-reviewed publications.

The Literature – Residency programs usually promote some form of literature understanding through several formats: journal clubs, evidence-based medicine projects, and education on clinical shifts. Faculty may lead discussions or projects for literature awareness, aimed at promoting a deeper understanding of EM studies. For faculty, a key component of academics is staying abreast of the current literature, as well as “classic” studies. This can be difficult with all of your other duties and clinical shifts, but this is vital to your own education. There are multiple means of remaining current, from subscriptions to journals (Annals of EM, American Journal of EM, Journal of EM, etc.), podcasts (EM:RAP, EMA, EMCrit), and blogs (ALiEM, emDocs, Core EM, EM Updates, REBEL EM). FOAMed has revolutionized medical learning, and residents and faculty can use FOAMed to remain abreast of new, exciting medical updates.

Goals and Persistence – Specific goals with a timeline are a necessity for success in academic medicine, and they must be written down to solidify their importance. The act of setting the goal with timeline, verbalizing it, and writing it creates a commitment. Remember, academic medicine can be and will be difficult. There will be setbacks, but do not be discouraged. You will have papers and grants rejected. Make changes and keep going.

Collaboration – Finding others interested in your niche or topic can benefit. With our schedules, it can be difficult to frequently meet with your mentor to discuss areas of interest. This is where collaboration can help. Team members can provide skills and perspectives that will improve the quality of projects. Just make sure you set specific goals for the project, with a timeline.

Other Specifics – Determine what percentage of your work week should be clinical and what should be given to the rest of your academic pursuits. You should consider what you want to be doing in 5-10 years. Where do you see yourself? Saying “no” is ok if you have too much on your plate.

I think I know how to succeed, but what can I mess up?

There are many pitfalls in academics. These include not enough protection from other duties (working too many clinical shifts with the expectation for academic productivity), not enough training for an academic career (research focus without training on research question and protocol formation), failure to have a mentor (one of the cornerstones of academic success), failure to form a plan/timeline of goals, lack of balance (which leads to burnout), biting off too much, and not listening to feedback.

Importance of Balance – Maintain balance and block off time for your family and hobbies. Success takes time, and it will not occur overnight. Recent years have seen an emphasis on physician health. This really comes down to balancing many aspects of life including your shifts, academics, community activities, exercise, hobbies, family, religious/spiritual concerns, friends, and future plans. Pushing too hard and too fast with too much will lead to burnout.

The Decision – Residency is a great time to explore academics and community practice. Rotations in both settings can help you determine which practice is the best fit for you. You can always switch settings, or in other words, it is never too late to go from community to academic practice. Work on perfecting your clinical skills and management early, as this is essential to both academic and community medicine.

Thanks for reading. For more, please see the resident section of the CORD website at http://www.cordem.org/i4a/pages/index.cfm?pageID=4077

Please comment below with other tips or questions!

References/Further Reading

  1. Stern SA, Kim HM, Neacy K, Dronen SC, Mertz M. The impact of environmental factors on emergency medicine resident career choice. Acad Emerg Med. 1999 Apr;6(4):262-70.
  2. Neacy K, Stern SA, Kim HM, Dronen SC. Resident perception of academic skills training and impact on academic career choice. Acad Emerg Med. 2000; 7:1408–15.
  3. Aycock RD, Weizberg M, Hahn B, Weiserbs KF, Ardolic B. A survey of academic emergency medicine department chairs on hiring new attending physicians. J Emerg Med. 2014 Jul;47(1):92-8.
  4. Sanders AB, Fulginiti JV, Witzke DB, Bangs KA. Characteristics influencing career decisions of academic and nonacademic emergency physicians. Ann Emerg Med. 1994;23:81–7
  5. Clinton JE. Educating academic emergency physicians. Acad Emerg Med. 1999;6:260–1.
  6. Stead LG, Sadosty AT, Decker WW. Academic career development for emergency medicine residents: a road map. Acad Emerg Med 2005 May;12(5):412-16.
  7. Hobgood C, Zink B (eds). Emergency Medicine: An Academic Career Guide, ed 2. Lansing, MI: Society for Academic Emergency Medicine; 2000.
  8. Faculty Development Web site. Available at: www.saem.org/ facdev/fac_dev_handbook/. Accessed Nov 10, 2016.
  9. Cydulka C. Preparing for a career in academics. Emergency Medicine: An Academic Career Guide. Available at: http:// www.saem.org. Accessed Sep 18, 2001.
  10. Hall KN, Wakeman MA. Residency-trained emergency physicians: their demographics, practice evolution and attrition from emergency medicine. J Emerg Med. 1999;17(1):7-15.
  11. Reinhart MA, Munger BS, Rund DA. American Board of Emergency Medicine Longitudinal Study of Emergency Physicians. Ann Emerg Med 1999;33(1):22-32.
  12. Kellerman AL. Are you considering an academic career? EMRA. Available at https://www.emra.org/resources/career-planning/practice-spaces/are-you-considering-an-academic-career-/. Accessed 04 November 2016.
  13. Pines JM. The young physician in academic emergency medicine: tips for success. AAEM. Available at http://www.ypsaaem.org/yps-articles/past-yps-articles/2006/the-young-physician-in-academic-emergency-medicine-tips-for-success. Accessed 04 November 2016.
  14. Sokolove P, Stern S, Baren J. An academic career: is it right for you? 2008 SAEM Annual Meeting, May 2008. Available at http://www.slideshare.net/changezkn/life-after-residency-academic-emergency-medicine. Accessed 04 November 2016.
  15. Taylor JS. Academic Medicine 2001;76:366-372.
  16. Stack SJ, Watson MJ. Enriching the resident-faculty relationship. Ann Emerg Med. 2001; 38:336–8.
  17. Osborn TM, Waeckerle JF, Perina D, Keyes LE. Mentorship: through the looking glass into our future. Ann Emerg Med. 1999; 34:285–9.
  18. Hazzard WR. Mentoring across the professional lifespan in academic geriatrics. J Am Geriatr Soc. 1999; 47:1466–70.
  19. Peluchette JV, Jeanquart S. Professionals’ use of different mentor sources at various career stages: implications for career success. J Soc Psychol. 2000; 140:549–64.
  20. Holmboe ES, Ward DS, Reznick RK, Katsufrakis PJ, Leslie KM, Patel VL, Ray DD, Nelson EA. Faculty development in assessment: the missing link in competency-based medical education. Acad Med. 2011; 86(4):460-7.

Healthy Patients with Potential to Crash

Authors: Daniel Ritter (Medical Student, The Ohio State University College of Medicine) and Mark J Conroy, MD (Assistant Professor of EM, The Ohio State University Wexner Medical Center, @mjconroy_md) // Edited by: Jennifer Robertson, MD, MSEd and Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital)

 Introduction

A 30-year-old healthy female presents to the emergency department (ED) complaining of nausea, vomiting, and diarrhea that have worsened over the last 24 hours. She admits to some lightheadedness and states that she feels “just out of it”.  She denies any abdominal pain or blood in her emesis and stool. Some coworkers have been out sick with similar symptoms following a company party over the weekend.  She takes “some pill” for a “gland problem”, but she lost the bottle a few days prior.

The patient’s initial vital signs include a heart rate of 105 beats per minute (bpm) and a blood pressure of 90/50 mmHg. The patient is physically fit and reports that her blood pressure always runs on the “low side”. Her examination reveals dry mucous membranes and tachycardia but it is otherwise normal.  The patient has no neck stiffness, cardiac murmurs, abdominal pain, or rashes. You order routine laboratory tests and and treat her symptoms with an antiemetic and intravenous (IV) fluids.

After about 30 minutes, the patient’s chemistry returns and demonstrates a marked hyperkalemia and hyponatremia. When you reassess the patient, you note that she has an altered mental status and her blood pressure is 72/40 mmHg.

Unhealthy healthy patients

One of the first steps in any ED evaluation is differentiating between those patients who are sick and those who are not sick. While a lifetime of patient care can make this a subconscious decision for most emergency providers, the process is still subjective. Criteria, algorithms, and/or clinical decision tools exist for many scenarios, but not all. It is especially difficult for clinicians to determine the severity of an illness in an otherwise young healthy patient with non-specific symptoms.

Among every group of nonspecific presentations is a new (or overlooked) diagnosis that, if missed, can seriously harm or even kill a patient. The goal of training and lifetime learning is for emergency physicians to become experts at teasing out those who are covertly sick. Several of the conditions discussed below can easily be overlooked because they may present, at least initially, with non-concerning symptoms. However, they have the ability to cause serious harm.

Acute Adrenal Insufficiency (Adrenal Crisis)

Background

Adrenal insufficiency is divided into three categories: primary, secondary, and tertiary.1  Primary disease is due to intrinsic problem(s) with the adrenal cortex, while secondary adrenal insufficiency is due to pituitary failure or a lack of responsiveness of the adrenal glands to adrenocorticotropic hormone (ACTH). Tertiary adrenal insufficiency is due to the impaired hypothalamic production or action of ACTH, vasopressin or both.1

Adrenal crisis can occur as an exacerbation of any chronic cause of adrenal insufficiency, or as an abrupt injury to any component of a healthy adrenal axis.  Common causes include abrupt cessation of exogenous glucocorticoid use, bilateral adrenal infarction/hemorrhage, or acute stress in the setting of previously undiagnosed chronic adrenal insufficiency.2

How it presents

Acute adrenal insufficiency can present with hypotension, abdominal pain and/or rigidity, nausea, vomiting, and fever due to coexisting infection.  Hyperpigmentation may be a feature of those with chronic adrenal insufficiency.  A history of chronic fatigue or abrupt cessation of chronic glucocorticoid use could be present depending on the etiology.2

Why the diagnosis can be challenging

Acute adrenal insufficiency is rare. The risk of developing acute adrenal insufficiency in a patient with chronic adrenal insufficiency is about 6-10 per 100 patient-years.3  It can also be easily overlooked as a diagnosis early on in a patient’s presentation.  Furthermore, endocrine causes of hemodynamic instability are not generally considered to be one of the four main categories of shock (obstructive, cardiogenic, distributive, and hypovolemic).  These factors can delay diagnosis and lead to worsening crisis before appropriate treatment is initiated.

How to catch it

A more thorough history can be key in identifying the right track for the emergency physician. Routine laboratory analysis often reveals hyperkalemia and hyponatremia.2 Patients in adrenal crisis face significant morbidity and mortality. Immediate treatment with fluid resuscitation and steroid replacement (dexamethasone 4-10 mg IV when no prior diagnosis exists4, otherwise hydrocortisone 100 mg IV or IM, with 100-300 mg every day thereafter for the duration of treatment2) is necessary before receiving confirmatory diagnostic tests in patients who are at risk.2

Other pearls

Cessation of inhaled glucocorticoids can precipitate acute adrenal insufficiency.5

Acute Pancreatitis

Background

A condition involving inflammation, and often hemorrhagic necrosis, of the pancreatic parenchyma. Several causes exist but gallstone obstruction of the pancreatic duct, metabolic/hereditary disorders, and alcohol use most commonly underlie this painful condition6.  In necrotizing pancreatitis, mortality can be as high as 17%.7 Severe cases can lead to marked hypotension and end-organ failure.6

How it presents

About 50% of the time, patients present with severe, persistent epigastric pain radiating to the back.8 Pain is usually associated with severe nausea and vomiting.6

Why the diagnosis can be challenging

The differential diagnosis for patients with abdominal pain is, unfortunately, very broad.  Epigastric pain could be the manifestation of intra-abdominal, cardiac, or intra-thoracic processes. In addition, pancreatitis due to alcohol or metabolic disorders can have a more gradual onset with poor localization of pain.  Degree of pain is also variable, and some patients may not be as uncomfortable as others.  In a patient who is otherwise healthy, and who presents with gradual onset, localized and unimpressive epigastric pain, acute pancreatitis could easily be missed.

How to catch it

Keeping broad differential diagnoses for patients with abdominal pain is key.  Consider abdominal computed tomography (CT) for lipase (+/ amylase) levels that are only mildly elevated, or with atypical presentations not otherwise explainable.

Other pearls

Acute pancreatitis on ultrasound appears enlarged and heterogeneous.  Hypoechoic fluid may be visualized, as well as gallstones in the gallbladder or common bile duct.9

Arrhythmia

Background

Abnormal cardiac rhythms vary in pathophysiology, appearance on electrocardiogram (ECG), and lethality.  They can range from benign ectopic beats (like PVCs) to very dangerous (like atrial fibrillation in patients with Wolff-Parkinson-White).

How it presents

Presenting symptoms are variable and can include palpitations, anxiety, syncope, dizziness, chest pain, and shortness of breath.

Why the diagnosis can be challenging

The difficulty is not in obtaining the ECG but instead the interpretation. Outside of the overt arrhythmia, ECG signs of channelopathy or structural abnormality in asymptomatic patients can easily be overlooked.

 How to catch it

Key features on ECG for high-risk syndromes include:

  • Long QT interval: A sign of the aptly named Long QT Syndrome. It can be congenital or can be acquired in the setting of electrolyte abnormalities or certain pharmacologic agents.  A long QT interval puts patients at risk for sudden cardiac death due to Torsades de pointes.10
  • Delta wave: Classic for Wolff-Parkinson-White syndrome. The “slurring” of the R wave is a sign of an accessory pathway, which can lead to an unstable tachycardia (rate often greater than 200), cardiovascular instability and death.11
  • Q waves, atrial enlargement, left axis deviation, inverted T waves: In a young, healthy patient, any of these could be a sign of hypertrophic cardiomyopathy. Look for signs of structural changes, such as P wave abnormalities suggesting atrial enlargement.  Hypertrophic cardiomyopathy is the most common cause of sudden cardiac death in young athletes.12
  • Pseudo-right bundle branch block and ST elevation in V1 and V2: Suggestive of Brugada syndrome, a sodium channelopathy. ST elevation can be divided into two patterns: type 1 features a convex, descending ST segment followed by an inverted T-wave, and type 2 features a “saddle-back” ST-T morphology.  A third type exists involving the criteria of Type 1 & 2 but with < 2 mm of elevation. Brugada syndrome predisposes patients to sudden-onset ventricular tachyarrhythmias.13

Other pearls

Often genetic, but not always, a family history is very helpful for assessing risk for different arrhythmias.

Substance Abuse

Background

Overdoses and withdrawal are an increasingly large burden on emergency medical service (EMS) providers and emergency departments as newly synthesized illicit drugs are abused and opioid addiction across the United States grows.14

How it presents

Signs and symptoms of overdose or withdrawal depends on the substance in question.  Some common examples include:

  • Opioids
    • Intoxication: Respiratory depression, altered mental status, bradycardia, miotic pupils.15,16
    • Withdrawal: Dysphoria, restlessness, myalgias/arthralgias, nausea, vomiting, tachycardia, diarrhea.16
  • Cocaine
    • Intoxication: Hypertension, tachycardia, mydriatic pupils, agitation.16,17
    • Withdrawal: Depression/anxiety, fatigue, anhedonia, increased sleep.18
  • Amphetamines
    • Intoxication: agitation/psychosis, tachycardia, hypertension, mydriatic pupils, diaphoresis.19
    • Withdrawal: dysphoria, fatigue, increased sleep, anxiety.18,19
  • Phencyclidine (PCP)
    • Intoxication: Hypertension, hallucinations, nystagmus, tachycardia, agitation.20
    • Withdrawal: Confusion, anxiety, depression, memory loss.19
  • Alcohol
    • Intoxication: Slurred speech, nystagmus, unsteady gait, nystagmus, disinhibition.21
    • Withdrawal: Insomnia, tremulousness, hallucinations, headache, diaphoresis, seizures, delirium tremens.22,23

 Why the diagnosis can be challenging

Intoxication or overdose from alcohol or drugs can be easy to diagnose with sufficient history.  Otherwise, an acutely altered patient with little available history can be a diagnostic challenge. Additional conditions can also be overlooked in the patients – head trauma following opiate and alcohol abuse, myocardial infarction with cocaine intoxication, or delirium tremens in a patient with no known history of alcohol abuse.

 How to catch it

Whenever possible, accurately identify the substance in question in order to prepare for potentially dangerous sequelae.  Try to keep a wide differential in patients who are altered or agitated.

 Other pearls

Remember to ask about alcohol, tobacco, and drug use in all patients.

Crush Injury

Background

The development of rhabdomyolysis and acute kidney injury in the setting of a crush injury is well-known. A more severe results of crush injury can occur in disaster victims who become trapped in fallen structures. In this case, these victims can often become hypotensive following extrication due to third-spacing of fluids into the freed crushed tissue. Thus, compartment pressures should be monitored closely in these patients.24,25

 How it presents

Providers in the field will most often encounter hypotensive patients following a crush injury.  However, providers in the ED should be aware of this possibility when caring for victims of natural or man-made disasters.

 Why the diagnosis can be challenging

Providers in the field must be aware of the dangers of crush injuries beyond the direct trauma to limbs.  If an IV is not placed and fluids not started before extrication, deterioration should be an ongoing concern. Additionally, it is possible that a provider in the emergency department setting could be unaware of a crush injury in a hypotensive trauma patient, prompting him or her to look for other causes of hypotension.

 How to catch it

When dealing with entrapped victims, an IV line and fluids should be started before extrication whenever possible.  This can prevent post-extrication hypotension as well as ameliorate the potential for acute kidney injury (AKI).25

 Other pearls

Bicarbonate and mannitol (1 amp and 10 g IV, respectively, during extrication) can be used to avoid AKI following crush injury.24

Heat Illness

Background

Heat illness is considered a failure of the body’s thermoregulatory system to handle intrinsic and extrinsic heat. It can be further classified based on signs and symptoms. Syncope, muscle cramps, heat exhaustion are all part of the spectrum of heat related illness, with heat stroke having the highest rates of morbidity and mortality.26

How it presents

Heat illness can affect populations of all ages, from very young to very old. Typically, younger patients present following a period of exertion.  Any rectal temperature greater than 104° Fahrenheit (F) with mental status changes necessitates active cooling. For patients with a temperature less than 104° but still greater than 98.6°, active cooling (ice water immersion, cooling mattress, etc) should seriously be considered. Passive cooling (removing the patient from the warm environment, getting rid of wet clothing, and hydration) is still a must. Rechecking a rectal temperature to ensure improvement is also necessary as some patients can continue increasing early on before passive methods have taken effect.

Why the diagnosis can be challenging

Older patients often present with heat illness without any preceding exertion. Often left unattended in the heat as well as additional medications complicating the diagnosis, these patients present with little to no history to direct your evaluation and treatment. Additionally, these patients can suffer from secondary electrolyte and cardiovascular complications. 26

How to catch it

Obtaining a rectal temperature is the gold standard when evaluating patients for heat illness. Keep heat illness in your list of differential diagnoses, especially when working on days with high heat indices or an endurance event nearby.

Other pearls

Ice packs in the axillae and groin as well as evaporative cooling with misting and a fan are the most feasible cooling options in the ED. Cold water immersion is the gold-standard when working events. Goal rate for cooling is 1° (F) every 3 minutes.  Antipyretics are not useful for decreasing temperature in these patients.27,28

“Vitals are vital” and “Keep your differential broad”

Providers have heard these phrases repeated since beginning medical school, and nowhere are they more applicable than when dealing with young healthy patients.

Abnormal vital signs need to be explained within the clinical context.  Hydration status can be an easy go-to for tachycardia but anchoring can lead you down the wrong diagnosis and treatment pathways if other alternative causes are not considered. In the case at the start of this post, symptomatic hypotension and an unclear medication history are key red flags that should not be overlooked.

Finally, when a patient does not respond as you expect (improved heart rate with IV fluids, decreased pain with medication, etc.) emergency providers should step back and re-evaluate. Make sure you have considered all life threatening diagnoses and that you have adequately evaluated patients for these diagnoses. Not every potential diagnosis needs to be tested for. However, considering the diagnosis is important because it helps avoid bias and potentially, missed diagnoses.

Pearls

Address abnormal vital signs or have a cohesive explanation as to why you are not addressing them.

Abnormal vital signs without a clear explanation, as well as vital signs that do not resolve with treatment, should prompt expanded consideration of the patient’s complaint, further investigation, and likely both.

-Bad things happen and even healthy people get sick.

References / Further Reading

1Charmandari E, Nicolaides NC, Chrousos GP. Adrenal insufficiency. The Lancet. 2014;383(9935):2152-2167.

2Puar TH, Stikkelbroeck NM, Smans LC, Zelissen PM, Hermus AR. Adrenal Crisis: Still a Deadly Event in the 21st Century. The American Journal of Medicine. 2016;129(3).

3Arlt W, Allolio B. Adrenal insufficiency. The Lancet. 2003;361(9372):1881-1893.

4Asare K. Diagnosis and Treatment of Adrenal Insufficiency in the Critically Ill Patient. Pharmacotherapy. 2007;27(11):1512-1528.

5Piédrola G, Casado JL, López E, Moreno A, Perez-Elías MJ, García-Robles R. Clinical features of adrenal insufficiency in patients with acquired immunodeficiency syndrome. Clinical Endocrinology. 1996;45(1):97-101.

6Lankisch PG, Apte M, Banks PA. Acute pancreatitis. The Lancet. 2015;386(9988):85-96.

7Banks PA, Freeman ML. Practice Guidelines in Acute Pancreatitis. The American Journal of Gastroenterology. 2006;101(10):2379-2400.

8Banks PA. Acute pancreatitis: Diagnosis. In: Pancreatitis, Lankisch PG, Banks PA (Eds), Springer-Verlag, New York 1998. p.75.

9Bollen TL, Santvoort HCV, Besselink MG, Es WHV, Gooszen HG, Leeuwen MSV. Update on Acute Pancreatitis: Ultrasound, Computed Tomography, and Magnetic Resonance Imaging Features. Seminars in Ultrasound, CT and MRI. 2007;28(5):371-383.

10Khan IA. Long QT syndrome: Diagnosis and management. American Heart Journal. 2002;143(1):7-14.

11Bhatia A, Sra J, Akhtar M. Preexcitation Syndromes. Current Problems in Cardiology. 2016;41(3):99-137.

12Elliott P, Mckenna WJ. Hypertrophic cardiomyopathy. The Lancet. 2004;363(9424):1881-1891.

13Littmann L, Monroe MH, Kerns WP 2nd, Svenson RH, Gallagher JJ. Brugada syndrome and “Brugada sign”: clinical spectrum with a guide for the clinician.  Am Heart J. 2003 May; 145(5):768-78.

14Rudd RA, Aleshire N, Zibbell JE, Gladden RM. Increases in Drug and Opioid Overdose Deaths — United States, 2000–2014. MMWR Morbidity and Mortality Weekly Report. 2016;64(50-51):1378-1382.

15Sporer KA. Acute Heroin Overdose. Annals of Internal Medicine. 1999;130(7):584.

16Hughes JR, Higgins ST, Bickel WK. Nicotine withdrawal versus other drug withdrawal syndromes: similarities and dissimilarities. Addiction. 1994;89(11):1461-1470.

17Merigian KS, Roberts JR. Cocaine Intoxication: Hyperpyrexia, Rhabdomyolysis and Acute Renal Failure. Journal of Toxicology: Clinical Toxicology. 1987;25(1-2):135-148.

18Lago JA, Kosten TR. Stimulant withdrawal. Addiction. 1994;89(11):1477-1481.

19Khantzian EJ. Acute Toxic and Withdrawal Reactions Associated with Drug Use and Abuse. Annals of Internal Medicine. 1979;90(3):361.

20Mccarron MM, Schulze BW, Thompson GA, Conder MC, Goetz WA. Acute phencyclidine intoxication: Incidence of clinical findings in 1,000 cases. Annals of Emergency Medicine. 1981;10(5):237-242.

21Camí J, Farré M. Drug Addiction. New England Journal of Medicine. 2003;349(10):975-986.

22Etherington JM. Emergency management of acute alcohol problems Part 1: Uncomplicated withdrawal. Canadian Family Physician. 1996;42:2186-2190.

23Ferguson JA, Suelzer CJ, Eckert GJ, Zhou X-H, Diffus RS. Risk factors for delirium tremens development. Journal of General Internal Medicine. 1996;11(7):410-414.

24Gonzalez D. Crush syndrome. Crit Care Med. 2005 Jan;33(1 Suppl):S34-41.

25Sever MS, Vanholder R, Lameire N. Management of Crush-Related Injuries after Disasters. New England Journal of Medicine. 2006;354(10):1052-1063.

26Leon LR, Bouchama A. Heat Stroke. Comprehensive Physiology. March 2015:611-647.

27Bouchama A, Dehbi M, Chaves-Carballo E. Cooling and hemodynamic management in heatstroke: practical recommendations. Crit Care. 2007;11(3):R54

28Smith JE.  Cooling methods used in the treatment of exertional heat illness. Br J Sports Med. 2005;39:503-7.

FOAMed Resources Part VII: Medical Education and Simulation

Authors: Brit Long, MD (@long_brit, EM Attending Physician, SAUSHEC) and Manpreet Singh, MD (@MPrizzleER – emDOCs.net Associate Editor-in-Chief; Assistant Professor in Emergency Medicine / Department of Emergency Medicine – Harbor-UCLA Medical Center)// Edited by: Alex Koyfman, MD (@EMHighAK)

Not all emergency physicians work in an academic center. However, all physicians teach, whether this includes nurses, technicians, residents, consultants, or medical students. Education is part of who we are. Whether by text, video, audio, experience, simulation, or a combination, we are constantly learning. Education is a core component of everyone who works in the medical field. A provider can have tremendous impact on the department through education of techs, nurses, students, residents, and other physicians.

Part VII of the FOAMed series will evaluate education and simulation resources. The following list is comprised of blogs/podcasts with great education pearls, valid contact, and major impact on EM, with clear reference citation. If you have found other great resources, please mention them in the comments below!

 

  1. http://lifeinthefastlane.com/ed-registrars-guide-to-clinical-teaching/

screen-shot-2016-10-16-at-6-57-08-am

When it comes to clinical teaching, LIFTL offers a tremendous guide with references, an approach to teaching, and overview of different types of learners and teaching methods. This is a great place to start.

 

  1. https://flippedemclassroom.wordpress.com

screen-shot-2016-10-16-at-6-57-13-am

FlippedEM Classroom provides educators with a virtual platform for core knowledge. The site also contains a link (https://flippedemclassroom.wordpress.com/12-tips/) with tips to teaching and using educational resources, along with links to the CDEM curriculum. The tips page covers multimedia use, forming objectives, segment lessons, quizzes, classroom discussion, providing feedback, using scripts, and more.

 

  1. http://emblog.mayo.edu/?s=how+to+succeed+as+a+teacher

screen-shot-2016-10-16-at-6-57-21-am

The Mayo Clinic EMBlog offers a fantastic video series on teaching in emergency medicine. Dustin Leigh and Daniel Cabrera cover preparing to teach, asking questions, goal setting, learning, feedback, and skills. Overall this series is a tremendous resource.

 

  1. https://cdemcurriculum.com

screen-shot-2016-10-16-at-6-57-26-am

The CDEM Curriculum site serves as a resource for medical students and clerkship directors. This is great for EM clerkship directors, as content focuses on third year, fourth year, and peds EM students. Videos, diagrams, and curriculum notes are provided. This resource is extremely helpful for those forming a curriculum. The EM Stud Podcast offers medical students an understanding of the application process and how to excel in EM.

 

  1. https://www.aliem.com/category/non-clinical/med-education/ and https://www.aliem.com/category/non-clinical/simulation/

screen-shot-2016-10-16-at-6-57-34-am

Academic Life in Emergency Medicine is designed for educators of all levels. The blog contains material not only on clinical content (learning capsules, AIR series, Tricks of the Trade, Diagnosis on Sight), but many non-clinical topics including simulation and educational techniques. The IDEA series provides material on cases, simulation, and procedural education, while the MEdIC series addresses challenging educational/learner scenarios.

 

  1. https://soundcloud.com/teachingcoursepodcast

screen-shot-2016-10-16-at-6-57-43-am

The Teaching Course Podcast comes from the originators of the Teaching Course. It is dedicated to providing educators with techniques and inspiration to teach those of all levels. Episodes including developing a network, asking great questions, designing a lecture or talk, the flipped classroom, and feedback.

 

  1. https://cordemblog.wordpress.com

screen-shot-2016-10-16-at-6-57-50-am

This blog from the Council of Residency Directors in Emergency Medicine provides posts on bedside teaching, publishing research, developing curriculum, remediation, asynchronous teaching, interviews, and procedural teaching. Each post is well-written and researched, providing succinct educational tips.

 

  1. https://emsimcases.com

screen-shot-2016-10-16-at-6-57-57-am

EM Sim Cases provides tremendous simulation cases, each with educational objectives and goals. Cases are broken down into subject matter (cardiology, toxicology, OB, GI, trauma, etc.), with each containing downloadable content covering a case vignette, objectives, required equipment, study results (ECG, Xray, labs), timing, key actions, teaching points, and references. Authors also provide tips on mannequin use. This is a premier simulation resource for emergency medicine.

 

  1. http://thesimtech.com/av-stimuli/

screen-shot-2016-10-16-at-6-58-05-am

The Sim Tech site provides downloadable simulation cases, all with objectives, key actions, and learning points. Videos on moulage, or applying mock injuries to add realism, are an important feature of this website. The blog also contains examples images, ECGs, ultrasound videos, Xrays, and injury photos.

 

  1. http://thesgem.com

screen-shot-2016-10-16-at-6-58-16-am

The Skeptics’ Guide to EM (SGEM) uses social media to disseminate the most current literature. This evidence-based medicine resources provides succinct literature reviews of studies that will affect your daily practice of medicine. The goal of SGEM is to shorten knowledge translation from 10 years to less than one year. Several sections include “Hot of the Press”, “Paper in a Pic”, “Xtra”, and “Journal Club.” This is a great blog for those interested in constructing an EBM curriculum or journal clubs.

 

  1. http://stemlynsblog.org

screen-shot-2016-10-16-at-6-58-23-am

St. Emlyn’s EM contains content ranging from core topics to educational techniques and theories, and the site aims at improving EM through free and open access education. The topic page links to educational posts, and the journal club category contains gold nuggets on how to conduct a journal club, posts on literature search/question design, and appraisal checklists. Sample Journal Clubs are provided, with links to the separate studies. A great place to start includes the educational theories page (http://stemlynsblog.org/educational-theories-you-must-know-st-emlyns/), which offers a foundation for educators.

 

  1. http://canadiem.org

screen-shot-2016-10-16-at-6-58-30-am

CanadiEM aims to improve emergency care in Canada and around the world by building an online community of practice for healthcare practitioners and providing them with high quality, freely available educational resources. Content ranges from clinical topics and flashcards to educational skills and simulation (http://canadiem.org/category/all/education-quality-improvement/fei/). Mentorship tips, student resources (CaRMS), and even department flow hacks make for an amazing resource.

 

  1. https://first10em.com

screen-shot-2016-10-16-at-6-58-39-am

First 10 EM makes the list again. This blog from Justin Morgenstern provides monthly literature updates, great blog posts on managing sick patients, and videos. The simulation page contains simulation resources, guidelines, and debriefing information.

 

  1. http://scanfoam.org

screen-shot-2016-10-16-at-6-58-46-am

scanFOAM contains a blog that asks experts in simulation “How I Sim.” This is a great series investigating how people in medical education look at teaching, simulation, debriefing, and simulation in the future. Several other lectures provide theories and tips on simulation and education.

 

  1. https://icenetblog.royalcollege.ca and https://icenetblog.royalcollege.ca/category/keylime/

screen-shot-2016-10-16-at-6-58-54-am

This blog and podcast (KeyLIME) provide great educational and simulation resources. The blog has posts on educational literature, educational design, simulation, technology, educational leadership, and scholarship. The podcast addresses common educational issues such as resident evaluation, duty hours, feedback, competency, running a clerkship, and much more.

 

That’s it for education and simulation resources. Please comment if you have found other blogs/podcasts providing great educational content.

Teaching When There is No Time

Author: Robert Cooney, MD (@EMEducation – EM Associate Program Director / Attending Physician, Geisinger Medical Center) // Edited by: Alex Koyfman, MD (@EMHighAK – EM Attending Physician, UTSW / Parkland Memorial Hospital) and Brit Long, MD (@long_brit – EM Chief Resident at SAUSHEC, USAF)

As you walk into your shift, the familiar din that made you fall in love with emergency medicine greets you.  You’ve barely sat down and logged into the EMR, when Jake, one of the interns, asks if he can present a patient.  As he presents, 2 other residents sit down and you can tell from their impatient looks that they too have patients to present.  A quick glance at the board confirms that the waiting room is 20 deep, the ED is holding 50% of its beds with admitted patients, and there are at least another half dozen expected arrivals.  “Well,” you think to yourself, “It’s another day in paradise,” and you begin to prompt Jake along so that you can get him and the other residents back to work.  After taking the 3 presentations, you pause to wonder, “Is there a better way to teach when it’s so busy?”

Between 1993 and 2003, total hospital beds declined by 198,000 while ED visits increased from 90.3 million to 113.9 million and continue to rise.  This loss of capacity within hospitals has caused the burden of care for patients needing admission to fall to the ED.  Academic emergency departments are particularly prone to this problem as they serve as receiving centers for patients in need of critical interventions and specialist evaluation.  Whether overcrowding affects resident education is a matter of debate. Berger et al1 found that productivity and teaching evaluations were not related; and surprisingly, the most productive attendings were also highly rated teachers.  Kelly et al2 found that clinical workload did not affect teaching scores.  Finally, Pines et al3 found no association between crowding and teacher-learner interactions.

While overcrowding may not have an effect on the quality of teaching, the Berger study did find that attending physicians did perceive the workload to interfere with the ability to teach well.  When it gets busy, seasoned educators will often rely on tried and true methods to accomplish effective teaching with minimal time.  Bandier et al4  identified methods that award-winning educators felt made the difference for their teaching.  These include:

Tailor teaching to the learner:

A few minutes spent at the beginning of the shift getting to know your learners is an investment that pays dividends.  This is especially true when working with medical students and off-service residents who are new to the department.  This helps to establish the relationship, determine their learning needs and goals, and you can also establish expectations.  Knowing the learner’s “story” will help you to tailor the teaching as the shift progresses.  Is the student going into radiology? Coaching them on image interpretation for all of their patients reinforces that you understand their interests.

Optimize faculty-learner interaction:

Once you know your learners, you can much more effectively tailor your teaching.  Learning to ask questions properly (https://www.aliem.com/2010/article-review-use-of-effective/)5 allows you to “diagnose” your learner’s level and can guide your learner through the case, improve retention, and structure their learning.  Going to the bedside is another way to optimize the interaction. Muck et al6 found that bedside rounding increased the amount of discussion about differential diagnosis, overall questions, and led to changes in diagnostic workup compared to board rounds.  While it did take longer to complete bedside rounds (4 minutes), the efficiency gained by a more appropriate patient work-up likely negates the time cost.  A full discussion of bedside teaching is outside the scope of this article.  If interested, Twelve Tips to improve Bedside Teaching by Subha Ramani7 is an excellent starting point.

Tailor teaching to the situation and actively involve the learner:

When it gets really busy during a shift, it becomes too easy to dismiss learning opportunities for the sake of speed.  Two tricks can be used when this situation arises.  First, the 1-minute preceptor8 ((Paucis Verbis Card) (https://www.aliem.com/2015/pv-card-one-minute-preceptor-nerds-mnemonic/)).9  After listening to the learner’s presentation, the educator will:

  • Probe for commitment: “What do you think is going on with this patient?”
  • Probe for evidence: “Why; what else are you considering?”
  • Teach a general rule: “The key to making this diagnosis is…”
  • Reinforce what’s right: “Your differential included the key conditions that I worry about when a patient presents with a complaint of…”
  • Correct mistake: “Prior to ordering a d-dimer, make sure that the patient’s pretest risk is in the correct range.”

Another simple way to teach quick pearls is the use the “What if…” question.  This question can change a routine simple case into a learning opportunity.  For example, if a person has URI symptoms, as “What if this person was just traveling in Yosemite (Hanta), or Africa (Ebola), or Puerto Rico (Chikungunya).  A simple case suddenly becomes a hit-and-run learning experience.

Actively seek opportunities to teach:

While on a busy shift, learners often are pulled in multiple directions to see patients, document, deal with consultants, perform procedures, and the list goes on.  Always being aware of the department can help you tailor the learning.  Perhaps you’ve taken a presentation for a patient that will require a more uncommon procedure.  Bring multiple learners into the situation.  What if it’s not busy?  Keep a teaching file.  I use a combination of Evernote and a USB drive filled with images to offer learners the opportunity to review cool cases when the time presents itself.

Whether we like to acknowledge it or not, there will always be impediments to good teaching in the Emergency Department.  Whether competing demands, lack of time and/or resources, or trainee issues such as lack of interest or knowledge deficits, we can use the above simple tricks to improve our teaching.  Our patients will be better for it.

References/Further Reading:

  1. Berger, Todd J., et al. “The impact of the demand for clinical productivity on student teaching in academic emergency departments.” Academic emergency medicine 11.12 (2004): 1364-1367.
  2. Kelly, Sean P., et al. “The effects of clinical workload on teaching in the emergency department.” Academic Emergency Medicine 14.6 (2007): 526-531.
  3. Pines, Jesse M., et al. “The effect of ED crowding on education.” The American journal of emergency medicine 28.2 (2010): 217-220.
  4. Bandiera, Glen, Shirley Lee, and Richard Tiberius. “Creating effective learning in today’s emergency departments: how accomplished teachers get it done.” Annals of emergency medicine 45.3 (2005): 253-261.
  5. Cooney, Robert. “Article Review: Use of Effective Questioning” Available at: https://www.aliem.com/2010/article-review-use-of-effective/
  6. Muck, Andrew, et al. “Bedside rounds versus board rounds in an emergency department.” The clinical teacher 12.2 (2015): 94-98.
  7. Ramani, Subha. “Twelve tips to improve bedside teaching.” Medical teacher25.2 (2003): 112-115.
  8. Neher, Jon O., et al. “A five-step “microskills” model of clinical teaching.” The Journal of the American Board of Family Practice 5.4 (1992): 419-424.
  9. Sudario, Gabe. “PV Card: One Minute Preceptor – NERDS mneumonic.” Available at: https://www.aliem.com/2015/pv-card-one-minute-preceptor-nerds-mnemonic/

The Future of Emergency Medicine Education

Rob Cooney, MD
EM Attending Physician/Associate Program Director
Conemaugh Health System
http://flippedem.com/

Edited by Alex Koyfman, MD

 
Trying to predict the future is a task that is riddled with risk. There is a very high potential that I will be wrong and my thoughts will end up being complete baloney. I’m okay with this. According to Strengths Finder 2.0, I’m futuristic, meaning that I’m inspired by the future and what could be, and hopefully will inspire you. With this in mind, two quotes that I believe should frame our conversation:

“The future is already here, it’s just not very evenly distributed.”
-William Gibson

“We always overestimate the change that will occur in the next two years and underestimate the change that will occur in the next 10.”
-Bill Gates

With these in mind, here are some trends that I see emerging.

The Role of Technology

I believe that this one is pretty obvious. Technology has changed our lives in almost every aspect. Who knows what will come next? We have some fairly incredible technology at our fingertips: high fidelity simulators, portable supercomputers (i.e. smart phones), and a wealth of Web 2.0 technologies. Technologies that would have taken years to learn a decade ago can be quickly learned and utilized by educators and learners alike. Each passing month brings new examples of how educators are harnessing blogs, wikis, Twitter, and apps to supplement classroom instruction. As online content continues to improve in terms of quality and availability, I believe that we will see an evolution in instructional delivery. Didactic lectures will likely give way to other delivery models, such as peer instruction, problem-based learning, case-based learning, or project-based learning. Instructors will be able to add a significant value in the limited amount of time together with learners. Educational materials will increasingly become “on demand” for quick reference during clinical shifts. Learners may even begin to take advantage of the overlap between educational psychology and technology. For example, apps, such as Anki, allow learners to use technology to harness the power of spaced repetition to increase their learning effectiveness.

Technology will also influence how we work clinically. We’ve already seen the change that the introduction of ultrasound (EUS) into clinical practice has made. Newer technologies will contribute as well. Think about how Google Glass could influence how we interact with prehospital providers and patients. Can you imagine “seeing” the patient and the monitor in the ambulance as you talk the paramedic through the management? As they wheel into the department, you can now view your own monitors. As you prepare to intubate, the vitals are there, but so is your checklist. As you run through it, the items are in direct view and you don’t even have to take your eyes off of the patient. Such potential. . .

A Focus on Outcomes

Medical education has jumped on the outcomes bandwagon with a fervor that hasn’t been seen since the original publication of the Flexner report. Specifically, competency-based medical education (CBME) is all the rage. With this focus will come new metrics regarding the assessment of medical learners. Technology, as mentioned above, will likely play an increasing role in these assessments. For example, could a standardized patient wear Glass to provide a first-person view of a learner’s interview? The potential for feedback from these types of interactions is quite powerful. Learners will be able to harness this technology to demonstrate their outcomes as well. Imagine a digital portfolio that includes photos or videos of select learner interactions with patients. With the ability to mash up media, a learner could take a recording of their interview and then offer their own reflective commentary on it within their portfolio. They could also potentially record procedures in this fashion. Now, instead of simply filling out a form to capture numbers, they can demonstrate their actual skill in performing the procedure. This is a huge advantage from an assessment standpoint in that, we, as educators, can now apply more objective criteria to the assessment of our learners.

As we get better at capturing objective, robust, reproducible assessments, we will move towards the true realization that competency-based medical education promises.   Learners will no longer be considered competent simply because they completed a preset amount of time. If they meet their educational milestones, they have the potential to advance. Likewise, for trainees failing to meet the milestones, more time can be granted for them to demonstrate the attainment of competence. As educators, we will also be able to critically evaluate our curriculum and adjust accordingly to the learner’s needs. This will promote a much higher degree of learner centeredness within medical education. While this holds great promise, this will not be an easy task in the United States given our current funding system. Ultimately, we will need to determine a method to make training duration more flexible.

Learner Centered Education

With the merger of CBME and technology, we will increasingly be able to customize education for our learners. As learners progress through their education, they will demonstrate mastery of a series of topics and will likely have their choice as how to demonstrate the mastery. As Curtis Bonk has written, “We live in the age of the learner, and it’s about time” (The World is Open, p. 306). Learners will increasingly demand a customized education. In fact, they will likely create it. In our hyper-connected world, each passing day brings more tools for doing exactly that. Online learning (de-learning) and mobile learning (M-learning) will allow learners to connect with each other and learn wherever they are whenever they want to. Free Open-Access Meducation (#FOAMed) is just one resource that is allowing this to occur. Dr. Bonk also lists e-books, open source software, MOOCs, and alternate reality environments (Second Life) as potential resources for increasing the learner centeredness of education. It is also likely that games will play an increasing role in learning. I can envision a future in which a learner dons a 3-D headset, such as Oculus Rift, that is paired to a motion sensor, such as the Microsoft Kinect or Leap Motion to provide alternate reality simulation. In combination, these tools could easily allow the learner to practice procedures that are difficult to learn. With proper design, difficult airways and rare procedures could become commonplace simulations for our learners. Ultimately, all of these resources will connect and learners and educators alike will be able to create Personal Learning Networks.

Focus on Quality

In 2013, Thomas Nasca, CEO of the ACGME addressed the participants at the Council of Residency Directors. The purpose of his keynote was to address the upcoming changes with the core competencies in the introduction of the Accreditation System and milestones. As he outlined the need, his commentary on the study by Landrigan, et al struck a nerve. The study was a 10 year review of patient safety improvements. The authors found that harm remained quite common despite significant efforts to improve patient safety. When I first read the study, I felt that improved recognition of patient harm over the course of 10 years may have explained some of the lack of improvement. Dr. Nasca feels differently. As he explained, the average longevity of a physician is 30 years. Since the study evaluated a 10 year period, we can estimate that one third of the physicians within this population were new graduates. In his opinion, Dr. Nasca explained that the failure to improve patient safety is a failure of our medical education system to train physicians with appropriate skills to foster safe medical practice and improve the quality of care that they deliver.

The skills needed to improve patient safety and quality will be increasingly required of medical learners. At the residency level, the Clinical Learning Environment Review (CLER) visits have made this readily apparent. Unfortunately, there is still a significant skill and knowledge gap within our medical faculty regarding this topic. We will likely see an increasing demand for physicians trained in quality improvement to help bridge this gap, provide faculty development, and lead change initiatives that involve learners.

As the quote above noted, the future is already here, it just isn’t very evenly distributed. All of the trends and tools that I’ve noted above already exist. Some are already in use within medical education, but many are not. So take a look around. See what is happening in industry, K-12 education, and undergraduate education. Take a look at what our learners are doing on their own time. As Abraham Lincoln has already said, “The best way to predict your future is to create it.” So bring these advances into medical education and let’s create the future together.

References

  • Frank, J. R., Snell, L. S., Cate, O. T., Holmboe, E. S., Carraccio, C., Swing, S. R., … & Harris, K. A. (2010). Competency-based medical education: theory to practice. Medical teacher, 32(8), 638-645.Frank, J. R., Snell, L. S., Cate, O. T., Holmboe, E. S., Carraccio, C., Swing, S. R., … & Harris, K. A. (2010). Competency-based medical education: theory to practice. Medical teacher, 32(8), 638-645.
  • Bonk, C. J. (2009). The world is open: How web technology is revolutionizing education. John Wiley & Sons.
  • Landrigan, C. P., Parry, G. J., Bones, C. B., Hackbarth, A. D., Goldmann, D. A., & Sharek, P. J. (2010). Temporal trends in rates of patient harm resulting from medical care. New England Journal of Medicine, 363(22), 2124-2134.