Article Review: Hidden cost of reducing resident duty hours

Patient care versus education

This is the tug-of-war struggle that residency programs constantly grapple with. Residents work in an apprenticeship model where they are both patient providers and learners. Both are critical in residency training, but they sometimes negatively impact each other. For instance, EM residents hand-off their patients to covering residents while attending their weekly conference classes. In contrast, residents may skip that day's board teaching rounds to manage an acutely decompensating patient.

In 2003, the Institute of Medicine (IOM) set the 80-hour workweek standard for all residency programs. More recently this year, the IOM proposed additional duty hour restrictions:

• When on call, the maximum on-call period is 30 hours. There also needs to be a 5-hour continuous sleep period during this time such that the resident's maximum awake period is 16 hours.
  
• Night float must not exceed four consecutive nights and must be followed by a minimum of 48 continuous off-duty hours after three or four consecutive nights.
• Both internal and external moonlighting should be counted against the 80-hour weekly limit. Currently moonlighting is not counted.
  
• The maximum in-hospital, on-call frequency should be every third night without averaging. As an intern on the orthopedics team, I remember taking q2 night calls, intermixed with some q4 and q5 night calls so that everyone can get a weekend off. This would be eliminated with this new rule.
• The minimum time off between scheduled shifts should be 10 hours after a day shift, 12 hours after a night shift, and 14 hours after any extended duty period of 30 hours.
• Mandatory time off duty should increase to 5 days off per month: one day off per week, without averaging, and one 48-hour period off per month.

On surface level, the IOM logic makes sense.
Give the residents more rest from patient care responsibilities. This will give us better learners.

But let's look deeper.
This Annals of Emerg Med opinion article discusses the faulty logic of these proposed duty hour changes.

• When residents graduate and practice as attending physicians, they may be asked to work more consecutive hours or more frequent shifts than they have ever worked during residency. Is this right?
• Having more hours off (eg. 5-hour nap), days off, and work hour restrictions will result in more patient hand-offs, which are known to increase patient care errors. It's too bad that patients change their clinical course dynamically and don't follow the work clock.
  
• Limiting the number of consecutive night shifts will result in more circadian dysrhythmias.
• Every specialty is different in training requirements, learning environments, and patient population. While some specialties (i.e. surgical programs) might benefit from a more structured reduction in work hours, imposing a blanket statement on all programs seems impractical and short-sighted.
• If residents work fewer hours overall, residency programs should be extended by at least another year of training. Experiential learning is critical in preparing a resident for clinical practice as an attending physician. You really never want to hear your doctor saying, "Hmm, I've never seen that before."
• With all the shorter work hours, hospitals will need to hire more attending physicians and mid-level providers to cover the gaps in patient care.
  

The Residency Review Committee for EM, ACEP, and EMRA have responded with a joint letter applauding the philosophy of optimizing resident learning and patient safety. They, however, opposed the implementation proposal for stricter duty hour rules. I totally agree.

While we're on the topic of duty hours,
I think we should also address
faculty duty hours too!

Reference
Millard WB. For Whom the Bell Commission Tolls: Unintended Effects of Limiting Residents' Hours. Ann Emerg Med. Oct 2009; 54(4):A25-A29.

Hot off the press: Free MP3s on Amazon

Are you like me and need catchy tunes
playing in the background to
get more work done on the computer?

I just discovered that Amazon is giving out $3 worth of free MP3s. The deal expires November 30.

Instructions:

1. Click on this Amazon link.
2. Be sure to enter the promotional code (MP34FREE) in the pop-up window before actually downloading the music.
3. Download MP3s that you want.

Enjoy!

Happy Turkey Day

Get off the computer and have a fun, belly-busting Turkey Day.

Trick of the Trade: Hum-out the jugular veins

Placing an IV in the external jugular vein requires venous distension maneuvers. This means having the patient perform a Valsalva maneuver or be placed in a Trendelenburg position.

Have you ever had a patient who didn't quite get the Valsalva maneuver concept, or couldn't tolerate a head-down position?

Trick of the Trade: Humming
Have the patient hum during IV placement. Humming increases the venous size of the external jugular (EJ), internal jugular (IJ), and common femoral vein (CFV). It is a closed-mouth, forced expiration which increases intrathoracic pressure.

This was found in a study done by several creative faculty in our department at UCSF! Using normal volunteers, the 3 veins were visualized by ultrasonography. Each vein's cross-sectional area was calculated under each of the following conditions:

• Baseline
• Valsalva maneuver
• Trendelenburg position
• Humming

The authors found that humming was just as good as the Valsalva maneuver and Trendelenburg position in dilating the 3 veins (EJ, IJ, CFV). See the ultrasound images demonstrating this phenomenon.

Give it a try.
Have the patient hum to maximize the vein's size.
Your humming along is optional.

Reference
Lewin M, Stein J, Wang R, et al. Humming Is as Effective as Valsalva’s Maneuver and Trendelenburg’s Position for Ultrasonographic Visualization of the Jugular Venous System and Common Femoral Veins. Ann Emerg Med. 2007; 50(1): 73-7.

Work in progress: Reading "Disrupting Class"

Sparked by the interesting dilemmas from yesterday's review of a Commentary on Graduate Medical Education, I'm almost done reading an intriguing book by Clayton Christensen et al, called "Disrupting Class: How Disruptive Innovation Will Change the Way the World Learns" (Amazon link). Dr. Christensen, interestingly is not an educator or physician by training, but rather a Professor of Business Administration in the Harvard Business School. I met Clay very briefly because he lectured at a course that I attended called the Harvard-Macy "Leading Innovations in Health Care and Education" Conference.

He coined the term "disruptive technology", which can best be described as innovations that improve a product or service in ways that the market does not expect, typically by being lower priced or designed for a different set of consumers. This originally was a term to describe for-profit companies and organizations.

However, the authors have found that "disruptive technology" can also provide an innovative way of totally re-inventing the K-12 public school system. They make a convincing argument and draw from many parallel examples in business. I've found that these lessons from industry might also be applied to medical schools and residency training. It is interesting to view education, from the eyes of "outsiders", who specialize in innovation and organizational systems.


Some interesting comments made in the book:

• You can't reform education by taking a head-on confrontational approach. It is a time-proven fact that a major innovative change can only occur by going around and underneath a current system. "This is how disruption drives affordability, accessibility, capability, and responsiveness." Successful examples of disruption in business are described, such as Apple Computer and Southwest Airlines.
  
• There are different kinds of learners. Education should provide a customized approach to learning, rather than teaching in a monolithic batch mode system. Teachers in this learner-centric model will serve more as learning coaches rather than traditional lecturers.
• Student-centered learning is the way of the future in education. Computer and online technologies will be at the core of the infrastructure.
• By the year 2019, 50% of high school courses will be delivered online. Are medical schools and residencies ready for this shift in learning culture? I don't think so.
  

A fascinating read for those interested in education. It's definitely given me a new perspective.

The significant problems that we have cannot
be solved with the same level of thinking
we were using when we created them."
-- Albert Einstein

Article review: Commentary on graduate medical education in the U.S.

"How ready are medical students for the clinical practice of medicine?"

This was the question addressed by the landmark 1910 Flexner Report from the Carnegie Foundation for the Advancement of Teaching. Back in the early 1900's, residency training did not exist yet, and students entered clinical practice immediately after graduation from medical school. The quality of medical training varied significantly with alarming deficiencies in many medical schools. An independent, nonprofessional organization was commissioned to report about the situation in order to pressure the public to reform medical school education.

This organization was the Carnegie Foundation for the Advancement of Teaching, led by Abraham Flexner. The result was the creation of laws that required physicians to have completed a defined set of educational experiences before starting their clinical practice.


The year 2010 marks the 100th year anniversary of the Flexner Report. Because there will certainly be many journal articles reflecting back to the original report in the upcoming months, I thought I'd read a little more about it. This is a review of a commentary by Academic Medicine's editor-in-chief, Dr. Michael Whitcombe. I met him several years ago at SAEM's national meeting when he gave an inspiring talk about educational research. An articulate visionary.

Unlike in 1910, current trainees must now also complete residency training after medical school before entering clinical practice. If updated, the revised Flexner report would focus instead on graduate medical education (GME) instead of undergraduate medical education (UME).

So, how ready are our residents for the clinical practice of medicine today?

Unfortunately, not so ready.

The Institute of Medicine and various articles in JAMA have documented this. Their conclusions are that GME needs a significant overhaul so that graduating residents can consistently provide high-quality medical care of our country's citizens. Unfortunately (1) identifying the problem and (2) making recommendations for change doesn't magically make change happen. Many regulatory bodies are stuck in how they currently practice the business and management of GME. Traditions are understandably difficult to change.

Confounding the picture even more is that each specialty has its own set of regulatory bodies which also have significant say over how their residents should be trained. In Emergency Medicine, some of the key players are the American Board of Emergency Medicine (ABEM), the EM Residency Review Committee (RRC), and the Council of Residency Directors in EM (CORD).

On paper, the solution might seem easy. The Accreditation Council for Graduate Medical Education (ACGME), which oversees the accreditation of all GME training programs, should make an overarching top-down change. The decree- Make residency training better. But no, things can't be that easy. As it currently stands, the ACGME has given the individual RRCs (each represents a medical specialty) to come up with the specialty-specific training standards. I support this philosophy because EM physicians on the EM-RRC know the nuances of EM training more than a non-EM physician in the ACGME office. Unfortunately, this adds another layer of complexity and creates an impasse for a blanket change across specialties.

In the commentary, Dr. Whitcombe summarizes some proposed ideas. Several revolve around some form of licensure demonstrating competency (a.k.a. "stamp of approval") before graduating from residency.

My thoughts

Personally, I don't think that the idea of having a standardized, exit exam licensure is going to work. Are we going to impose yet another standardized test on our trainees, knowing that it poorly measures the multifaceted complexities of clinical competency and medical decision making?

I think the responsibility lies somewhere on the shoulders of the ACGME and individual RRCs.

My crazy idea
Here's a crazy outside-the-box thought. If JAMA published several papers (see references below) documenting survey results that new practicing physicians feel inadequately trained in particular aspects of medicine, why can't we use these survey tools annually during residency training? We should be addressing and assessing clinical competency throughout residency and not just before they graduate. Each resident would perform a honest self-assessment of his/her competencies (or lack thereof) in various areas.

Inevitably, different trainees will have different deficiencies, even within the same residency program. This means that the curriculum should shift towards a new model - a learner-centric model. This would involve annual custom-tailoring of each trainee's clinical experiences and other learning opportunities, based on their subjective or objective deficiencies. I would get rid of a large portion of the weekly conference lectures (passive learning where everyone gets taught the same topics whether they knew them already or not) in exchange for more personalized, active-learning networks.

There are obvious down-sides to my idea.

• Education is placed directly at odds with clinical service. For instance, a resident may need to do an elective in bedside ultrasonography. This may require pulling them off of an Emergency Department rotation. That leaves a gap in clinical coverage in the ED. This translates to more dollars needed by the department to ensure adequate clinical coverage. Asking for more money for the sake education is always a touchy subject.
  
• Because each resident has a customized personalized curriculum, lots of faculty and administrative time will be needed to ensure each resident's success. This is a resource-intensive endeavor.
• This is an operational and scheduling nightmare.
  

Hey, I said I had a radical idea. I didn't say that I could operationalize it. I look forward to following the upcoming papers addressing the 100th year anniversary of the Flexner Report.


Reference
Whitcomb ME. Flexner redux 2010: Graduate medical education in the United States. Academic Medicine. 2009; 84:1476-8.

JAMA references
Wiest FC, Ferris TG, Gokhale M, et al. Preparedness of internal medicine and family practice residents for treating common conditions. JAMA. 2002;288:2609 –2614.

Blumenthal D, Gokhale M, Campbell EG, Weissman JS. Preparedness for practice. Reports of graduating residents at academic health centers. JAMA. 2001;286:1027–1034.

Cantor JC, Baker LC, Hughes RG. Preparedness for practice: Young physicians views of their professional education. JAMA. 1993;270:1035–1040.

Hot off the press: Review of "EM Clerkship Primer" book

In an upcoming issue of the Academic Emergency Medicine journal, there is a glowing review of a collaborative project that I was involved in. If you are a medical student about to do an EM rotation, or serve as a faculty advisor for an EM medical student, feel free to distribute this EM Clerkship Primer (FREE book!) for them to read. This was the first official project to come out of the Clerkship Directors in Emergency Medicine (CDEM). It was written by 22 established medical educators in EM, led by our fearless leader/ editor-in-chief, Dave Wald. Go, Dave!


EMERGENCY MEDICINE CLERKSHIP PRIMER: A MANUAL FOR MEDICAL STUDENTS. Edited by David A. Wald, DO. Free for students and educators; 108 pp; download PDF at http://www.saem. org/CDEM (look under "Resources for Medical Students").

The Emergency Medicine Clerkship Primer is a unique and authoritative introduction for medical students entering the specialty of emergency medicine (EM). It has been prepared by physicians who are nationally recognized for their dedication to medical student education. The guide provides a thorough, yet succinct, primer that introduces the steps to not only have a successful clerkship, but also to understand issues central to the practice of EM.

The primer has 24 chapters, including introductions to EM and the clerkship, unique aspects of EM and ED workups, complaint-directed history taking, formulation of differential diagnoses, enhancing oral case presentation skills, diagnostic testing, whether obtaining a diagnosis is important, and appropriate disposition and discharge instructions. There are also helpful chapters on topics such as ED documentation pearls, interacting with consultants, meeting patient expectations, and procedural skills.

This primer has been prepared for all medical students rotating in EM, regardless of their chosen specialty. It begins by providing some background into EM and then transitions into how to perform well in an EM clerkship. The medical student, by reading these well-organized and concise chapters, will develop an understanding of the skill set that is utilized by emergency physicians. In addition, the medical student will learn that the presentation and assessment of an undif- ferentiated patient in the ED is distinct from that of the patient with a known diagnosis in the inpatient ward.

For the medical student planning a career in EM, the Emergency Medicine Clerkship Primer provides a single, inclusive resource that contains references for articles that are essential to emergency physicians. It also provides insight into the background of EM residency education via a review of the core competencies required for residency training.

Overall, the Emergency Medicine Clerkship Primer is an exceptional guide for medical students. Its concise style and valuable content make it a distinctive and irreplaceable resource. Reading it is a highly recommended first step for a successful entrance into a career in EM.

Kapil Dhingra, MD, MBA
Erik Laurin, MD (eglaurin@ucdavis.edu)
University of California, Davis Medical Center
Sacramento, CA

Cool opportunity: TED translators needed

TED is a nonprofit group, whose sole mission is "spreading ideas". It now hosts several conferences annually to bring together leaders from the worlds of Technology, Entertainment, Design. This group features inspirational speakers who discuss a broad spectrum of topics, such as "Secrets to Success", "Global Warming", and "How Photography Connects Us". Here is my previous discussion about two of my favorite TED videos on creativity.

You too can get involved! They are looking for volunteer translators to help their global efforts to disseminate really inspiring and informational material. If you speak one of the languages below, I encourage you to volunteer. This may be the closest you'll ever get to inspirational leaders and celebrities such as Bill Gates, Al Gore, and Jane Goodall.

• Akan
• Assamese
• Filipino
• Galician
• Gujarati
• Icelandic
• Khmer
• Maltese
• Marathi
• Mongolian
• Nepali
• Panjabi
• Sinhala
• Tagalog
• Tibetan
• Tswana
• Yoruba
• Zulu

Plus, no matter what career you go into, this is always a great and unique CV builder. Here is the link for more TED Translator information.

Trick of the Trade: The defensive arts against pimping

Thanks to Dr. Rob Roger's podcast on EM-RAP Educator's Edition series, I learned of one of the funniest publications EVER in a medical journal. It was published on April 1, 2009 in JAMA. The article focuses on teaching medical students the essential skill set-- how to survive "pimping".

Pimping traditionally occurs when an attending physician poses a difficult question to a learner in a public forum, such as board rounds or in the operating room. As a student or resident, you know that this will happen during your training, and you should be prepared. If you think of pimping as a form of battle, you will need a good defense, and you should mix it up to be successful.

Which of these techniques have you used in the past?

Avoidance

Don't make eye contact with the teacher. Stay very still. Lower your head as if you are deep in thought. But don't look like you are sleeping and not paying attention. Bottom line is to not draw attention to yourself while appearing to listen. It's a fine line to walk.

The Muffin
Hold a large muffin in front of your mouth, as if you are going to take a bite. If you don't know the answer, take a big bite. If you still get called on, pretend to choke. I would go one step further and say - If desperate, syncopize.

Hostile Response
The best defense is a good offense. Take a tone and body posture of hostility. Say "I -- DON'T -- KNOW." Personally, as a teacher, I'd be afraid of asking this student questions -- ever --again.

The List
If asked to contribute to a list of answers, you can repeat a response from earlier pretending that you didn't hear it, because you were busy with patient care responsibilities (answering pages, working on your medical charting).

Honorable Surrender

Tell the teacher that you are uncomfortable with the open forum of questioning.

Pimp Back
Another version of - the best defense is a good offense. Ask questions in a subspecialization which the teacher may not be as familiar with. Careful - this technique may totally backfire, since pimpers often know and don't appreciate when they are being pimped back.


Politician's Approach
Don't answer the question asked but rather answer a question you would have preferred to answer.







Use Personal Digital Assistant
Use your handheld device to find answers in real-time.





Don't Sulk or Cry
Pimpers rarely remember who gave incorrect answers - this happens all the time. But sulkers and weepers definitely are memorable. Whatever you do, don't be labeled as one who loses composure. I feel like Emergency Medicine trainees do well in this area. We are constantly barraged by stressors, and it takes a lot for us to lose our composure.

Reference
Detsky AS. The art of pimping. JAMA. April 1, 2009; 301(13): 1379-81.

Work in progress: CORD/SAEM abstracts due Dec 2, 2009

The December 2 deadline is quickly approaching! Get your CORD and SAEM abstract submissions in. If accepted, many of these abstracts will be published in the Academic Emergency Medicine journal.

I am submitting my educational research study to CORD, since I will be there anyway to teach other educational activities. Also the CORD Academic Assembly is veritably the most education-centric national conference in EM. Our working abstract draft is shown below.

Bottom line of my abstract:
Overcrowding in the Emergency Department seems to correlate with decreased faculty teaching in the ED, according to the EDWIN crowding score. That means that teaching is negatively impacted by a crowded ED.

This crowded ED photo was captured from our ED at
San Francisco General Hospital. The SAEM folks liked
it so much that they featured it on their website as part
of their push to highlight crowding as a national crisis.

Impact of Overcrowding on Faculty Teaching Time
in the Emergency Department
Michelle Lin, MD
Christy Boscardin, PhD
Sandi Ma, MS
Bridget O’Brien, PhD

PURPOSE
Emergency Department (ED) crowding is known to result in delays in pain management and worse medical outcomes, but there are very few studies focusing on the impact of crowding on teaching. Survey-based studies report that crowding does not result in lower faculty teaching evaluation scores, contrary to anecdotal evidence. This study is the first prospective study objectively documenting whether attending physician teaching behavior changes as a function of crowding.

METHODS
A prospective, observational time-motion study was conducted at an urban, academic ED. During September-December 2008, 19 unique faculty members were observed during a 6-hour block while working in a zone with medical students and PGY-1 residents. A single observer documented attending physician behavior every 30 minutes for 15 consecutive minutes during the 6-hour period, yielding 12 discrete observation periods. Within each 15-minute period, attending behavior data were collected in 1-minute intervals as one of 6 outcome variable activities: direct patient care teaching (attending with learner and patient), indirect patient care teaching (attending with learner), direct non-teaching patient care (attending with patient), indirect non-teaching patient care (attending with other person), attending working alone, and personal time. Every 30 minutes, the same observer also recorded crowding variables. The predictor variable (crowding) and outcome variable (attending behavior) were calculated as a continuous variable for 12 observation points per shift. A repeated measures analysis of variance was performed with four predictor variables (number of years as an attending, EDWIN crowding score, Workscore crowding variable, and occupancy rate) and each of the six outcome variables.

RESULTS
The EDWIN score was significantly associated with decreased teaching time, specifically in indirect patient care teaching time (p=0.02). The EDWIN score also correlated with the attending spending more time with direct and indirect non-teaching patient care duties (p=0.02 and 0.03, respectively). The number of years of experience as an attending physician was also a significant predictor for more direct patient care teaching (p=0.04) and less attending-alone time (p=0.001).

CONCLUSIONS
This is the first observational time-motion study to demonstrate that crowding may detrimentally impact teaching in the Emergency Department, using the EDWIN score. Crowding, as measured by the Workscore and occupancy rate, however, did not correlate with decreased teaching time.

Article Review: Learning assessment using virtual patients

I am developing a new microsimulation module to help EM clerkship students gain a more realistic exposure to high-acuity patients. Emergent conditions, such as ectopic pregnancy, acute tricyclic overdose, and ST elevation MI, are usually cared for by senior residents and attendings. Rarely are students primarily involved in these cases.


That's why we at CDEM are developing a microsimulation module, called Digital Instruction in Emergency Medicine (DIEM). The DIEM cases would essentially be online "choose-your-own adventure games" which allow learners to manage sick patients. More true to life, these cases are non-linear in format. This means that you can order an EKG, then ask a few history questions, order a nurse to place an IV, give a sublingual nitroglycerin tablet, and then examine the abdomen. These cases are timed and have critical-action timepoints. This means that you may see the phrase "the attending comes in the room and orders ..." if you haven't performed a particular critical action by a certain timepoint.


Compared to the standard multiple-choice question exams (commonly employed by national licensing organizations), virtual patients are a far superior learning assessment tool. It is better at evaluating medical knowledge, skill, application, and future clinical performance. As an example, such Assessment Virtual Patients (AVPs) are used in the form of a computer-based simulation in step 3 of the USMLE board exam.

AVPs are difficult to create and implement, but provide a useful assessment tool. This article was useful because it helps remind me what comprises an ideal assessment tool. It's all about validity, reliability, and feasibility. Here are some definitions (which I always have to look up because I can never remember!):

• Content validity - Does the assessment tool test the intended subject?
• Concurrent validity - Does the assessment tool yield results comparably well with an already-established tool?
• Predictive validity - Does the assessment tool predict future learner performance?
• Construct validity - Does the assessment tool accurately test abstract concepts (eg. empathy)?
• Face validity - Does the assessment tool appear to test its intended subject?
• Reliability - Does the assessment tool consistently give the same result?
• Feasibility - Can the tool be implemented without excessive costs and resources?

This review article discusses how AVPs may be an ideal assessment tool, especially compared to standard multiple-choice questions. AVPs come in 3 levels of complexity.

Level 1 AVP: A series of multiple-choice questions which are presented to the learner, based on his/her previous answer. The assessment tool is still functionally linear, but it is tailored based on the user knowledge. It's hard to read this figure, but you get the sense that starting on the left, you progress down one of the arms for further questions, based on your previous answer.

Level 2 AVP: Similar to Level 1 AVP testing, different multiple-choice questions are presented to the learner based on his/her previous answer. The difference is adaptive testing. That means that the questions become progressively more difficult if the learner is answering questions correctly. This helps distinguishes the poor, average, and stellar students.

Level 3 AVP: This is the most difficulty AVP to design because of the complexity of options. Instead of changing the multiple-choice questions, Level 3 AVPs actually change the patient's condition based on your previous actions. Although hard to read, you definitely can see the degree of complexity in the branch logic. Step 3 of the USMLE boards and my DIEM cases use level-3 AVPs.


Reference
Round J, Conradi E, Poulton T. Improving assessment with virtual patients. Medical Teacher. 2009; 31: 759–63.

A radiology pearl: A subtle orthopedic diagnosis

A man recently presents with knee pain after pivoting and torquing his knee while falling. He complains of concurrent mild ankle pain. He presents with this tib-fib xray.


Realizing that a proximal fibular fracture can present concurrently with a medial malleolus fracture or deltoid ligament rupture, we obtained xrays of the ankle. We were looking for a Maisonneuve fracture.

Do you see an ankle injury?

Answer

• There was no medial malleolus fracture.
• There was no obvious deltoid ligament rupture, because the ankle mortise appears normal.
• Always be sure to look at the lateral ankle view. You need to check for a posterior malleolus fracture.
• This patient indeed had a Maisonneuve fracture, which was splinted and referred to orthopedics for operative repair.

Question: Have you had any interesting radiology findings on your ED shift?

Hot off the press: Cool medical student opportunity

As a medical student interested in Emergency Medicine, I always had a hard time trying to meet academic emergency physicians outside of my medical school. That's why I always try to keep a look-out for great opportunities for medical students. Well, I just found one.

Are you a medical student interested in EM and available during June 2-6, 2010? The Society of Academic Emergency Medicine (SAEM) is looking for 10 medical students to help the Programming Committee to organize and staff the entire Annual Meeting. This is the primary annual meeting, which hundreds of academic faculty attend including most residency directors.

Here is the link for the 2010 Annual Meeting, which is going to be in Phoenix AZ.

Check out the posting below:

SAEM’s Program Committee is looking for about 10 medical students to work with their committee at the Annual Meeting in Phoenix in June 2010. The Program Committee is responsible for the planning, coordination, and execution of SAEM’s annual meeting. It is comprised of nearly 40 faculty members from programs all over the country. The week long meeting typically attracts over 2000 medical professionals and students.

As a medical student on this committee, you will:

• Have your registration fee to the Annual Meeting waived
• Have a member of the Program Committee assigned to you for future EM Pursuits
• Learn much more about the current research and educational activities taking place in the field of emergency medicine
• Have the opportunity to form relationships with faculty members from EM programs around the country

Interested medical students should submit their name and contact information to the SAEM office at Jennifer@saem.org - Please write “Medical Student Volunteer for Annual Meeting” in the subject line of the email. Please include a very short statement of interest and an updated electronic copy of your CV.

12/15/ 09 UPDATE!!
The new contact person for this amazing opportunity is Jim Tarrant (jtarrant@saem.org) now. He is the Executive Director for SAEM. He told me that there still are open positions and will know more in January 2010. SAEM is in the process of moving the main office from Lansing, MI to Chicaco, IL.

Trick of the Trade: Don't have a mirror in the ED?

Several times in the ED, I have needed a mirror for patient care.

Example 1
A moderately intoxicated patient presents with a facial or scalp laceration. S/he adamantly refuses to have it repaired in the ED, because of the disbelief of that there is indeed a laceration. You want to show the patient, using a mirror, but you don't have one.


Example 2
A patient presents without a family member or friend with a possible new facial droop. The patient hasn't noticed it, but you want to ask if his/her face appears differently. Alas-- no mirror.

Tricks of the Trade
1. Take a picture. Use your cell phone or iPhone to take a picture of the patient. You can show the patient his/her laceration. Or you can show the patient how his/her face currently looks. I did this when a Neurology resident was trying to ask if a patient's face had a subtle facial droop, which accompanied her arm and leg weakness. The resident had spent 5 minutes trying to find a small compact mirror and was shocked at how easy the solution was.

2. Use a photo ID: For asymmetric facial weakness, you can also ask to see the patient's Driver's license or any photo ID card. This can help you evaluate if the patient has a new deficit.

Work in progress: Highlights in EM Educational Research 2009

The gang is all back together!

In June 2009, 5 of my good friends in academics and I collaborated to write an article for the journal Academic Emergency Medicine (AEM). This manuscript, entitled Highlights in Emergency Medicine Educational Research: 2008, will be published in AEM in the next few months. We are getting together again to work on the 2009 review.

I'm lucky to be able to work with well-respected and well-published educators in EM. I'm not exactly sure how I got to "roll with this crowd", but I'm thrilled to be able to. I'm following my first rule in academics -- surround yourself with inspiring and dedicated individuals, and you can't steer wrong. Here's the powerhouse team:

• Sue Farrell, MD EdM (Harvard/Brigham)
• Wendy Coates, MD (Harbor-UCLA)
• Gloria Kuhn, MD PhD (Wayne State)
• Jonathan Fisher, MD MPH a.k.a. "Fish" (Beth Israel)
• Philip Shayne, MD (Emory)
• ... and me.

This paper highlighted the 5 best medical education research articles for 2008, relevant to EM. These high-quality articles were selected based on consensus opinion of 6 independent reviewers, using a priori criteria each assessed on a 5-point Likert scale.

• Clarity of the study question
• Applicability of the research design to the study question
• Data collection methods
• Data analysis
• Relevance to teaching
• Generalizability of the results
• Innovation of the study
• Clarity of writing

What were these top 5 educational research articles?

• Baskin C, Seetharamu N, Mazure B, Vassalo L, Steinberg H et al.: Effect of a CD-ROM-based educational intervention on resident knowledge and adherence to deep venous thrombosis prophylaxis guidelines. J Hosp Med. 2008;3(1):42-7.
• Chenkin J, Lee S, Huynh T, Bandiera G: Procedures can be learned on the Web: a randomized study of ultrasound-guided vascular access teaching. Acad Emerg Med. 2008;Oct15;(10):949-54.
• Lampe CJ, Coates WC, Gill AM: Emergency medicine subinternship: does a standard clinical experience improve performance outcomes? Acad Emerg Med. 2008;15:82-5.
• Wenk M, Waurick R, Schotes D, Wenk M, Gerdes C et al.: Simulation-based medical education is no better than problem-based discussions and induces misjudgment in self-assessment. Adv Health Sci Educ Theory Pract. 2008;Jan 24 [ePub ahead of print]
• Youngblood P, Harter PM, Srivastava S, Moffett S, Heinrichs WL, et al.: Design, development, and evaluation of an online virtual emergency department for training trauma teams. Simul Healthc. 2008;Fall;3(3):146-53.

We are starting to bring the team back together to start reviewing the EM education research articles from 2009. We are currently thinking about incorporating the MERSQI instrument (described in yesterday's blog) for scoring quantitative educational research studies into our scoring system. The problem with the MERSQI instrument, however, is that it does not evaluate qualitative research, which is also a valid approach to studying education.