Better in Emergency Medicine

Advice to New Interns

noreply@blogger.com (Rob) — Fri, 08 Jul 2011 01:39:00 +0000

It's that time of year again. The time of the year that you see the new interns scrambling through the department, eyes wide as saucers, running scared, and hungry for experience. As an educator, it's a refreshing time to be at work!

With the start of the interns, many blogs have been providing advice to help them on their way to a successful career. Some of the better examples are here and here.

But this is emergency medicine, and while the given advice still applies, I wanted to add a little more, just for our learners. When I began my residency, one of our attendings handed us a copy of "The Ten Commandments of Emergency Medicine." I still have my original copy and now and then I hand it out to my residents. As I dusted it off this year, I realized that the article was written in 1991! Are the commandments still relevant? Read on. . .

Secure the ABC's

Relevance: High

We pride ourselves on being the masters of resuscitation. Mastering the patients' ABCs should be the priority the moment you walk in the room. Simply walking in and observing your patient can give you an amazing amount of information. Is the patient able to speak full sentences? Are they talking at all? Do they make sense? How is their color, work of breathing, pulse, etc? If you find a problem, fix it first.

The authors of the article expand the ABC's mnemonic a little ABCD2EFG2. While most of these are familiar to us, the addition FG2 is useful to remember:

Fetal Heart tones: a needed vital sign in pregnant patients
RhoGam: Consider getting the type and Rh in pregnant trauma patients
Guardrails: Confused and elderly people fall out of bed far too often. If you put them down or find them down, then take the 10 second and put them up!

Consider or give naloxone, glucose, and thiamine

Relevance: Glucose, high; others moderate

Any patient with altered mental status or a new neurologic deficit deserves a fingerstick glucose. Almost every one of us has forgotten this truism once. The embarrassment experienced by performing the stroke workup only to get the critical glucose level back from the lab is never forgotten

As for naloxone, consider it, but give it in smaller doses if you give it at all. Remember "Priumum non Nocere." After witnessing an addict in iatrogenic withdrawal once, I'm more likely to give 0.2 to 0.4 mg or simply intubate the patient and wait.

Thiamine is safe and potentially helpful. While we still give it to the patient with alcoholism, the population that seems to need it the most these days are the post-gastric bypass population.

Get a pregnancy test

Relevance: Very High

I remember a story about a seasoned senior EM attending being asked what the biggest development of his career was. The answer? The urine pregnancy test. Any female, age 10-55, deserves this quick test. You'll lose count of how often your workup will be changed by the results of this test.

Assume the worst

Relevance: Very High

Amal Mattu likes to quip, "When emergency physicians here hoofbeats, we think lions, and tigers, and bears." We aren't after the zebras. Whatever can kill the patient we rule out first. Only then do we move on less severe and more likely conditions. Check your attitude at the door. Don't get hung up on the 20/10 pain while the patient sits eating a bag of chips. Take them at their word, do your best exam, and give them the benefit of the doubt. You will be humbled time and time again by the seemingly stable patient who tries to die, sometimes successfully, in front of you.

Do not send unstable patients to radiology

Relevance: Moderate

This is one area that has changed in recent years. It no longer takes as long to get studies done, and sometimes that septic elderly patient will need a CT to find the phlegmon of infection. I would change the commandment to: Do not send unstable patients to radiology alone; you must go with them. If conditions exist which can be fixed first then do so: secure the airway, begin fixing volume problems, etc. If an alternative exists, such as bedside ultrasound, use it to your advantage, but don't fail to make the diagnosis simply to avoid taking the patient out of the department. Oh yeah, and when you take them, take the right equipment too.

Look for common red flags

Relevance: High

I always get a little but of a laugh when reading this one. It talks about FOUR vital signs! With pulse ox and capnography and pain (really?) we have more vitals than we know what to do with! The point is simple: look at the vitals and explain them. Your history will gain you more than an entire battery of labs. Ask about comorbidities. Ask about risk factors; that patient with an IV drug addiction who has back pain and a low grade fever isn't looking to score narcotics. Remember the extremes of age. Pay particular attention to revisits. These patients are giving you a second or third chance to make the correct diagnosis. And remember, before anyone goes home, they must be able to eat and walk.

Trust no one, believe nothing (not even yourself)

Relevance: High

Anything that any tells you, in person, or in writing, might be false. The "frequent flier" may be in the department often, but also might have real disease. Always start with a open mind, talk to the patient, examine the patient fully, and look at every image and study yourself. Remember, the cardiologist and radiologist aren't seeing the patient and can miss significant findings.

The same advice applies to your teachers, and to this post. Be skeptical but not cynical. Take the time to check the facts, read the literature yourself, and try both old and new techniques. Did you find an absence of evidence about a treatment? You may have just found your research project!

Learn from your mistakes

Relevance: High

I've learned far more from my mistakes than my successes. We all make mistakes. The important part is to learn from them. Possibly even more important is learning OF them. Emergency medicine is particularly prone to an absence of feedback about our mistakes. Did you have an uncertain diagnosis? Look into the case and follow up on the patient after discharge. Learning about our errors is essential to improving our practice.

Since we all make them, try not to judge others by their mistakes. Learn from their errors, but look deeper as well. Were there any system issues, communication errors, etc, that may have contributed to the error? Can any of these be fixed to prevent the error from occurring again?

Do unto others as you would do to your family (and that includes coworkers)

Relevance: High

You'll more often do the right thing when you follow this maxim. Respecting our patients, colleagues, and coworkers demonstrates the caring attitude expected of a good physician. And remember this if you decide to be rude: "The toes you step on today might be connected to the backside you need to kiss tomorrow."

When in doubt, always err on the side of the patient

Relevance: High

We see the patients that society and even healthcare tend to forget: the homeless, the addicted, the psychiatric, etc. We need to be the ultimate patient advocate. We strive to relieve suffering. To do what is right for the patient, we need to consider the course of action that would minimize their suffering and keep the patient safe. This will unfortunately put us at odds with our administrators, and at times, our peers, but if we fail to take care of our patients, then no one else will either and we will have violated our sacred oath.

As you can see, despite being 20 years old, these "commandments" still have a significant amount of relevance today. For sure, they could be added too, but for the start of your career, paying attention to this short list will help you to save lives become a better emergency physician.

Stick with the Herd?

noreply@blogger.com (Rob) — Wed, 15 Jun 2011 13:43:00 +0000

Knowing is not enough. We must apply.

-Johann Wolfgang von Goethe

My daily commute to work takes me through the hills of western Pennsylvania. It takes me 40 minutes to make the trip so I've really come to love podcast and audio based education. Mel Herbert and the crew at EMRAP do a great job of putting on a quality show.

Recently, the crew recorded a debate between Mel and Billy Mallon about the Ottawa Aggressive Protocol for Atrial Fibrillation. During his rant, Dr, Mallon makes some important criticisms of the protocol. If he had stuck with his numbers, he would have made a convincing argument against the protocol. But then, he blunders. As an educator, he makes a statement to his residents and students that I see as irresponsible of an educator.

It goes as follows:

"My top 10 reasons for not doing this are: 1. Most don't. And just as an idea in medicine and a concept: stay within the herd. If you want to know what the problems are of not being in the herd, turn on the nature channel. The gazelles that are not in the herd, are lion food. Okay? Stay with the herd! The herd doesn't do this."

Really? REALLY? An idea and concept? That's the number 1 reason? Do what everyone else does? That sounds more like lawyer speak than physician speak. Almost like when I overheard a fellow faculty member tell a resident to get ankle x-rays on a Ottawa negative patient "because this isn't Canada; Canadians don't get sued."

The "go with the herd" mentality is a dangerous preposition in medicine. Medical history is filled with vivid examples of how patients were harmed because the this mentality. Virchow, the leading authority in his time, was particularly critical of Ignaz Semmelweis and his data to suggest that physicians could cut disease rates by simply washing their hands. Who knows how many lives were lost due to the fact that physicians were "gentlemen" and felt that they didn't need to wash their hands. 160 years later, we're still dealing with the fallout.

Why is it that interventions known to be effective take so long to put into practice. Herd mentality. If nobody else does it why should I? There is an old joke in medicine that you don't want to be the first to do something. But, you also don't want to be the last.

As educators, we have a responsibility to be second or third. We need to be early adopters and try out new ways of taking care of patients especially when the literature shows some support. We need to take what others have done and reproduce it, testing it with our learners and demonstrating that science constantly changes. Even more, we need to measure our results and disseminate them with time. Only then can we advance the care of our patients.

Take the Ottawa Protocol, for example. I've used it for 4 patients now with a 75% success rate. To be fair, I haven't sent the patients home. We don't have the most reliable outpatient followup. That being said I've managed to admit patients to beds without the need to advanced monitoring since they didn't need vaso-active drips and have kept them off of the nastiest of nasty drugs, warfarin.

And that is only one example of a countless list. The last 2 decades have shed light on the failure of medicine to adopt treatments that benefit society. We have become far more capable of creating knowledge than using it. Perhaps our fear of leaving the herd is partially responsible for this failure.

So lets change it. Let's take the time to venture outward, leading the herd. Let's generate knowledge and take time to test it, apply it, and teach it.

What of the risks? Remember, when you lead the herd, you don't need to outrun the fastest lion, only the slowest gazelle. You're never alone out there!

The Academic Practice of Wilderness Medicine?

noreply@blogger.com (Rob) — Wed, 08 Jun 2011 13:19:00 +0000

The recent Society for Academic Emergency Medicine Annual Meeting just concluded after several fun and learning filled days in Boston. I was fortunate to be able to attend and learn from the best and the brightest.

One of the presentations that stands out in my mind was a panel discussion about the "Academic Practice of Wilderness Medicine." Wilderness medicine probably got me into medicine to begin with. In my teen years, I was a member of a Venture Crew and spent many hours learning to climb, kayak, and haul a pack. Our leader was a former paramedic and encouraged several of us to pursue training as EMTs to be better prepared for handling emergencies in the outdoors. Thus began my love of emergency and wilderness medicine.

Being in a community academic site, I've always put wilderness medicine onto the back burner thinking that I didn't have the skills or resources enough to make it into a viable niche. This presentation, given by Sanjay Gupta, N. Stuart Harris, and Michael Millin, was a nice summary of the growing field and has rekindled my interest in wilderness medicine.

First, what is wilderness medicine?

At its most basic, it is the practice of medicine in austere environments. While generally thought to represent the out-of-doors, this can encompass military settings, event medicine, disasters, and other less than ideal settings.

How do you start in wilderness medicine?

There are many ways to get started. As an academic, we're always looking to cement our niche. Probably the most basic way to do this is training. Fellowships now exist in many places that are dedicated to wilderness medicine or wilderness medicine and EMS. For those who have already graduated, there are any number of courses, seminars, and experiences available to build your expertise. The Wilderness Medical Society even has a fellowship track for physicians to demonstrate a level of expertise within the field.

But what makes it Academic?

Here is where the presentation got interesting. I've always thought of academic practice within this field as being research based; high altitude medicine, tropical diseases, etc. Like many academic pursuits, there is so much more to practicing wilderness medicine. You can, for example:

Become the faculty mentor for a wilderness medicine interest group
Teach at medical schools, residencies, or CME courses
Become a military, expedition, or event consultant
Serve as a medical director for a search and rescue team
Serve as a travel medicine consultant
Actually become a researcher
Participate in the leadership of Wilderness Medicine oriented committees, interest groups, or the WMS

At SAEM, we became a fully fledged interest group at the meeting. We even were able to head to the nearby quarry for an afternoon of learning the basics of high angle rescue. The excitement on the participants faces as they took that first uncertain step into the air during their rappel was a priceless reminder of why I love teaching and emergency medicine.

Having had my assumptions challenged and realizing that there are opportunities for developing an academic niche in wilderness medicine even at a community site, you can expect to see more on various topics related to Wilderness Medicine in the future!

I would like to thank N. Stuart Harris for his leadership over the last year, his vision to start the interest group, and his willingness to share his rope, local crag, and experience with us this past week.

Another Satisfied Customer?

noreply@blogger.com (Rob) — Sat, 30 Apr 2011 04:32:00 +0000

Do you believe in patient satisfaction? For the majority of my training, I had my doubts. As an impressionable intern, I remember a conversation between 2 seniors discussing a patient complaint about the wait. The conclusion was something like this: "This isn't Burger King. In the ED, you don't get it your way, right away." For a long time, I believed that good care comes first and satisfying the patient comes second.

I'll also admit that my opinion was further skewed by the wealth of poor data collected by various "satisfaction" surveys that using a sampling that would be laughed at by any respectable researcher. We see more than 200 patients per day. One month our sample was derived from a sum total of 14 patient responses. Hard to make valid conclusions with data that is derived from <1% of total patients.

Needless to say, as I mature in my practice, I have come to realize that there is a lot of truth to the statement, "They don't care how much you know until they know how much you care." With that in mind, I want to share some key points from a nice review of customer satisfaction that I stumbled upon from the Emergency Medicine Clinics of North America.

So why pursue a goal of having more satisfied patients?

There are multiple demonstrating benefits from hospitals which perform better:

-Staff morale improves
   (Turnover decreases, work is more enjoyable)
-Malpractice risk decreases
   (Happy patients sue less frequently)
-Patients respond better to treatment
   (Patients follow instructions when they believe that they received good care)
-Hospital finances improve
   (Patients recommend the facility and will come back)

The list is pretty impressive. I'd be happy with improvement in one of those categories! So we know that happy patients can bring us happiness, but how can we improve the current quagmire that is emergency medicine?

Obviously, you know your local environment best. Each department will need to tailor a program to its needs. The first step is figuring out those needs: what is the goal you want to strive for? If you already have a program, great! Hopefully you've been keeping tabs. The data gleaned from your surveys can highlight areas in need of immediate attention. What if you haven't kept tabs? Look at complaints, get staff input, administrative input, and use good ol' common sense.

Leadership will be vital. You'll be attempting to change something fundamental about emergency care: our culture. First, get the key players on board: administrative, nursing, and physician leaders. Don't forget the "leaders" within the ranks who may not formally hold a title.

As the leader, you'll be tasked with the following:
-Setting goals
-Modeling and insisting on specific behavior
-Monitoring the behavior and progress towards the goal
-Delivery of rewards and recognition for good performance

Goals take on two forms: philosophic and specific. The philosophic goals helps set the vision for the change, the specific gives the down and dirty expectations and guidance for attaining the vision. Remember to involve the staff. Using goals that they create will help promote buy-in.

Some specific examples:
-Answer all phone calls within X rings
-Door to Doc of X minutes or less
-Door to discharge of X hours or less
-Door to bed of X hours or less
-Each patient will be re-evaluated by a provider every X minutes

Once you choose your goals, it will be up to the leadership to hold people accountable. Some people will resist. Giving that person an exemption will deep six any cultural change before it even has a chance.

Educating the staff will be important. Everyone will need to learn to modify their behavior: physicians, nurses, registration, techs, transporters, housekeeping, etc. The success of your program will depend on universal participation.

Remember to reward the people who contribute. Publicly acknowledge them, give bonuses, a parking spot, etc.

Remember the need for a scoreboard. Even if you missed the first half of a game, you know who's winning by looking at the board. So it is with the staff: they need to know where they're at in order to improve. Publish your results widely: newsletters, emails, bulletin boards, etc. Let patients know too. Success is contagious.

Invariably, there will be some people who choose not to come on board. Once they become obvious, they will need to be removed. Letting them stay within the department will create a division amongst the staff and hurt your chances of success.

There are tools available to help you succeed:

Scripting: developing specific comments for registration, nursing, and even docs can help diffuse anger and demonstrate an attitude of caring.

Patient advocate: This person can make sure that patients who are waiting are up to date with an explanation. They can also help keep the patient comfortable while waiting.

Surveys: You can't change without data. Develop your own, and distribute them widely. The more the merrier. Don't forget to allow family members to fill them out as well.

Call Back System: This tool can help to salvage what may have been a negative impression. You can target specific conditions: Against Medical Advice discharges, left without being seen, etc.

Patient Satisfaction is a worthy goal to persue. It's not easy, that is obvious from our day to day practice. Start by being honest with yourself. Would you want your mother, father, spouse, or child to receive the same care given to the majority of the patients waiting in your waiting room. If you answered no, then step up, become a leader, and promote the improvement that is within your reach.

Reference:
K Worthington. Customer Satisfaction in the Emergency Department. Emerg Med Clin N Am. 22; 2004: 87-102. PMID: 15062498

Better Consultations

noreply@blogger.com (Rob) — Fri, 15 Apr 2011 21:19:00 +0000

A while back a reader asked the following question:

"How do you get them to buy in? as a resident in a surgical specialty, I'd love the EM residents to give better referrals, but often they want nothing more than to sell the patient and move the meat."

This immediately made me think of a lecture given by Emergency Medicine Superstar Chad Kessler. He actually has a research paper on the way studying the effect of his approach that I'm looking forward to reading. In the mean time, I'll settle for listening to him lecture, repeatedly, again and again, on consultation skills. In his lecture, he offers up some consultation pearls that we would all benefit from learning:

The Five "C's" of Consultation

1. Contact: This is where you call your consultant. Before picking up the phone, make sure you need the consultation. I'm currently a dedicated night doc. When admitting a patient to a medical service, the accepting physician will often ask me to "consult" service x,y, or z. Knowing when to simply write an order for a "routine" consultation versus calling each service in the middle of the night goes a long way towards improving your relationship with each service. When you call appropriately, they begin to recognize that when you call, you need them.

When first making contact, make sure to identify yourself and get their identity as well.

2. Communicate: Once you've made contact, tell them about the patient. The level of detail will vary by specialty. Surgery often needs a one liner while medicine wants a thorough review of the patient.

3. Core Question: Here's the money issue: What do you need? Be as specific as possible. "I need you to admit this patient for fluids and antibiotics," or "I need you to take the patient for emergent cardiac catheterization."

4. Collaborate: Let your consultant digest the information presented and respond with their needs. They may need you to order additional tests, call in the cath team, etc. I've found that this are is where the consultation can quickly break down, especially with the uber-specialists. Their plan may deviate from what you believe the patient needs. You may need to take a quick time out and engage in some shared problem solving. I find this to be most true when they're asking for a test to "stall" the need to see the patient.

For example:
"I have a patient with a fever, back pain, and loss of sensation in the L4 distribution who I think has an epidural abscess. I need you to come and evaluate him for operative drainage."

"Order the MRI and call me back after the results."

Unfortunately, this behavior delays the needed evaluation.

Shared problem solving allows you to advocate for the patient and get them to the person they need to see. For example: "How about you send your resident or PA down to get a quick baseline neurologic exam while I order the bed, the MRI, and antibiotics after a set of cultures."

5. Close the loop: Take the time to repeat the plan back. Letting them hear it allows for correction of errors or the addition of something that they may have forgotten. Make sure to take the time to document the date, time, name, and nature of your conversation.

Another important point that Dr. Kessler makes is the need to practice. Just like intubation or suturing, consultation is a skill. To improve this skill, we need to take the time to practice. As teachers, we can help our residents with a "practice run" so that they don't end up frustrated on the phone. With luck, this short list will help to ease the frustration felt with difficult consultations.

A Practical Checklist?

noreply@blogger.com (Rob) — Fri, 15 Apr 2011 20:29:00 +0000

It seems like checklists are the "in" thing in patient safety right now. It makes sense; follow this list of things and you won't hurt patients. The problem is, they only work when you use them.

While doing some background research on checklists in prehospital settings, I found this gem in the open access Scandinavian Journal of Trauma, Resuscitation, and Emergency Medicine. The article is the print version of an oral presentation, so it isn't "science" but it is practical. Prehospital airway management is a hotbed of controversy right now. The data seem to point to worse outcomes, delays to definitive care, and decay of skills. With all of these problems, anything to make the procedure safer is a welcome addition. Enter the "checklist."

This group of prehospital providers created a novel approach to their airway management. They took a disposable plastic sheet and printed it up with the following graphic:

Notice anything cool? While it still has a text driven checklist (on left), the visual representations offer a rapid and convenient way to prepare for intubation.

Their checklist approach is broken into the following areas:

Pre-anesthesia checklist

Monitoring:

Equipment:

Drugs

Staff

It would be easy to replace their text with the more familiar "P's" of intubation:

Preparation

Positioning

Preoxygenation

Pretreatment

Push the Drugs

Placement with Proof

Post-Intubation Management

On the far right you'll also notice a box for induction medications and maintenance medications.

The thing I really like about this list is the visual representation of the equipment. Just looking at it, I believe that it would really decrease the time in the "preparation" phase. Look at what it includes:

Equipment for bag ventilation: oral and nasal airways

Drugs for the procedure (I would like to see these boxes include dosing guides for the common medications)

Equipment for intubation:

2 laryngoscope handles and blades

2 different sized endotracheal tubes

syringe

tube holder

qualitative end tidal CO2 detector with BVM connector

Backup Equipment:

Bougie

LMA

This is HUGE. How many of you out there really take the time and get your backup equipment out before you need it? This demonstrates true foresight.

The only thing that I see missing is the suction.

When working clinically by myself or with the residents, I'm constantly running through a little mental checklist that includes most items on the above list. Being able to pull out a little plastic sheet that has the list already prepared would free my mind up to think ahead and address other important issues with the sick patient in front of me. I can easily see how this has potential to really make both prehospital and emergency intubations safer.

Below is a video demonstration of the checklist in action:

Reference:

A pre-hospital emergency anaesthesia pre-procedure checklist

R Mackenzie , J French, S Lewis and A Steel

from Scandinavian Update on Trauma, Resuscitation and Emergency Medicine 2009
Stavanger, Norway. 23 – 25 April 2009

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2009, 17(Suppl 3):O26

Great Video for Those Beginning Academic Careers

noreply@blogger.com (Rob) — Fri, 08 Apr 2011 02:25:00 +0000

I was perusing my stack of journals the other day and came by a "Dynamic Emergency Medicine" Article in Academic Emergency Medicine. Typically this section contains useful videos about new procedures and has a very heavy ultrasound slant.

What I found instead in this particular journal was a link to a 40 minute video interview of some of the leaders in Emergency Medicine, people at the leading edge of the bell curve. It's a goldmine of good advice for those with interest in becoming a better academic physician.

Take a look and let me know your thoughts!

Interviews with Leaders in Emergency Medicine from Academic Emergency Medicine on Vimeo.

So You Want More Feedback?

noreply@blogger.com (Rob) — Fri, 01 Apr 2011 20:51:00 +0000

Learners, do you want the truth? Can you handle the truth? In order to receive better feedback from your teachers, you need to take an active part in the process. Here's how:

1. Remember that not all feedback is positive. You need demonstrate a higher level of maturity and self awareness in order to improve.

2. Create your own learning goals and share them. If your teacher knows what you want to learn, they can provide more focused feedback. Don't forget to ask your supervisor for input when creating goals in order to keep you goals realistic.

3. If you're not getting feedback, ask for it. Emergency physicians are action oriented and a passive leaner will get left behind.

4. Clarify. If your teacher says, "You did a great job today," don't be satisfied with your performance. Ask them what you did well and what needs improvement. You won't improve if you don't know where you need improvement.

5. If you get some negative feedback, understand that it is meant not as a personal attack, but an opportunity to improve. Find out from you teacher what the issue is, why it is an issue, and what you need to do about it. If there is an interpersonal issue (rare occurrence) with the teacher, ask your advisor to help you work through the issue.

6. Don't forget to discuss your success as well as what needs improvement. You don't want to lose those skills that you do well.

7. You are probably your harshest critic. Don't be too hard on yourself. Take the credit when you do something well.

8. Be aware of yourself. If you are feeling stressed, rushed, or simply tired, don't be afraid to ask to reschedule for a time when you have your mental faculties in line.

Your teachers want you to succeed. Sometimes we're equally rushed or simply afraid of giving you the advice you need. Following the above list will help us maximize your potential.

Reference:

Rider EA,

Longmaid HE.

Feedback in Clinical Medical Education: Guidelines for Learners on Receiving Feedback. JAMA. 1995; 274(12): 938.

Failing at Feedback?

noreply@blogger.com (Rob) — Fri, 01 Apr 2011 20:17:00 +0000

In the last post, we discussed a some background and general tips on feedback, focusing on the seminal article by Jack Ende, MD. Unfortunately, despite all of the hype and hoopla surrounding feedback skills, learners still complain about not receiving enough feedback.

Problems with feedback identified in some studies include:

Too teacher-centered
Too much positive skew
Low cognitive level (fails to engage learner)

So why are we failing at feedback? Perhaps the problem lies with the learner and not the teacher. In a 2009 article titled "Why Medical Educators May Be Failing at Feedback" Bing-You and Trowbridge offer an alternate view on our failure and suggestions for improvement. In their article, they highlight 3 key problems with the learners:

1. Poor ability for self reflection

2. Overpowering influence of affective reactions to feedback

3. Lack of adequately developed metacognitive capacities

Lets take a look at each of these.

Physicians are notoriously bad when it comes to self-reflection. We tend to overestimate our abilities. Just look at the difference between pilots and surgeons on the perception of the effects of sleep deprivation. Even worse, the most deficient performers may be have the least insight into their incompetence.

So what happens when these learners are faced with negative feedback? Pure emotion. The feedback becomes a personal attack. The feedback may trigger emotions such as guilt or anger. The learners unconsciously fall back on ego defenses (denial, distorting information) that prevent a fair assessment of the feedback. Knowing this, it makes sense that learners who have negative reactions to feedback find it less useful.

Learners also need strong metacognitive skills to appropriately process feedback. Metacognition is a the process of "thinking about thinking." Reflection is a valuable metacognitive skill that students can use to critically evaluate the feedback and apply the needed changes. A lack of this skill probably accounts for some of the overconfidence displayed by learners.

So how do we overcome these barriers and get through to the learners?

We need to recognize the affective component of feedback. Knowing that negative feedback will likely invoke some degree of ego-defense, we can use guided reflection to help our students process the information at a metacognitive level. Using follow-up activities to reinforce the positive changes may also help overcome the negative emotions.

There is a growing body of literature about how to teach metacognition. In emergency medicine, we constantly practice procedures. Why not teach metacognition early? Practice with the metacognitive skills students will increase their self awareness and, hopefully, their self-assessment skills.

We need to take another look at feedback. Efforts to improve feedback need to take these learner factors into account. We owe it to our learners and our patients.

Reference:

Bing-You RG, Trowbridge RL. Why medical educators may be failing at feedback. JAMA. 2009 Sep 23;302(12):1330-1. PMID: 19773569 [PubMed - indexed for MEDLINE]

What is the Deal with Feedback?

noreply@blogger.com (Rob) — Fri, 18 Mar 2011 20:24:00 +0000

"Anyone willing to be corrected is on the pathway to life. Anyone refusing has lost his chance."

-Proverbs 10:17

"We are training a group of physicians who have never been observed"

-Ludwig Eichna, MD

Today marks the first of a series of posts on feedback. I had initially planned on a single post but as I dug deep into the literature, I realized that there is far too much good stuff for a single post.

Feedback is such a hot topic in the medical education literature. We pay a lot of attention to it, yet students still rate our feedback skills as mediocre at best. They want feedback, and from what I've seen clinically, they NEED feedback. Unfortunately, as in many educational endeavors, we haven't been trained in appropriate techniques. Even with training, learners will often miss the fact that they've even received feedback.

Feedback is an essential component to improvement. Without insight into our failures and successes we fall into a routine and make the same errors over and over.

So what is feedback and why does it matter?

August 12, 1983: A Call to Arms. It was on this day in JAMA that Jack Ende, MD, published what is possibly the most referenced article on feedback. His work is still relevant today.

He defines feedback as "An informed, nonevaluative, and objective appraisal of performance that is aimed at improving clinical skills rather than estimating the students personal worth."

The above definition highlights some keys to good feedback:

Informed and objective: Feedback is based upon first person observations of skills, behaviors, and attitudes. Without this first person account, a student will tend to discount the value of the feedback.

Nonevaluative: Feedback is much different from evaluation. Evaluation is a summative judgment that occurs at the completion of a period of time. Feedback is formative; it allows the learner to identify areas in need of improvement in real time without fear of a negative evaluation.

Aimed at improving clinical skills: The skills we need to master to become a competent physician are so vast that it is almost overwhelming. Feedback helps to accelerate the process by offering tips and pearls for improvement.

Dr. Ende also includes his guidelines for giving feedback within the article.

Feedback Should:

1. Be undertaken with the teacher and the learner working as allies, with common goals

Start each shift by finding out what skills your learner wants to focus on. This gives the learner an active role and allows you to create a metric for feedback later in the shift.

2. Be well timed and expected

Feedback should be expected by the learner, or better, solicited by the learner. An understanding on the teacher part is needed to avoid times when the learner is not overly stressed.

3. Based on first hand data

The best person to provide feedback is the person who observed the trainees performance. This is often the same person experienced enough to make relevant observations of performance.

4. Regulated in quantity and limited to behaviors that are remediable

Keeping feedback short and limited to only 1-3 behaviors or skills needing improvement allows for the learner to make the needed corrections without overwhelming them with information.

5. Phrased in descriptive, nonevaluative language

Care should be taken to word the feedback effectively in a nonjudgemental fashion. "Your differential did not include _____" is much better than "Your differential is limited and needs a lot of work."

6. Deal with specific performances, not generalizations

How often do you hear "Good job today" as the only feedback a student gets? While good for the individual ego, this kind of feedback is useless when if comes to effecting improvement. Focus on "actions" in order to provide more effective feedback. Statements that allow for psychological distance are helpful as well. For example,"The choice of sux for a paralytic in this dialysis patient didn't account for the possibility that he may have hyperkalemia" is better than "You completely failed to consider the contraindications to sux when performing RSI on this patient."

7. Offer subjective data, labeled as such

When offering subjective data, make sure to use "I" statements, especially when offering personal opinions or reactions. Consider the following: "While watching you perform the history, I felt that you were uncomfortable addressing the sexual history" vs "You looked uncomfortable addressing the sexual history." The latter statement could give the learner the fear that their discomfort was on show for all to see.

8. Deal with decisions and action, rather than assumed intentions or interpretations

By focusing on the decisions or actions, and not the learner per se, the learner and teach can review the effects of the decision without assigning blame and inducing psychological protection mechanisms that would prevent to learner from accepting the feedback.

Feedback is an essential part of learner improvement. While Dr. Eichna identified the problem with the lack of observation more than 30 years ago, he missed the fact that even when observed, faculty fail to offer insights for improvement. This is where the value of good feedback skills becomes mandatory. Without it, mistakes continue uncorrected, sound practice is not reinforced, and the students rarely become clinically competent. Feedback is hard, but not as hard as some believe. With practice, these skills will become second nature and you will make a difference in the care of thousands of patients.

Reference:

Ende J. Feedback in clinical medical education. JAMA. 1983 Aug 12;250(6):777-81. PMID: 6876333 [PubMed - indexed for MEDLINE]

Becoming a Better Mentor

noreply@blogger.com (Rob) — Fri, 11 Mar 2011 16:31:00 +0000

Mentor and Telmachus, son of Odysseus

Mentoring has been identified as a critical factor in achieving success in many fields. Unfortunately, like many skills related to the education of healthcare professionals, mentors rarely receive any training in how to become a better mentor.

This is unfortunate. Faculty who have had an effective mentor report the following:

-Increased confidence

-Increased research productivity

-Higher career satisfaction

-Meaningful involvement in academic activities

-Development of close collaborative relationships

With all of the above benefits, it's surprising that their isn't more attention paid to developing more effective mentors. As with many of the skills, we're often left to figure it out ourselves.

So what skills are needed to be a better mentor?

While not an exhaustive list, some traits identified with being an effective mentor include:

1. Being knowledgeable and respected in their field

As I identify mentors for myself, this is a key trait that I look for. But what about the typical residency mentoring structure? Residents are often assigned to a random faculty member based on volume and availability. One change we made to our program was to allow residents to self-select after the first 6 months. Residents can also change mentors as they see the need. As a mentor, I know that I constantly need to continue to improve my expertise within my chosen niche.

2. Being responsive and available to their mentees

This can be a difficult task with the demands of clinical emergency medicine. We're often at work while the rest of the world goes to dinner, watches TV, and heads to bed. Setting aside dedicated time to meet with the mentee goes a long way. I try to make myself available on the residents education day. They're already going to be around, so why not take the time to sit down with them and see how they're doing.

3. Interest in the mentoring relationship

This trait is somewhat of a no-brainer. Why would you participate if you aren't interested? Take a deeper look. Many times we enter the mentoring relationship with full intentions to make the relationship work. While our initial interest may have been high, sometimes life happens and we let the relationship stagnate. We need to constantly monitor the effectiveness of our mentoring relationships and know when to direct our mentees on to a more effective mentor if we can no longer meet our end of the bargain.

4. Being knowledgeable about the mentees capabilities and potential

This can only be acheived with time dedicated to learning about the mentee. Fortunately, working with residents offers ample time to learn about them and observe their capabilities first hand. When initiating a mentoring relationship, it is helpful to dedicate at least 30 minutes of time to a relaxed interview with the mentee to delve deeper into their interests, goals, and to learn about what they desire from the relationship.

5. Motivating mentees to appropriately challenge themselves

I constantly struggle with this skill. Unlike teaching, where the challenge comes from the subject matter, challenging a mentee is more difficult. How do you challenge your mentee? I try to offer my mentees involvement in projects that come along. Follow this up with your expectations, and you have issued the challenge that they need for professional growth. Don't forget to offer support in additional to challenge. It take just the right amount of each to grow.

6. Acting as an advocate for their mentees

Failing to act on this trait came close to ending my academic career. Early in my first year out of residency, I was mentoring a new intern who was having academic and professional difficulty. In the ensuing months, I had a seat at the table for many remediation sessions. Unfortunately, the whole situation became quite hostile. What I should have done better was to take my concerns up the chain of command. If I had been a better advocate for my mentee the situation would likely not have progressed as far as it did. Like many things in life: Live and Learn. As mentors, we owe it to our mentees to be their advocates. If they need resources to get research done, we can help them get it. If they're having difficultly, we can level the playing field to make sure that each party has equal representation at the table.

Mentoring is a difficult skill to master. With all of the demands of being a clinician and faculty member, it isn't surprising that our skills are mediocre at best when it comes to being a mentor. The above simple traits can help to guide you in the right direction as you continue to improve as a mentor to your students and residents.

If you're already an expert, what traits do you feel are needed to be effective?

Reference:

Ramani S, Gruppen L, Kachur EK. Twelve tips for developing effective mentors. Med Teach. 2006 Aug;28(5):404-8. PMID: 16973451

Toxic People

noreply@blogger.com (Rob) — Tue, 01 Mar 2011 23:42:00 +0000

Do you ever have to work with people that just drain the life out of you? I'm not referring to patients, but to those colleagues and consultants that you have to deal with on a daily basis. I recently had the opportunity to sit in on a lecture given by Marsha Petrie Sue, author of Toxic People and The Reactor Factor. I think we can all benefit from an understanding of her approach to reading people and managing conflict.

So who are the players?

Steamrollers: These are the bullies. They come off as overbearing and try to make you feel small

Zipper Lips: "Verbal Anorexic." They think of their knowledge as power and don't share it

Back Stabbers: People that are in it for themselves, always looking for an advantage

Know-It-All: These guys LOVE the limelight and have a hard time letting other contribute

Needie-Weenie: People with this type of personality are fearful of change and have a need to be liked

Wine and Cheeser: Nothing is ever right to these people. They do make good Devil's Advocates though. . .

And how do you deal with them?

First, reflect on whether you react or respond. You need to take the time to mentally step back and respond. Reacting just gets in the way of progress.

Since Steamrollers try to be overbearing, first, use their name. A persons own name is the most recognizable word in their vocabulary. This technique stops them in the tracks and opens their ears.

Example: "Rob, as I was saying, to fix this we could _______."

To deal with a Zipperlip, you need to change the rules they like to play by. Call them on their habit. Give them deadlines but be willing to wait, and wait, and wait, if they decide not to respond.

Example: "I expected you to respond by now, we can schedule a time to meet this afternoon instead if it is better for your schedule." This puts the ball into their court. Resisting involvement now takes time away from them until they participate.

Back Stabbers are best dealt with in public. Try to call them out on their behavior.

Example: "That did sound like you were serious. Is this something we need to address? Does everyone else feel this way"

Know-It-Alls: In this case, busy hands are happy hands. Give them a task and they're in seventh heaven.

Example: "Rob, you're the expert in this case. Why don't you help me understand where you're coming from. Also, can you help me keep track of all of the other ideas offered today?"

Needie-Weenies: In order to get buy in, you need to allow this type of personality to lead some of the change.

Example: "I'm glad that you basically agree with the curriculum updates. What part could be most improved?"

Wine and Cheesers: These guys just love to complain. To deal with them, call their issue and offer to help.

Example: "Are you looking for specific solutions to the call schedule mishap, or do you just want me to look into the problem with you?"

These are just a few of the many methods for dealing with the various types of personalities. A better understanding of the players helps to make teams more effective and improves the workplace culture.

Now that you know these quick tricks, what is your type? I personally think that I'm a know-it-all and when I don't feel appreciated, I can become a zipperlip. You?

Also, what techniques have you found helpful in dealing with the various types?

The Microskills

noreply@blogger.com (Rob) — Tue, 22 Feb 2011 11:00:00 +0000

It's a typical Saturday night in the department. You're busy. I mean really busy; the "too busy to make a run to the bathroom and empty your overly distended bladder" busy. Your resident comes up to you with their next patient. At first, you think of just hearing out the chief complaint, telling them what to order, and moving on to the next patient. Fortunately, a voice in your head reminds you that there is a better way, a way to promote a morsel of learning despite the challenges stacked before you. Enter the microskills.

The microskills model of teaching, also referred to as the "One Minute Preceptor," is a series of easily performed steps that allow you to maximize a teaching encounter when time is precious. The steps are:

1. Get a commitment: I love using this step to shorten the presentations from my learners. Too often, they get lost in the forest when presenting a case. Simply stepping back and asking, "What do you think is causing their symptoms?" allows me to hone in on the important parts of their presentation. I can then focus my questions to help me understand why they are concerned about possible conditions on the differential that they have created. "I don't know" is not an acceptable answer.

2. Probe for supporting evidence: The follow up. Once they take a stand, you're able to ask the why and what if questions. The more direct questioning focuses them on the task at hand and allows you to understand the history a little better as well as determining the learners decision-making process.

3. Teach general rules: The time to teach a mini-lecture is not when time is limited. Instead, focus on a key point of the case, whether a historical factor, workup issue, or interpersonal problem and teach short and succinct pearls.

4. Reinforce what was done right: Reward the learner for their efforts. Point out the good catches on the history or exam, congratulate them on making the correct diagnosis or picking the most effective workup.

5. Correct mistakes: Feedback is always critical. Point out errors in their decision-making and explain methods to correct them in the future. Point them toward resources for future learning.

The microskills have been employed in clinical teaching for over 20 years now. While effective use of the skills takes more than the allotted "one-minute" advertised by the other name, the skills are quite helpful at keeping the teaching encounter short and focused. When it gets too busy to teach, reach into your armamentarium for this quick and easy teaching tool. You'll be glad that you did.

Reference:

Parrot S, Dobbie A, Chumley H, Tysinger JW. Evidence-based office teaching-the five-step microskills model of clinical teaching. Fam Med. 2006 Mar; 38(3): 164-7. PMID: 16518731

See you next week!

noreply@blogger.com (Rob) — Tue, 15 Feb 2011 14:12:00 +0000

Sorry about the lack of posting this week. I'll be heading to sunny Florida for a quick conference and a few days rest and relaxation. I'll be back next Tuesday with a discussion of the microskills. Talk to you then!

Whither bedside teaching?

noreply@blogger.com (Rob) — Thu, 10 Feb 2011 21:05:00 +0000

Observe, record, tabulate, communicate. Use your five senses. Learn to see, learn to hear, learn to feel, learn to smell, and know by practice alone you can become expert. Medicine is learned at the bedside and not in the classroom. Let not your conceptions of disease come from words heard in the lecture room or read from the book. See, and then reason and compare and control. But see first.

-Sir William Osler

I recently received my quarterly faculty evaluation. I usually take a cursory look into the scores and file the report away for future reference. On occasion, the residents take the time to write some useful comments that help me to become a better teacher. I was a little surprised by such a comment with this evaluation:

"Please do not ask the resident medical questions in front of patients, wait until we have exited the room."

In my practice, I find it exceedingly difficult to go to the bedside with my learners. I often fall victim to the nursing station presentation as I hurry off to see other patients. Despite this, I make the occasional effort to get to the bedside with my residents and students. As Osler points out, the best learning is that which is done at the beside with a patient. While less frequent than I desire, these encounters are fulfilling as a teacher and really allow me to see my learners in action.

Perhaps that is why I find the above comment troubling. Have we abandoned the bedside for so long that our learners are so uncomfortable in front of patients with a teacher? Are they so afraid of appearing to be wrong when asked more advanced questions? I can respect their fear. I've been there. I have also learned far more from being wrong and making mistakes. It's simply part of being a learner.

Reflecting upon the comment, I decided to pull out one of my favorite articles on bedside teaching and review some tips for making it work.

Before going to the bedside:

Prepare: Formulate goals, know learning needs of your students and residents

Orient learners: Learners should know what is expected before going in. I guess I have failed to explain to them that it is okay to be wrong. Uncomfortable, yes, but still okay.

Orient Patients: Let the patient know everyone and their role; they should already know the learner. Explain that you'll be asking some medical questions and make sure to thank them for their role in teaching the learner

At the Bedside:

Establish the environment: Try to make the atmosphere comfortable. I try to keep the discussion less formal. I'll ask some clarifying questions of the patient and then focus on the learners. The key is to challenge them intellectually without humiliating them.

Respect learners and patients: Be human. You must remain sensitive to the patient and how illness affects them. I do find that patients enjoy learning at the same time as the learners. Often, the medical discussion forces me to really focus on communicating the same information to the patient in a manner that they can understand.

Engage everyone: Often not a problem where I practice; usually it is just one learner, but if you teach in a setting with a lot of learners, make sure you have questions for all, from the beginning medical student to the PGY-IV resident.

Involve the patient: Make sure to allow the patient to correct unclear parts of the history. Make sure that they're able to ask questions as well.

Match teacher and learner goals: This topic fits into the "before" category as well. I try to start my shift by asking my learners what their goal for the day will be. This allows me to cater the learning to their needs and wants. With residents, I'm also able to cater to their deficiencies since I work with them often.

After leaving the bedside:

Debrief: This has 2 purposes: clarify the encounter and plan and to provide feedback. The learner gets some time for questions, we finalize our workup plan, and then I can provide brief feedback on how to improve.

While bedside teaching is underutilized, with practice it is one of the best clinical teaching tools. We all have something to offer to our learners, sometimes skills that can only be learned through observation, practice, and reinforcement at the bedside. Unless we go there and face our (and our learners) discomfort, we cannot begin to realize our full potential.

Reference:

Ramani S, Orlander JD, Strunin L, Barber TW. Whither bedside teaching? A focus-group study of clinical teachers. Acad Med. 2003 Apr;78(4):384-90. PMID: 12691971

Safe Patients, Smart Hospitals

noreply@blogger.com (Rob) — Tue, 08 Feb 2011 13:22:00 +0000

Peter Pronovost, MD, PhD is a name synonymous with patient safety. He and his team have made patient safety a respectable area of expertise within the house of medicine. He recently published a book, Safe Patients Smart Hospitals, which explains his quest to improve patient safety, first at Johns Hopkins, and now across the country. While well written, I wouldn't recommend it to the random reader unless you have an interest in patient safety.

As someone who has a strong interest in making my patients safer, I found many helpful pearls within the pages. As many of you know the recent media has a myopic focus on checklists as a major way to reduce error. This is partially due to a misunderstanding of the work that Dr. Pronovost's team has performed. While checklists do work, and that is clear from the NEJM article listed above, 2 very important facets of their technique have been somewhat ignored: changing culture and rigorous data gathering.

As Dr. Pronovost explains, patient safety depends on 3 things: Translating Research Into Practice (TRIP), a Comprehensive Unit-based Safety Program (CUSP), and rigorous data collection.

TRIP and CUSP have since morphed together into an inseparable approach to teaching about safety. The two are difficult to discuss as separate entities and as I learn more, I hope to share more details with you.

TRIP is the approach to a problem from a research standpoint; it is the background research. When they first began their central line project, the team went through all of the guidelines, recommendations, and original research and boiled it down into 5 practical points that needed to occur to reduce central line infections. This became the checklist.

CUSP is all about culture, and changing culture. Personally, this is where the rubber meets the road. Without addressing culture, challenging the status quo, and making people accountable to their actions, a checklist is just a piece of paper sitting in a stack somewhere. The CUSP program works with the individuals, identifies where failures occur, and changes the status quo. It encourages people to speak up, and gives them the authority to be able to. It was fascinating to read about the challenges their team faced when moving from one unit to another and how CUSP made all of the difference.

The final important factor in patient safety is rigorous data collection. Remember "Measure Something?" This is often the limiting factor in safety research. The data must be as good if not better than any other research trial or else the conclusion cannot be supported, and therefore, the intervention will be questioned. The point is made over and over: Physicians are scientists at heart. It is so true.

So what does this mean to an emergency physician? If you take the 30,000 foot view, this is a very simple and easily reproducible approach to create change:

-Identify a problem
-Look for evidence of how to fix the problem
-Simplify the solutions as much as possible, you really want a short list
-Start to institute it in your department.

Just like in education, make sure to give feedback to your team on how they're doing, as well as soliciting their input. If you do this and combine it with strict data collection, you will likely see marked improvements in the departments' morale all while making the care you provide much, much safer.

May the best blog win!

noreply@blogger.com (Rob) — Fri, 04 Feb 2011 22:44:00 +0000

If you read Michelle Lin's Academic Life in Emergency Medicine or Scott Weingart's EMCrit then you already know about the quality information that these two giants are providing to Emergency Medicine. It's no wonder that they've both been nominated for the 2010 MedGadget Weblog Awards. Take a look and vote for your favorite!

EMCrit is Featured in the Best Medical Weblog Category

and

Academic Life in Emergency Medicine is featured in the Best Clinical Sciences Weblog Category

There's a lot of competition from some other great blogs so make sure to vote!

Why Blog?

noreply@blogger.com (Rob) — Fri, 04 Feb 2011 03:15:00 +0000

Why create a blog or use a wiki for education? One good reason is that blogging fulfills the "write something" mandate that Atul Gawande recommends as one of the keys skills in becoming a positive deviant; another is the metacognitive aspect of the experience discussed in this video:

There are many reasons why people blog. As an educator, I have found that my students depend more and more upon web-based resources. Learning to use these resources, and better yet, create them, offers an incredible opportunity to teachers. Lets say that you've decided that you're going to take the leap and begin to blog, or create a wiki, for your students. What tips can get you started? If you're unaware of the "Twelve Tips" series published in Medical Teacher, check them out. The following tips are a few that I found helpful from an article published from that series regarding these web 2.0 tools.

1. Appreciate the uses of blogs and wikis

These web 2.0 resources have 3 main uses: read, write, and interact.

Reading a blog or wiki are easy to access. As the author, many programs allow easy incorporation of digital media such as video or pictures that can be shared with the learner. Links to outside sources are easy to add as well.

Writing can be done by the learner. This is useful for creating reflection in learners. These tools can also be used to create online portfolios for the learners. For some time, I've wanted to do an experiment with my residents and see whether learners in difficulty would benefit from writing a blog covering the content that they find difficult.

Interaction is fairly easy through blogs and wikis. Through the use of co-authoring or comments, these tools foster the creation of an online discussion board. Learners can even exchange documents. While interaction holds the biggest potential, I've found it to be the most difficult use to facilitate in my learners.

2. Be clear about why you are using a blog or wiki. These tools do have some limitations. Make sure you are matching the technology to the needs of the learner. These tools tend to have reduced functionality compared to tradition websites which can limit the amount of content delivery. Fortunately, as technology improves, the amount of content that you can deliver via these tools only seems to increase.

3. Decide how you want to use the reading of a blog or wiki as a method to enhance learning. I use both a wiki and a blog. The wiki hosts the entire formal curriculum for the residency. Residents can download their assignments at their leisure, log the completion of assignments, and a few even have personal pages where they share their knowledge with the rest of the class (EKG and Critical Care pages). From a teachers perspective, our curriculum is literature based and I'm able to rapidly change reading assignments to keep the curriculum current, and well ahead of any textbook. The blog is more of a hobby. It allows me to digest the materials that I'm studying and keep them handy for future reference.

4. Choose appropriate technology to create the blog or wiki. The tools that "create" your sites vary in their functionality and cost. Some are completely free but others will increase in cost as the feature go up. For our wiki, we use Google Sites, which is simple to use and inexpensive ($10 per year for the storage we need). One thing that we're now finding we need is the ability to limit access to certain pages. The site unfortunately doesn't allow this feature. Knowing what you might need in advance will save you time and headaches in the long run.

5. Expect barriers. While many of todays learners are tech savvy, I've encountered moderate resistance from some. Participation from the learners varies widely, with some jumping right in and creating content to others who just use it to download their assignments.

These are just some of the tips with my own 2 cents added. The article provides 7 more which you will find useful if you're just jumping into this. One thing is fairly certain. Web 2.0 tools are going to be around for a while and are very popular to the learners coming through the system currently. Mastery of their use offers a unique opportunity to improve their learning and possibly even accelerate knowledge translation.

Reference:

Sandars J. Twelve tips for using blogs and wikis in medical education. Med Teach. 2006; 28(8): 680-2. PMID: 17594577

Making M&M Better: The Healthcare Matrix

noreply@blogger.com (Rob) — Tue, 01 Feb 2011 14:14:00 +0000

First, I think Michelle Lin must be psychic. If you didn't catch her post on morbidity and mortality conference yesterday, then read it! In fact, read her blog daily. It contains an amazing wealth of information of interest to anyone interested in faculty development and teaching.

At the conclusion of her post, she gave a glimpse into a tool called the Healthcare Matrix. Always showing the she is leading the curve, her program already uses it in their M&M conferences. I had this post planned out for several days since our program is just making the switch and I think it is going to be an awesome tool. So what if you aren't in a residency and don't have M&M conferences? Take a close look at it, because it very nicely illustrates a method to investigate errors and suggest potential solutions. Here we go.

The Healthcare Matrix is a tool developed by some brilliant minds at Vanderbilt University Medical Center. They linked the Institute of Medicine's "dimensions of quality," which are safe, timely, effective, efficient, equitable, and patient centered, with the ACGME core competencies for residency programs. Unfortunately for educators, the competencies of professionalism, communication and interpersonal skills, and practice based learning and improvement are very difficult to teach let alone assess. Since you cannot have quality care without quality education and vice versa, this tool attempts to present a formative approach to this problem.

So how is this tool used? First, notice the aims across the top and the competencies down the left side. The first step is to ask a yes/no question about patient care related to the aims. Was the care we gave safe? Was the care timely? And so on and so forth. For each column that receives a "no" answer the specific competency is examined to determine their contributions to the low quality care given to the patient. The final step occurs beneath the green bar at the bottom. In the "Practice-Based Learning and Improvement" row, the user attempts to suggest strategies that can be pursued to improve the system of care.

In an article in the Journal on Quality and Patient Safety, Bingham et al give 2 examples of the matrix in use. In the first case, a resident was asked to provide an account of a case that went poorly. The resident compiled a list of "important learning topics and issues. . ." Here is what the resident turned in:

1. DIC—what is it?

2. DIC in pregnancy—what are the causes?

3. Fibrinolysis in DIC (significance of an in vitro clot test)

4. Local anesthetic toxicity

5. Postpartum hemorrhage with regional anesthesia versus general anesthesia

6. Pulmonary edema secondary to massive transfusion/ volume resuscitation

7. Hypocalcemia from massive transfusion

8. Blood-tinged epidural aspirate—significance?

9. Carboprost, misoprostol, and methylergonovine maleate-indications and uses

10. Third-spacing—can specific IV fluids prevent it?

11. Arterial-line indications—use with massive transfusions or not?

12. Who needs a type and cross? Why does it take 30 minutes?

If you apply these 12 learning points to the matrix, you realize that they only cover 4 of the cells within the matrix, most of which fall into medical knowledge. This is in keeping with the typical discussion that occurs in a M&M conference, with the attending physicians demonstrating how smart they are to the residents who should have "known better."

In this case the resident was then was asked to complete the matrix and this is what was returned:

As you can now see, the resident was able to identify issues within 17 of the 36 cells. Even more importantly, 5 cells fall into the PBLI row and have a HUGE potential for translating into improved patient care.

It doesn't take much imagination to see that the use of this tool will uncover care issues and likely will promote learning as a team. With luck, gone will be the days of severe hindsight bias and the "shame and blame" approach to dealing with medical errors. While the matrix contains a great deal of information, the cellular approach allows for focused learning.

With a little practice, this tool will be easy to use and will provide a nice forum for improving not only M&M but patient care overall.

If you already use this tool, please comment on it and let me know your experiences. I'm looking forward to working with our residents with this tool and any advice will be helpful.

Some Tips:
This is best used as a framework for improvement. Residents seem to do best when they have to relate each cell to their M&M presentation.

All of the cells do not need to be filled. Improvements in learning will occur simply because the tool provides a guide for reflecting on all of the factors related to the case.

Try having the attending and resident each fill out the matrix and see where the similarities and differences occur.

Keep a copy of the completed record the residents portfolio, this is a great tool to document learning of competencies that have been difficult to assess and document that learning has occurred.

Reference:
Bingham JW, Quinn DC, Richardson MG, Miles PV, Gabbe SG. Using a healthcare matrix to assess patient care in terms of aims for improvement and core competencies. Jt Comm J Qual Patient Saf. 2005 Feb;31(2):98-105. PMID: 15791769

Teaching Residents Soft Skills

noreply@blogger.com (Rob) — Wed, 26 Jan 2011 20:32:00 +0000

Professionalism. Communication. Empathy. Skills needed for all physicians. Unfortunately, with the hustle and bustle of everyday work and the "do more in less time" mentality that pervades our practice, relationship skills are often overlooked or frankly ignored. If one was to look at the satisfaction with practice in emergency medicine, they would find a significant amount of burnout and unhappiness with practice. Keeping this in mind, how do you work with residents to teach them the soft skills which lead to the rewarding practice of medicine and a more satisfying relationship with patients?

Wright et al set out to identify a list of practices that lead to a more fulfilling practice life. The list that they have created captures behaviors and attitudes that may help achieve this goal on a personal level. Even more helpful to the educator, the list creates a wonderful set of tasks that you use to help a trainee assess themselves and continue on the journey to personal and professional growth.

To use the list, I've begun to create a set of cards, each containing one precept. I like to start a shift by asking the resident what they want to learn on that particular shift. I often find that their list is somewhat generic, such as "I want to work on my procedures." Instead, by pulling out these cards resident can pick any card and suddenly we have a simple task to practice. I can then observe their behavior and offer simple feedback on their success with the task.

The list can be customized, expanded, and is designed to change as medicine changes. Look it over and try it out. I think that you'll find it helps both the learner and the teacher. As Robert Heinlein pointed out, "When one teaches, two learn."

The List:

Promotion of relationships with patients
1. Greet patients by their names, tell them you name and your role in their care
2. Smile
3. Sit down when talking to patients
4. Listen
5. Be wholly present when interacting with patients and avoid unnecessary interuptions
6. Learn who your patients are and consider sharing something about yourself with them

7. Show the utmost respect for all patients

8. Be humanistic, compassionate and caring

9. Even if it is a struggle to think positively of a patient, always speak of them in a positive way; this will influence your thinking positively

10. If you are feeling negative emotions towards a patient, try to understand why you are feeling this way

Principles of the effective clinician

11. The history and physical examination are not like a biopsy fixed in formalin, but are dynamic entities that should be revisited frequently

12. A patient’s history should not be “aspirated”; it should instead be “built” purposefully with effective communication skills

13. Be curious – seek to find out exactly how and why events occurred and do not accept diagnoses and conclusions made by others

14. Recognize the patient as teacher

15. Elaborate a differential diagnosis that is as broad as the history and physical examination dictate

16. After forming a diagnostic hypothesis, focus on any symptoms or signs that are either atypical or incompatible with the diagnosis; these must be explained and not ignored

17. Always consider and exclude catastrophic treatable diseases

18. Continually strive to improve your diagnostic skills by mentally committing to a specific answer or conclusion before definitive testing

19. Watching patients walk is a critical component of the physical examination, particularly if their level of function is compromised

20. Look at the sacrum and heels of any patient who is bed-bound

21. Think about and plan for how to best deliver the information before telling important news to patients about their health

22. Explain medical concepts in simple language; avoid medical jargon and make sure that the patient understands

23. Teach patients what they need to know to make an informed decision

24. Strive to become a healer

25. Solicit help when you are stumped or at a loss in caring for a patient

26. Review your patient’s drug list and require explicit justification for every medication

27. Remember that the ill patient is not at his best

28. Do not discuss patients in public places (eg, elevators)

29. Appreciate the contributions of all members of the health care team

30. Try to be as organized as possible – be prepared and be thorough yet efficient

31. Focused reading to answer specific clinical questions is more nourishing leafing through a current issue of a medical journal

32. Know that much practice, reading, and years of hard work are essential parts of becoming an excellent physician

33. When you have made a mistake in the care of a patient, follow these steps: (a) admit it, (b) inform the patient, (c) if possible, initiate reparation, (d) institute a mechanism whereby you will not repeat the error, (e) attempt to establish a mechanism whereby others in the system cannot make the error, (f) forgive yourself

Growth and improvement

34. Strive to achieve personal awareness and an understanding of your beliefs, values, and attitudes

35. Recognize and acknowledge powerful experiences

36. Seek out and embrace helping relationships

37. Make time for reflection

38. Observe other physicians carefully and learn from role models

39. Realize that people are watching you closely – strive to be a role model for others

40. Be creative and innovative

41. Try to look into an accurate mirror

Values to guide one’s career in medicine

42. Avoid being cynical

43. Understand that medicine is a public trust

44. Be humble

45. Be ethical in all of your work as it relates to the profession of medicine

46. Aspire to become a great teacher

47. Stand up for what you believe in

48. Aim for a comfortable balance between your personal and professional lives

49. Try your best

50. Continually search for meaning in your work in medicine

51. Celebrating successes may help to avoid burnout

52. Be thankful and happy that you are in medicine

Reference:

Wright SM, Hellmann DB, Ziegelstein RC. 52 precepts that medical trainees and physicians should consider regularly. Am J Med. 2005 Apr;118(4):435-8. PMID: 15808145

Deviant Skill: Mindful Practice Part 2

noreply@blogger.com (Rob) — Wed, 26 Jan 2011 12:53:00 +0000

In the last post, we covered the types of knowledge relevant to clinical practice. Now, we're going to delve into exactly what mindful practice entails.

Mindfulness is an extension of reflection. Mindful practice involves being mentally aware of action, thoughts, sensations, images, and emotions.

A quote from the cited article that explains the theory of the practice so well:

"mindfulness leads the mind back from theories, attitudes, and abstractions. . .to the situation of experience itself, which prevents us from falling prey to our own prejudices, opinions, projections, expectations and enables us to free ourselves from the straightjacket of unconsciousness."

Wow, deep stuff! I love the mental image of the straightjacket of the unconsciousness. Mindful practice may derive from a philosophical basis but in practice is just active reflection on mental processes.

The goal then is to become aware of your mental processes. To do this you must:

-Listen more attentively

-Become more flexible

-Recognize bias and judgement

-Act with principles and compassion

-Have curiosity about the unknown

-Be humble about the imperfect understanding of another's suffering

Consider the following: a resident is having difficulty with an intubation that you are supervising. What options does he have? He has to weigh the humiliation of admitted incompetence, the loss of self esteem related to said admission, and the pride of knowing when to ask for help. If he isn't a student of mindful practice then he will learn little and will probably blame himself or the patient for his failure. If instead, he is mindful, he will reflect on the factors that influenced his failure, such as technique, patient factors, choice of position, choice of tools, etc, and will be mentally and technically ready for the next intubation.

Mindlessness, on the other hand, is responsible for many of the negative deviations in clinical practice. This behavior seems to pervade the more emotionally involved or high pressure situations. In emergency medicine, this may be due to attempts at efficient flow, feeling of being overwhelmed, or a desire to avoid admitting incompetence.

There are a variety of ways to become mindful.

-Keep a journal of reflection

-Practice meditation

-Review videotapes of sessions of yourself with patients

-Create personal learning contracts when deficiencies are discovered

-Evaluations, both self and peer created

-Critical incident reports after an error

Ultimately, becoming mindful takes time and practice which is why it is probably viewed as an expert skill. As educators, we can begin to teach these skills. We can ask our students questions to make the unconscious conscious. How do feel about this patient? What are you uncertain about in this case? How will address your feelings of revulsion about this particular case?

Barriers to mindfulness are many. In emergency medicine, we are victims of mental and physical fatigue, pressure to do more with less, patient anger and unreasonable expectations, and more. All of these can lead to close mindedness and resentment of practice.

As you can see, becoming a mindful practitioner is within reach of all of us. Despite the many challenges, simple awareness and practice of this skill will lead you toward better patient care and becoming the ultimate "positive deviant."

As mindful practice is easier with guidance, has anyone out there practiced this in any form? I would love to hear insights from active practitioners who could provide tips and tricks to accelerate learning these skills. Leave a comment!

Reference:
Epstein RM. Mindful Practice. JAMA. 1999 Sep 1; 282(9): 833-9. PMID: 1047868

Deviant Skills: Mindful Practice

noreply@blogger.com (Rob) — Tue, 25 Jan 2011 22:35:00 +0000

Want to take your expertise to the next level? Do you really want to become a deviant? To do so, then you must become a student of "Mindful Practice." In this post, the first of two parts, I hope to explain about types of knowledge present in medical practice. In part 2, I will explain the nature of mindful practice and mindless practice.

Mindful practice is a term that is applied to a practice used by elite clinicians. At it's most basic, it is critical self reflection. Unlike normal reflection, used at the end of a process, mindful practice is experienced in real time.

It is the ability of a physician to listen attentively to a patient while recognizing personal biases in play; it is the ability to recognize and correct for mistake, refine technical skills, make evidence based decisions, and act within a personal value system. It allows the practitioner to act with the highly desired skills of compassion, competence, and insight.

In practice, there are 2 types of knowledge that we use: explicit and tacit. Explicit knowledge we all know and love. It is the conscious application of rules or objective data to a patients condition. It also tends to be easily quantified and studied. Tacit knowledge, on the other hand, tends to be unconscious and not easily studied. It is gestalt at its finest. Think about riding a bike. As you ride, you make adjustments for speed, position, and direction almost without thinking. In a similar fashion in emergency medicine, a expert can walk in the room and determine that a patient is septic before having objective data before them to confirm their suspicions.

This ability is the result of preattentive processing by the brain. Essentially, the unconscious mind of the expert is evaluating perceptions and features and relegating some information to the background, all before these thoughts are made conscious. There are many tasks in medicine that fall within this behavior: realizing that a patient has provided enough history to make a diagnosis, proper depth of insertion of a laryngoscope, or manipulating a hip to reduce a dislocation.

Unfortunately, this tacit information is very difficult to teach and is learned instead through practice and observation. While many of us practice some form of evidence based medicine, the tacit knowledge of an expert takes the evidence and adds to it the messy details:

-Cost

-Context

-Convenience

-Patient Values

-Personal emotion

-Bias

-Prejudice

-Risk aversion

-Tolerance for uncertainty

-Personal knowledge of the patient

The awareness of this process remains relative unconscious to the expert and continues to demonstrate how judgement is both a science and an art.

In addition to tacit and explicit knowledge, there are also some domains of knowledge that we all have:

Propositional: fact, theories, concepts, and principles

Since this knowledge often comes from books and instructors, we need to be self aware of what we know and do not know. We also need to appreciate the transient nature of this knowledge as it is constantly changing

Personal: knowledge gained through experience; intuition, personal interpretation

This knowledge is often neglected during training due to confusion between personal knowledge and anecdote. Consider uncritical application: What if you missed a pulmonary embolism and subsequently ordered a d-dimer on every patient with pain or shortness of breath? This is application of an decontextualized anecdote. We see this all the time in medicine. How many of you have been taught: "Any patient with an elevated WBC count and belly pain gets imaging." Compare instead the physician who increased their tacit knowledge by self reflection that made them aware of the processes and thought that led to the misdiagnosis and allowed them to recognize the error in the future.

Process Knowledge: knowing how to accomplish a task, gathering information, procedures, etc

This includes the knowledge of metacognition, or thinking about thinking. Process knowledge allows us to modify actions, whether diagnostic or procedural. Reflection on processes also all us to gain insight into our blind spots. It uncovers "unconscious incompetence."

Know How: knowing how to get things done

Remember your first month on the real job? You probably we a fairly inefficient physician. Know how is knowing not only what test to order, but that communication with all involved parties, i.e. nursing or radiology may get the test completed sooner.

So now that we know what knowledge is, how do we become mindful to using it to become a positive deviant? In the next post, I will cover the characteristics of a mindful practitioner and cover the dreaded opponent: mindless practice. Stay tuned!

Reference:
Epstein RM. Mindful Practice. JAMA. 1999 Sep 1; 282(9): 833-9. PMID: 1047868

Patient Safety: Whose Job Is It Anyhow?

noreply@blogger.com (Rob) — Thu, 20 Jan 2011 11:00:00 +0000

Today I went somewhere that I've never been before. Despite working my job in the emergency department for the last 2 and a half years, I had never been to the medical staff dining room. As I perused the bulletin board filled with newspaper clippings of local physicians in the news, I came upon a letter to the editor written by a physician somewhere in the midwest.

The headline made reference to airlines and checklists and caught my eye right away. Unfortunately, the writer used his podium to rail against the current patient safety movement. He made fun of checklists, insisted that an "airline" style of patient safety is too expensive and manpower intensive, and, in general, failed to acknowledge medical errors are a huge issue!

Reading though to the end, I was disappointed that the authors' narrow view misses the fact that if we are to improve patient safety, we all must focus on change. The airline industry is often held as an example because of the remarkable record of safety. It wasn't always this way. In the late 1970's, a spate of incidents caused the entire industry to take a critical look at their processes and design new ways to deal with the errors. Checklists, team training, simulation, process redesign, and multiple other safety innovations were the result of their efforts. They took the time to test their ideas and redesign them. In short, they changed, and they're still doing it!

Medicine can learn a lot from their efforts. The message isn't that 2 doctors (pilots) per patient (plane) with 3 nurses (hostesses and hosts) and a host of support staff armed with checklists will make care safer. The message is that we need to study our processes, learn about the latent conditions that predispose us to err and make changes to eliminate them. We can create tools to improve care. These may be checklists but they're not the only tool to use. We can study staffing and it's effects on waiting, technology, teamwork, and more. This list goes on and on. Perhaps the best thing we can learn from the airline industry isn't about the tools they use, but the methods they used to create the environment in which all players want to be a positive deviant. After all, being ahead of the curve when it comes to refining the process of providing safe care is at the heart of our oath towards humanity: "Primum non nocere, or first, do no harm."

Formula One and Patient Handoffs

noreply@blogger.com (Rob) — Mon, 17 Jan 2011 23:26:00 +0000

Gentlemen, start your engines! Who can resist the high octane, high speed formula one races? Okay, maybe a lot of people could care less about these high stakes races but if you look closely at a successful race team, some patterns of excellence begin to appear that have crossover lessons applicable to medicine. This was recognized by some British physicians who recently published a their experience in using the lessons learned to improve patient handoffs.

Handoffs have become a real hot topic in medicine. With the increase in resident work hours restrictions, handoffs have been identified as one of the more hazardous times in patient care.

This study was an interesting prospective intervention looking at performance change before and after the introduction of a standard handoff protocol. The specific protocol was designed to look at the transfer of a child after surgery for congenital heart disease to the ICU. Before the researchers began their protocol design, they spent a day with the Ferrari F1 racing team at the team headquarters in Maranello, Italy. (How can I sign up for this?)

Why Formula One? The pitstop in Formula One racing is a great example of how a multiprofessional team functions together under high stakes conditions to perform a complex task with minimal error. Think about it: stop car, jack it up, change 4 tires, fully fuel it, clean the drivers visor, drop the jacks, and back to the races, all in about. . .7 SECONDS! Needless to say, the lessons to be gleaned were many and became the basis for the new protocol.

To be truthful, the actual results of this study are not nearly as interesting as the lessons that they learned. Their protocol did result in a decrease in errors to be sure: technical errors went from 5.42 to 3.15, information omissions dropped from 2.09 to 1.07, multiple errors dropped from 39% to 11.5% and so on, but I digress.

So what did they learn that is useful to us?

Leadership: In F1 racing, there is a "lollipop" man who coordinates the entire procedure. How many of you walk into a trauma resuscitation and know who will lead the team, what resident is doing what, which nurse is on monitor duty, drug administration duty, or documentation duty? In this particular study, these roles became defined.

Task Sequence: In racing as well as aviation, the order of events is known. In handovers we are terribly inconsistent with our information. We often have no set sequence to follow leading to omission of critical information. This study broke a critically ill patients transfer into 3 phases: equipment and technology handover, information handover, discussion and plan. This allowed the team to focus on specific transfer issues and markedly decreased technical handoff errors.

Task Allocation: In racing, each team member does only 1 or 2 tasks. Need I make a reference to medicine? In the study protocol, when a transfer took place, people were assigned a specific task who were identified to receive the critical information about their task, ie ventilator, pumps, drains, monitor, etc.

Predicting and Planning: In racing, there is a method used called Failure Modes and Effects Analysis which allows breakdown of tasks and risks to predict problems. Use of a similar tool allowed these researchers to identify and refine safety checks and develop tools such as a ventilator transfer sheet to streamline the transfer of care.

Discipline and Composure: In racing, there is little to no verbal communication; the whole stop only takes 7 seconds. In medicine, handovers can be chaotic, with multiple people trying to give information to others at the same time. The nurses rarely know what the docs say to each other and vice versa. Having the discipline to allow one practitioner to talk uninterrupted can minimize the loss of information during a handoff.

Checklists: Well established in racing and aviation. I'll be posting more on this later, lots more. . .

Involvement: More of an aviation trait, but all team members are trained to speak up with concerns. In medicine, we have a long way to go to improve this area. Simply encouraging the behavior as part of the protocol was how this particular study addressed the issue.

Briefing: Again, well established in racing and aviation. In the emergency department, I rarely see this employed. Multidisciplinary handoffs are far from the norm and are potentially a rich area for improvement.

Situational Awareness: The previously mentioned lollipop man has this responsibilty in racing. Being at the front of the car, the driver doesn't go until he or she gives the okay. Identifying one person to stand back and make safety checks when handoffs occur or other chaotic processes such as codes can improve the overall situational awareness.

Training: Racing and aviation are fanatical about training and repetition. Despite being experts, the pit crew practices time and time and time again to improve their skills. Pilots routinely make trips to the simulator to practice the usual and unusual situations they may face. In the study, they found that staff turnover limited the ability to train. This situation is so common in emergency medicine as well. Instead of long and grueling training, this study focused on a simple process that could be learned in 30 minutes and made helpful training sheets available at EVERY bedside as a memory prompt.

Review Meetings: In racing and aviation, review of past actions is a way of life. Creating an open forum to frequently review problems and suggest solutions will promote lasting change in medicine. Everyone from residents, nurses, docs, and ancillary staff should be encouraged to attend and provide input.

Handoffs are a way of life in emergency medicine. It's pretty easy to look at this study and see parallels that would make our practice safer for patients. Simply focusing on improving the culture in one or two of the themes above will yield exciting dividends in the long run. Are you in?

Reference:

Catchpole KR et al. Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality. Paediatr Anaesth. 2007 May; 17(5): 470-8. PMID: 17474955

For My Mentor: My Favorite Apps

noreply@blogger.com (Rob) — Sat, 15 Jan 2011 20:01:00 +0000

If one wanted an example of a positive deviant, i.e. a person on the leading edge of the bell curve, in emergency medicine education, Michelle Lin, MD would top the list of potential candidates. I am very fortunate to look to her as a friend and virtual mentor as I develop as an academic clinician. She has her own amazing blog: Academic Life in Emergency Medicine, which you need to check out now if you haven't already. Recently, she put out a request for clinicians to report on their favorite apps for a presentation she is working on. I figured this would be the least I could do to help out.

In no particular order:

DropBox: This is a great "cloud" file hosting app and program. Download both to take full advantage of the program. The program works just like a usual folder on you desktop but once a file has been placed inside, it syncs with the cloud and your files magically appear on any computer or device that has dropbox installed. Also, you can share your files. I recently uploaded an entire folder of "Resident as Teacher" articles to share with another EM guru. This prevented me from having to attach lots of files to an email and send them to him.

Evernote: Michelle has talked about this app at length but I figured I would share my .00002 cents as well. Evernote is my go-to note program. Like Dropbox, use the desktop program in addition to the app. It allows you to add PDF files, pictures, and free text and then put them into notebooks, tag them with memory clues, and free text search them. Here's the real sweet part though: the company has made add ons for your internet browser that allows you to "clip" an entire webpage of portions of text from online and saves it to the program automatically.

Medical Mnemonics: This program is a lot of fun. I often have a hard time remember mnemonics which makes them more difficult to use. Not any more. This app lists them all and also allows you to use your own. You can also search by condition: Ranson Criteria anyone? GA LAW comes right up. For more "mnemonically" oriented learners, I can share this with them to their hearts content.

MediMath: The app has calculators galore. It's almost as good as mdcalc minus the clinical risk stratification tools that are located on that site. Its interface is quick and easy to use.

Persiflagers Annotated Compendium of Infectious Diseases: One of my two antimicrobial guides. This app is written by an infectious disease specialist with a wonderful sense of sarcastic humor that he writes into his advice on treatment in the form of Rants. For example: Necrotizing Fasciitis and hyperbaric therapy, "I said it was great for the bends, but primarily served to make hyperbaric doctors richer. Why do you ask? Turns out he was the medical director for a hyperbaric chamber. Oops. Open mouth, insert foot." Beyond the therapy, his recommendations are up to date and cover the spectrum of possible causes.

Radiology 2.0: One Night in the ED: This is a case based app that reviews pathology on abdominal and pelvic CT scans. The images display beautifully on the iphone and even better on the ipad. If you have a learner who wants more, sit them down with this for a few minutes.

Perfect OB Wheel: The best OB Wheel I've found. It lets you enter the due date, LMP, or even the current weeks and gives you the remainder of the missing information. It also gives you an estimate of the fetal size. Pretty cool.

PediSafe: This one is an ipad only app but is really pretty spectacular. It takes the Broslow Tape colors and gives you all the information up to 99 kg! That would be a VERY big kid. Apps like this one really have helped make practicing medicine a little safer.

Neuromind: Written by a neurosurgeon, this app contains all the neurological scores you need. Also included are some nice anatomical diagrams to demonstrate relevant anatomy, dermatones, etc.

GoodReader: This is another ipad only app but is my favorite reader. Since our curriculum is so heavy on literature, I read a LOT. This program helps me to save paper and my notes since I can highlight, markup, and add notes to the PDF files.

Eye Handbook: A great reference to all things ophtho. I like the toolkit is contains as well as atlas to help demonstrate the exam findings that I discuss with my residents.

Epocrates: I think everyone knows this app and either uses it or chooses not to. I'm in the former group. I like the fact that I can do an interaction checker through it as well.

Stroke Track: Written by an EM physician and it shows. The app gives you all of the contraindications to tPA use and puts a real time NIHSS calculator in your hand. It even gives you hints on how to perform the exam!

SlowMo: I learned about this app from Scott Weingart, MD, of EMCrit fame. A few podcasts back he talked about vestibular stroke and physical exam findings. One of the problems with the exam is actually seeing what the eyes are doing. This app allows you to slow down a video taken on your iphone/ipod touch and see exactly whether the reflex is expected or pathological.

EMRA Antibiotic Guide: My second go to antibiotic reference. Simple, well thought out, and designed by the future leaders of our professional. It's updated annually.

Emergency Medicine Ultrasound: A nice little gem of an app. I recently came by this one and have found it useful to teach residents about ultrasound. It includes video in addition to still pictures and text.