Hot off the press: Google Voice account using your existing phone number

Just a few days ago, Google Voice has opened a new option such that you can use your own phone number to enable several cool options. Request a free invitation here.

Let me step back a bit and explain what Google Voice is. Google Voice is a FREE service, which essentially converts your voicemails into emails. What is cool is that it transcribes your voicemails into text and then sends it to your personal email account! By getting a new phone number, assigned by Google, this service goes above and beyond with features such as:

• One number: a single NEW phone number that rings all your phones
• Free SMS: send, receive & store text messages online
• Block calls: send unwanted callers straight to voicemail
• Record calls: record phone calls and store them online
• Conference calls: join several people into a single call (max 4 people)
  
• Screen callers: hear who is calling before you pick up

I personally didn't like this, because I want to keep my phone number. But now there is a new option to KEEP your number, while retaining the transcription service. This is perfect for me.

My Visual Aid Photographer capturing a
glimpse of our elaborate ED Halloween decorations.

Imagine working in an ED where the walls are so insulated that you can't get any phone reception service. Yes, this is where I work. I occasionally get a one-bar signal on my iPhone. My phone knows just enough that someone is calling but I can't connect. So I get "missed call" and "voicemail" notifications frequently. Frustrating to say the least.

Now I can just check my voicemail using Google Voice.

Another interesting feature is that Google can connect your call for free anywhere in the U.S., supposedly without using minutes from your phone plan. Here's a snapshot of this feature from my Google Voice page.



Check out the informational video from Google:

MERC - Strengthing your educational research skills

Educational research traditionally is a "fuzzier" science than clinical and bench research. These studies often have to work around intangible human dynamics and variables. The unique aspects of educational research has led to the development of the Medical Education Research Certification (MERC) program, sponsored by the Association of American Medical Colleges (AAMC).

The MERC curriculum consists of a series of workshops in educational research. This has been slightly adapted by the Council of Residency Directors (CORD) in EM. The entire curriculum consists of 11 key workshops.

• Getting Started in Medical Education Research/ Formulating Research Questions and Designing Studies
• Searching and Evaluating the Medical Education Literature
• Hypothesis-Driven Research
• Data Management and Basic Statistics in Education Research
• Reliability and Validity of Educational Outcomes
• Institutional Research Boards and Ethics
• Qualitative Research Methods
• Scholarly Writing
• Program Evaluation and Evaluation Research
• Questionnaire Design and Survey Research
• Capstone (to end the program)

How can I go beyond a satisfaction survey to determine if my educational intervention translates to improved patient care?

The first two workshops will be held on the Pre-Day (March 2, 2010) of the 2010 CORD Academic Assembly in Orlando, FL. The third workshop (Hypothesis Driven Research) will be held on March 5, 2010 at the same CORD meeting.

I'll be facilitating a small-group session on educational research on the Pre-Day. Small groups will be formed to discuss individual research projects and ideas. My table will specifically focus on studying the educational uses of technology. If you are interested, please come and join! This is a great opportunity to network and hear of other exciting educational research projects at the ground level.

Trick of the Trade: Super-sensitive to eyedrops

We commonly encounter ocular complaints in the Emergency Department. Eye pain can result from chemical exposure, a foreign body, or infection. The first step involves instilling a few drops of topical anesthetics, such as proparacaine, to provide some pain relief. Occasionally, however, you encounter a patient who just can't keep his/her eye open because of the fear of eyedrops.

Trick of the Trade
Instead of dripping the anesthetic directly onto the cornea, gently trickle-in the liquid. To do this, first position the patient such that his/her nose is pointing towards the ceiling. Keep the patient's eye closed. Apply several drops of the anesthetic into the medial canthal well. The solution will slowly work its way under the eyelids to anesthetize the eye.

SurveyMonkey is the key to building quick surveys

Need a quick way to obtain anonymous assessment of a conference lecturer from individual audience members?

Need a quick online application where you can collect user demographic information?

Need to build a quick survey on how medical students felt about a new curricular change?


A few years ago, I learned about SurveyMonkey-- a versatile and user-friendly online survey-building service. I have no financial ties with the company. For only $200 annually, I love the fact that I can build an infinite number of surveys. The data is automatically collated and I can download in Excel format. If your department doesn't have access to this yet, it might be worth looking at.

To give you an idea of a sample layout, check out this survey that I built in 15 minutes. I would like to assess the utility and effectiveness of my microsimulation DIEM case for CDEM. Don't worry about accidentally entering data. I'm clearing the test data after I start the official launch of the DIEM case. Suggestions and comments welcome on this first-draft survey layout!

Click Here to take survey

Currently, our SurveyMonkey site houses such tools as:

• Previously, I used this to collect our weekly EM residency and weekly medical student conference lecture evaluations.
• Monthly faculty evaluations of off-service residents who rotate through our EDs
• Monthly evaluations of faculty by medical students, interns, and residents
• Application for medical students to get a CDEM's E-Advisor
  
• Application to become a CDEM E-Advisor
  
• Schedule request for our Research Internship Program for SF State University
  

Article review: Bedside teaching in the ED

Bedside teaching is a unique educational skill, which academic faculty are often assumed to just know how to do. In the ED, it is especially difficult to do this well, because of crowding and unexpected time-sensitive clinical issues, which create distractions and general chaos. Experientially, unpredictable clinical issues negatively impact bedside teaching. Thus, faculty should be flexible and knowledgeable of basic bedside teaching tenets.

A good friend of mine, Dr. Mike Gisondi (Associate Program Director at Northwestern) co-authored this much-needed faculty development review paper on bedside teaching in Academic Emergency Medicine in 2006. Mike was the resident on my very first shift as a faculty member at SF General! I was fresh out of residency and lucked out having Mike on shift with me.
The authors provide 10 building-block strategies to improve your bedside teaching:

1. Plan the teaching session BEFORE the shift. Select a few teaching points on common chief complaints or classic high-risk conditions. I often focus on either (1) first-trimester bleeding or (2) walking the learner through central line placement using a sample kit. Take advantage of any free moment to do a little quick teaching.
   
2. Know one's team and their goals. Are your learners senior medical students? Pediatric interns? Family practice residents? Senior EM residents? Asking them what they'd like to learn more about for that one shift guarantees more learning buy-in from your team members. For instance, I have noticed that our pediatric interns want to learn more about wound closure such as suturing, stapling, and tissue adhesives. So I keep a lookout for laceration cases for them.
3. Choose the right time to teach. Don't feel like you have to be teaching all the time. Obviously, acutely ill patients requiring immediate medical attention should trump bedside teaching. Having the learner observe your actions and interactions, however, is still a valuable observational learning period. Whether you realize it or not, you are teaching. For more stable patients, you can preview patients' chief complaints in the triage notes and pre-plan your 1-minute teaching session while the learners are seeing the patients.
4. Set realistic expectations for yourself. Start slow. Pick only 2-3 topics to teach each day. For example, pulmonary embolism and aortic dissection should be at least briefly considered in all chest pain patients. With more experience, you will become more comfortable and efficient with bedside teaching, and your bedside teaching repertoire will naturally expand.
   
5. Limit the amount of time with each patient. You don't have to teach every medical concept for each patient. Let's be realistic! Pick 1 concept and discuss a little more in-depth. This is a crucial strategy to remember. Teaching 1 concept well is much better than glossing over 5 concepts, overwhelming the learner, and slowing down the ED flow.
6. Be professional.
7. Use the Socratic method with caution (if the patient is present). Making the learner look bad in front of the patient may negatively impact the patient-physician relationship for the learner. If you use the Socratic method, try to ask questions of other team members in the room - not the actual primary provider.
   
8. Summarize and evaluate. After each patient case, summarize what the learner has learned to solidify the educational process. Also, don't forget to give feedback to the learner at the end of shift. This is a form of teaching also.
9. The "teach-only" attending. Because the clinical pressures in the ED constantly are at odds with bedside teaching time, some institutions have a teaching attending. This faculty member's sole responsibility is to teach learners. S/he has no clinical responsibilities that day. This teach-only attending can do bedside teaching, give 5-15 minute didactics, and/or teach a brief procedural workshop. This attending can also observe learners and provide immediate feedback on their clinical skills, professionalism, and efficiency.
10. Train residents how to teach at the bedside. Having senior residents as near-peer teachers has been shown to be extremely effective in an Internal Medicine clerkship. I can't wait to have UCSF-SFGH EM senior residents! We are currently recruiting our third class in our 4-year program.
    

Reference:
Aldeen AZ, Gisondi MA. Bedside teaching in the emergency department. Acad Emerg Med. 2006 Aug;13(8):860-6.

TGIF: What photos are on my iPhone?

Curious what photos are on my iPhone recently? This isn't really relevant to academic EM, but I'm tapped dry for topics this week. If you have any suggestions for things you'd like to read about, please let me know!

Slow day shift: "Clear!"

View from Starbucks window before my
"Topics in EM" CME talk.

View of Union Square from 16th floor suite in

Saint Francis Drake hotel for my Tricks of the Trade
workshop at "Topics in EM" conference.



Building $10 solar-panel LED light jars.
Could have used them on the stormy evening when the
ED lost power for a few minutes...

How to successfully "manage" a project

My training to be an emergency physician never included how to be a project manager. This is surprisingly a lot of what we do in academics -- overseeing projects led by really enthusiastic medical students and residents. I have had some really great self-driven collaborators and some really (ahem) not-so-great collaborators.

Yesterday, I attended a small-group Faculty Mentor (a.k.a project manger) orientation session at UCSF, because I'll be helping a medical student build a legacy project specifically in the field of medical education. She has chosen to build an online, Flash-based, multimedia module for EM clerkship students on the topic of "Approach to the patient with shock". This will supplement the 2 Virtual Lectures that I already have - Chest Pain and EKG Interpretation.

We will incorporate a survey looking at whether the students prefer this online learning approach. Furthermore, we will conduct a cohort study assessing the students' medical knowledge on shock as compared to historical controls.

The most useful part of the session involved (1) getting to know the amazing and humbling educational research resources around at UCSF and (2) a faculty development writeup on how to manage students who are working on longitudinal projects under your guidance. The latter is really easier said than done, because everyone gets busy and project momentum is hard to keep up.

The Project Management Template handout, created by Christian Burke, Dr. Carrie Chen, and Dr. Tracy Fulton breaks up project development into 4 stages, each with its own laundry list of questions that should be addressed by the mentor and mentee. The sample questions I picked out are especially to relevant to me, based on past projects gone a little awry. Think about how this list might have made your last collaborative project better, whether you were the manager or the student.

1. Define the project

• Why is this project necessary?
• What are the crucial deadlines? Build the project timeline starting with that and work backwards.
• How will you measure the results of your project?
• Are your project goals realistic in the defined time frame?
• Do you have all your project team members in place to successfully carry out the project?
  

2. Plan the project

• List the critical tasks that need to be accomplished.
• What are the rate-limiting tasks (i.e. applying for IRB research approval)?
• What obstacles do you anticipate in the project?
• What resources are needed?
  

3. Execute the project

• How often do you plan to meet and in what format (in person, phone, videoconference)?
• How will you, as the project manager, constantly monitor progress?
  
• When will you meet to check in on the work-in-progress to make sure things are on track?

4. Closure

• How will the project be used in medical education?
• How will you evaluate your project to determine usefulness and efficacy?

The most practical words of advice that I have are:

• Be sure the scope of the project is feasible and narrow enough. Projects always take 300% more time and effort than people expect.
• Constant check-ins of how the project is progressing is key. I think I'm going to request weekly updates either via email or an online e-Portfolio system called Mahara.
• Build a timeline early on in your discussions.

Tricks of the Trade: Low tech solutions to esophageal foreign bodies

Doxycycline pills

Patients can present to Emergency Departments with esophageal foreign bodies. Recently, a patient presented with a doxycycline pill stuck in her esophagus at the mid-chest level. She was taking it for pneumonia. Despite drinking deluges of water for the past 12 hours, the pill remains stuck. You know that doxycycline is one of several medications (along with iron or potassium supplements, quinidine, aspirin, bisphosphonates) known for causing erosive pill esophagitis.

She presents to your ED.
What do you do?

With so many direct visualization tools in the ED now available to emergency physicians such as Glidescopes and nasopharyngoscopes, you might be tempted to take a look. However, you can first take a low-tech approach to propel the pill into the stomach. Each of these options has its unique risks and complications, and the risks/benefits should be weighed appropriately.

• Glucagon IV - relaxes lower esophageal sphincter (LES)
• Nitroglycerin SL - relaxes LES - beware of acute hypotension
• Nifedifine SL - relaxes LES - beware of acute hypotension
• Carbonated beverage PO- gas forming agent to increase intraesophageal pressure

Instead of pharmacologically moving the pill into the stomach, you can also consider mechanically pushing the pill down using an orogastric tube or blindly pulling it out through the mouth using a foley catheter.

Trick of the Trade: What did we do?
Before we entertained the pharmacologic options, we gave the patient a can of Ensure, because it has a higher viscosity than water. Fifteen minutes later, the pill was pushed into the stomach and the patient's foreign-body symptoms resolved. A simple $1.50 solution.

Teaching point
Tell all your patients receiving doxycycline to drink plenty of fluids when taking the medication.

Caveat
These low-tech solutions are only appropriate for pill foreign bodies and impacted food boluses in the esophagus, which are at low risk for esophageal perforation. These are NOT applicable to special situations such as button batteries, sharp objects, fish/chicken bones, and coins.

Topics in Emergency Medicine CME Course

"Topics in Emergency Medicine" is one of two national CME courses that our UCSF department hosts annually, in addition to "High Risk Emergency Medicine" every May. This week Topics is being held in the fancy-schmancy Sir Francis Drake Hotel in San Francisco. It has an amazing line-up of speakers, most of whom are from UCSF and San Francisco General Hospital (SFGH).

I just gave a lecture yesterday on High Risk Back Pain, which focuses on key history and physical exam elements, imaging options, and advanced concepts in the 4 red flags of back pain (spinal fracture, cauda equina syndrome, spinal infection, and vertebral malignancy). My talk incorporates Flash-based modules, such as on the topic of reading thoracolumbar films. Basically, you should use an ABCS approach:

• A- Alignment
• B- Bone
• C- Cartilaginous (i.e. disk space height)
• S- Soft tissue

Thoracic spine

• A- Anterior and posterior vertebral line
  
• B- Vertebral body, pedicle, lamina, facet jt, spinous process
  
• C- Intervertebral disk space
  
• S - Paraspinous stripe
  

Lumbar spine

• A- Anterior and posterior vertebral line
  
• B- Vertebral body, pedicle, lamina, facet jt, spinous process
  
• C- Intervertebral disk space
  
• S - Psoas shadow
  

Article review: Handoffs in the Emergency Department

One shared experience amongst all emergency physicians is the "handoff" or "signout" of patients at the end of your shift to the oncoming physician. A recent article in Annals of Emergency Medicine explores and explains how this process can often lead to delays and errors in patient management. Just envision ED handoffs as a high-stakes game of Telephone, which you played as a child.


Sentinel events involving medical errors often can be traced back to errors in communication. A particular high-risk window is during patient handoff. Interestingly, poor handoffs were at the root cause of 24% of malpractice claims in the ED. In 2006, the Joint Commission actually published a National Patient Safety Goal paper recommending a standardized approach to handoffs for this very reason.

There are 4 phases in handoff practices:

1. Pre-turnover time - Physician A getting ready to go off-shift
   
2. Arrival - Physician B arrives for shift
   
3. Meeting - Exchange of info between physicians
   
4. Post-turnover time - Physician B assumes care of patients
   

The ED especially is a hotbed for handoff errors. Examples provided include:

• Signal-to-noise ratio: In a chaotic environment, it is often to discern the important information from the less important during signout rounds.
• No standard approach: Everyone has a different way of signing out. Lack of standardization may make it more difficult for one physician to communication with the other effectively.
• Cognitive bias: The oncoming physician may misinterpret or disproportionately rely too heavily on one piece of information during the handoff process. This "anchoring" bias can sometimes lead to patient management delays and errors.

Standardizing handoffs, however, is easier said than done. No single template fits the spectrum of patient presentations. There are important concepts behind handoffs, which are good to know about to optimize your handoff practices:

• Reduce the number of unnecessary handoffs
  
• Limit distractions during signout rounds: Find a quieter central place to round
  
• Provide a succinct overview: Don't make the critical points hard to discern. It's not meant to be a needle in a haystack.
  
• Communicate outstanding tasks, anticipated changes, and clear plan
• Make info readily available for direct review
• Encourage questioning and discussion
• Account for all patients: Don't forget to sign out the patient who is temporarily in dialysis or ophthalmology clinic.
  
• Signal a clear moment in transition of care

Because there is little evidence in the area of handoffs, this topic is a rich area for new research. Researchers should not only include emergency physicians but also communications experts, pyschologists, and behavioral scientists.

My 2 cents
I have been the giver and receiver of sub-optimal handoffs for a variety of reasons outlined above. Distractions, anchoring biases, and missing data elements have all been contributors (sometimes all concurrently). Here are my thoughts about handoffs:

• I keep handoffs extremely short where I have signed the bottom line of the chart - those whom I have discharged or admitted to the hospital. A simple diagnosis, plan, and potential questions that might come up from the patient.
• I provide a much more detailed presentation for undifferentiated patients. I spend extra time on higher-risk patients so that the oncoming physician has no questions. I consider higher-risk undifferentiated patients as: chest pain, febrile, or age older than 65.
• I present as much of a concise and algorithmic plan at the end. Specifically, I include some version of "if all the tests are negative, I would... ". However, if I am still unsure, I would state that instead. It's far worse to provide premature closure to the patient's workup for the sake of handoff.
• When receiving a patient handoff, I very, very, very rarely change the workup plan. For instance, I recently had a student who asked about canceling an abdominopelvic CT scan for a patient with RLQ abdominal pain because she was feeling much better. It was true - she only had minimal tenderness on exam. However, because the prior physician was impressed enough by the initial tenderness to order imaging, we continued the plan. The CT scan showed perforated appendicitis.
  

What are your handoff pearls?

Reference
Cheung DS, Kelly JJ, Beach C, et al; American College of Emergency Physicians Section of Quality Improvement and Patient Safety. Improving Handoffs in the Emergency Department. Ann Emerg Med. 2009 Oct 1. [Epub ahead of print]

Free EM clerkship primer for medical students

Emergency Medicine as a specialty approaches patients in a slightly different way from other specialties. We first look to rule-out emergent, life-threatening causes of each patient's presentation. Is the headache a subarachnoid hemorrhage? Is the shortness of breath from a pulmonary embolism? Emergency physicians need to be especially skilled in a broad range of clinical knowledge in addition to multitasking, communicating to patients and consultants concisely, and overall efficiency.

So why hasn't there been a specific reference book addressing the unique aspects of EM for the medical student? It seems a bit unfair to ask the medical student, who is new to the Emergency Department setting, to acclimate to the chaotic environment and not get lost in the shuffle.

Thus about a year ago, the Clerkship Directors in Emergency Medicine (CDEM) group put together an EM Clerkship Primer to address these very issues. We wrote a reference manual called "Emergency Medicine Clerkship Primer: A Manual for Medical Students", which is available for free. The project editor was Dr. Dave Wald (Temple), and I was fortunate to be one of the Associate Editors. There are lots of notable contributing authors.

The chapters include:

1. Intro to the specialty of EM
2. Intro to the EM clerkship
3. EM clerkship goals and objectives
4. Unique educational aspects of EM
5. Differences between the ED, the office, and the inpatient setting
6. Undifferentiated and differentiated patients
7. Performing a complaint-directed history and physical exam
8. Data gathering skills
9. Developing a case-specific differential diagnosis
10. Diagnostic testing in the ED
11. Developing a plan of action
12. Diagnosis: Is it possible? Is it necessary?
13. Disposition of the ED patient
14. Discharge instructions
15. Documentation
16. Enhancing your oral case presentation skills
17. Interacting with consultants and primary care physicians
18. Patient satisfaction - meeting patients' expectations
19. Providing anticipatory guidance
20. Procedural skills
21. Suggested reading and other educational resources for med students
22. How to get the most out of your EM clerkship
    

If you are a medical student interested in EM or a faculty advisor, you should download and read this FREE resource. Yes, I said it's free. We received a generous donation from the University of Rochester to hire a copy-editor.

Link: http://www.saem.org/saemdnn/Portals/0/NTForums_Attach/ED%20Primer.pdf

Hot off the press: Tarascon Medical Translation Pocketbook

Go to Amazon link.

At my residency alma mater Harbor-UCLA, my friend Dr. Tim Horeczko (pediatric EM fellow) co-wrote a medical translation pocketbook guide with Dr. Ross Donaldson. I wish I had thought of the idea. This guidebook is so convenient, because doing a 3-way translation through a telephone service every time you have a basic question is a pain. What if you just wanted to ask "Are you having pain right now?" It makes sense that we should have a basic list of commonly-used questions/phrases in various languages.

In this reference, common words, questions, and phrases are translated into 17 languages including: Arabic, Farsi, French, German, Hindi, Italian, Japanese, Korean, Mandarin, Polish, Portuguese, Russian, Spanish, Tagalog, Thai, Ukrainian, and Vietnamese. Check it out!

Just as an example, I took some quick snapshots of the phrase "Do you have pain?" in French, Hindi, and Mandarin. It's hard not to chuckle at yourself when you pronounce these words aloud using the phonetic guide.

French

Hindi

Chinese Mandarin

Trick of the trade: Straightening the guidewire

Did you know that a medical guidewire consists of a flexible central "ribbon wire" externally wrapped with a coil-spring wire?

J-shaped guidewires are commonly used in many medical procedures, such as central lines, arterial lines, and pigtails for pneumothoraces. Knowing more about the guidewire makes it possible to carry out a unique Trick of the Trade. For example, let's say that the plastic introducer is missing or unusable. Using one hand to stabilize the needle in the patient, how do you use your other hand to re-insert a curved guidewire tip into the hub of a needle?


Trick of the Trade:
The J-tip of the internal ribbon wire will straighten out if you increase the external coil density in this area. To accomplish this, stretch the wire just proximal to the J-tip. When you stop stretching the guidewire, the J-tip will magically return. I actually got a little gasp of delight from an Anesthesia intern the other day who couldn't believe her eyes.

See this guidewire trick in action!


Thanks to Lourdes Adame (Visual Aid Project team member) who helped film this quick iPhone video, when I got a free moment between seeing patients.

Faculty highlight: Dr. Lisa Moreno-Walton

A large part of the reason why I love academics so much is that I get to meet really inspiring emergency physicians, who are passionate about their cause. I can't imagine a more dedicated person than my friend Dr. Lisa Moreno-Walton, who is the Associate Program Director at LSU in New Orleans.

Dr. Lisa Moreno-Walton
Associate Program Director, Emergency Medicine
Assistant Professor, Louisiana State Univ Health Sciences Ctr, New Orleans
Clinical Research Scholar, Tulane University

Lisa, I know that you have your hand in lots of areas within Emergency Medicine, but what would you call your niche?
My academic niche is translational research. When I started my residency in EM, I had no clue that I liked research; in fact, I thought it was boring. My mission and my passion was providing excellent clinical care to under-served populations. I knew that I wanted to do academics, because the opportunity to teach residents to deliver good clinical care with compassion and respect is a great way to serve even more patients, indirectly.


How did you decide on translational research?
In my last year of residency, one of my mentors, Dr. Yvette Calderon, used her great persuasive powers to get me involved in a research project. And suddenly, I saw the light. Not only did I love doing research, but I also realized that by doing research and establishing best practices through evidence based studies, I would be able to improve the care of hundreds of thousands of patients during the course of my career. That is both humbling and exciting. Also, I am the kind of person who is always asking questions. I want to know why we do things the way we do them in the ED. I always wonder if there is a better way. And I wonder why certain diseases or injuries evolve the way they do. Research is the way you get the answers to your questions. So, now, I have three professional passions!

What are some things that you have learned during your time in academics?
The most important thing I've learned from my mentors is to choose the right mentor. I got the best advice on the characteristics of a good mentor when I attended the AAMC Minority Faculty Development Seminar, and I would be happy to share what they taught me:

• You need a mentor who is successful in his or her own career, otherwise how can s/he guide you towards success?
  
• S/he should be powerful at your institution or in EM; someone who other people know and respect, so that when s/he recommends you for committees, speaking engagements, etc. people will listen and respect the recommendation.
  
• S/he should be influential. That is not the same as being powerful. There are powerful people who couldn't get anyone to follow them to a water cooler during a drought!
  
• You want someone who can open doors for you, whose intellectual and professional currency is reliable, someone who can make things happen. Your mentor does not need to be the same sex or the same race or of the same cultural background as you are, but s/he needs to be someone who is willing to understand your world and your perspective and who wants you to reach your career goals just as much as you want to reach them.

Now, that being said, the second most important thing I learned from my mentors is that you must be willing to work very hard and you must follow through. It does no good to have your mentor opening doors for you if you don't walk through them, or to have him get you a speaking opportunity and then you show up unprepared, or for him to get you on a national committee by saying that you are enthusiastic and a hard worker, and then you turn out to be a slacker. You discourage him, you ruin your reputation, and you ruin his credibility for recommending the next mentee who comes along.

Dr. Peter Deblieux on PBS

Who is your mentor?
My mentor is Dr. Peter DeBlieux, and he is an absolute rock star. He is not interested in research, but he has a real gift for moving a young faculty member through all the right steps to achieve her career goals and get her from one success to another. He knows when I am taking on too much, when I am not focusing on the right things, when I am not organizing my tasks and dividing my time appropriately. I may not always love everything he tells me, but he tells it to me straight and his advice is always on target.

I remember Peter being interviewed on TV multiple times post-Katrina. He is consistently so poised and well-spoken. You are lucky to have him as your mentor. I totally agree about Peter being a rock-star, although he's got a mischievous side to him...



You are the Chair of the SAEM Diversity Interest Group (DIG). What is this group all about?
Well, I'm the Chairman this year, and thanks to Dr. Michelle Lin, we have actually recently realized one of our goals. For a long time, we have wanted to be involved in a virtual advisor program where we could be available to students who come from under-represented minority groups, who are interested in EM but may not have doctors in their family group or among their friends who can advise them, or who may not have had opportunities to be exposed to research or science in school.

We are also in the midst of doing a study to look at how women and racial minorities are represented in academic EDs around the country. A similar study was done just over ten years ago, showing that women and URMs are under-represented at all levels, but especially at the higher academic ranks of Associate and full Professor. We wonder if the disparities have in any way changed. And we wonder how leaders in EM feel about these disparities and whether there is a motivation to change them.

Eliminating disparities for our patients and within our profession is what the DIG is all about. We are dedicated to the concept that EM is better for everyone when health care disparities are eliminated and when there is parity in the work place. And our success depends on the continuous influx of committed, effective young students and residents. Everyone of us needs to have one hand up, reaching for the next rung on the career ladder, and one hand down, pulling the other folks up behind us.

So what are you working on this week?
Well, my major project is the study of the effects of moderate alcohol intoxication on the secretion of epinephrine, norepinephrine, and arginine vasopressin in the trauma patient. This week, I will also start to work with one of the basic scientists at the Medical School who is studying the effects of alcohol on the regulation of mononuclear cell tumor necrosis factor production in the murine model. Tumor necrosis factor is a significant marker for sepsis. Should this relationship prove to be significant, we will be developing a study to quantify this relationship in trauma patients. We know that intoxicated trauma patients develop sepsis more frequently than unintoxicated patients, but we don't fully understand why or what can be done to prevent it.

This week, I will also attend classes at Tulane, where I am studying for a Masters Degree in Clinical Research, I will work a shift in the ED side by side with my excellent residents, I will moderate a didactic clinical conference for our residents, and I will work with a few residents on their clinical research projects. One resident will start a project with me this week looking at the effectiveness of an educational intervention designed to encourage patients admitted for ROMI/ACS to modify their cardiac risk factors.

Yesterday, I completed the writing of a manuscript and did some of my committee work for the SAEM Diversity Interest Group. Later in the week, I will start the research to put together a lecture that I'll be giving at AAEM in February.

Wow, is this an average week for you?
So, by looking at my work week, this is a pretty average week for me. You can really see that Emergency Medicine provides me with a very well rounded professional life. I can see patients, do bedside teaching, do didactic teaching, and do both clinical and translational research. I get to be a learner and a teacher. I have the stimulation of working with students and residents, and of interacting with basic scientists who do work that is substantially different from what I do in the ED. I am able to serve my patients and my colleagues with work in national EM organizations, and I am beginning to have opportunities to publish and to lecture nationally.

I work with a really outstanding group of dedicated and really smart EM faculty and residents in a really terrific city, where I enjoy living and spending time with my family. I have a mentor, a Medical School Dean, and my Masters program advisory faculty who really want to see my career progress. I can't imagine that anyone who does anything else for a living could be as happy as I am doing EM at LSU. I mean, my work is not work...it's a pleasure!

I'm living my dream.

Wow, Lisa. You are indeed living the dream. You are the epitome of a classy academician. Keep up the great work.

Article review: Optimal training during fourth year of medical school

U.S. medical students traditionally spend the first 3 years of training in a pre-determined curriculum. In their 4th year, however, students have significant flexibility in how they tailor their time. For this last year before residency, they shift from a learner-centered curriculum to a patient-centered curriculum. There is a shift in mentality from "I am here to learn as much as I can about medicine" to more of a "How do I best prepare myself for working in a hospital in my chosen specialty?"

A 2007 prospective, qualitative study focused on residency program directors' (PD) perspectives about this 4th and final year of medical school. Semistructured interivews of 30 PDs were conducted, spanning the top 10 most popular specialties for UCSF medical students during 2001-2006. At least 2 investigators independently coded the transcripts from the interviews.

PDs were asked the following questions:

1. Name rotations you think students going into your specialty should take in their 4th year. How do you feel about away rotations?
2. How much time should a student spend in his/her chosen specialty versus in other fields?
3. We want to assess the level of responsibility that a 4th year student should have in order to be adequately prepared for internship. What are the differences you'd like to see between a 3rd year and 4th year student?
4. What additional competencies do you expect a student to gain in the 4th year that he/she did not get in the 3rd year?
5. Think of the last 5 interns that really struggled. Were there any themes?
6. Invent for me two to three 4th year medical school rotations that would strengthen a student's arrival for your internship.
   

Results
PDs felt that competencies interns should gain as 4th year students included:

• 60% - Advanced clinical reasoning
• 53% - Near intern-level independence
• 33% - Self-reflection and improvement (be teachable and willing to learn)
• 30% - Effective use of evidence based medicine
• 27% - Capacity to care for more patients
• 27% - Responsibility and reliability
• 27% - Ownership of patient care
• 27% - Communication with patients

PDs recommended the following rotations during 4th year:

• 93% - subinternship in field in which they are applying
• 63% - internal medicine subinternship
• 50% - internal medicine subspecialty
• 43% - critical care
• 27% - ambulatory care
• 27% - emergency medicine (I can't fathom why this number is so low. Most residencies require their interns to complete an EM rotation.)
  

Conclusion of article
Students in their final year of medical school should focus on preparing them for their future career. This patient-centered training, framed within the ACGME competencies, should focus more on (1) progressive responsibilities in patient-care skills, (2) practice based learning and improvement, and (3) professionalism.


My 2 cents
I have to echo the overall sentiments of this article for all students. I have a few thoughts specific to students, applying to Emergency Medicine residencies:

• If possible, do an away rotation in EM. This allows for you to see what EM is like at another location and for you to get another EM letter of recommendation. Having 2 independent EM letters vouch for you helps to build a stronger application.
  
• Do a critical care rotation.
• High-yield elective rotations that might help prepare you for EM residency include: radiology, cardiology, orthopedics, and anesthesia. If you have more free time, consider ophthalmology or ENT.
• During your EM rotation(s), focus specifically on your organizational skills, ability to manage multiple patients simultaneously, and comfort level with more autonomy. Identify 1 or 2 high-functioning residents and determine what skills you need to work on. You will be a senior resident before you know it.
  

Reference
Lyss-Lerman P, Teherani A, Aagaard E, et al. What training is needed in the fourth year of medical school? View of residency program directors. Acad Med. 2009; 84:823-9.

Hot off the press: Improving medical student presentations in the ED

Website: www.emrapee.com

The EM-RAP Educator's Edition podcast just released its 6th podcast episode. Dr. Rob Rogers et al discuss practical tips and approaches to giving feedback on medical student presentations. Presentations in the ED are very different from those in other specialties, such as internal medicine and surgery. The discussants dissect and comment on parts of the presentation.

The comical examples of less-than-perfect presentations alone make the podcast worth listening to! Some of them made me feel like the photo below. This was an out-take picture of Dr. Esther Choo and Nick Johnson (UCSF medical student) during a video shoot that we did teaching how to give good feedback.


While we often recognize when a presentation is poor, it is very difficult to concisely describe what was wrong and to give constructive student feedback. This podcast provides some useful, practical examples.

Some topics discussed:

• Giving some positive feedback
• Do you interrupt the student mid-presentation to make comments or corrections?
• Dealing with a difficult patient

Behind the scenes as an ACEP Scientific Assembly speaker, Day 3

My favorite part about my "Tricks of the Trade" lecture is hearing audience members talk about their own creative trick-of-the-trade approach to common dilemmas in the ED. This lecture was no different. A lot of folks came up with some great tips that I hope to highlight in future ACEP News columns. I'll be working on getting photos.


To whet your appetite, I got some amazing tips about:

• Creating a temporary fingernail bed cover to keep the eponychial folds patent until the new nail grows out
• How to endotracheally intubate a patient using a generic (non-intubating) LMA apparatus
• How to endotracheally intubate a morbidly obese patient with shortness of breath
  

Thanks to all who came up to chat with me. I feel like I'm really the lucky one to serve as the central repository of ideas. It's great to hear of everyone's creative approaches. I'm looking forward to sharing with those in our specialty.

Common dilemma in lecturing:
Which screen do you look at when you have a screen on either side of the podium? Do you laser-point on both or just one?

Answer:
Since I was able to use my Macintosh laptop for my presentation, I can actually draw on the slide itself when I hit command-p. This converts the mouse arrow to a pencil icon. This allows me to draw on both slides at once. I hit "e" to erase my marks. To return the mouse key to look like an arrow icon, I hit command-a for automatic.