#IMconf is Joining the Party

Over the last few months the EMconf hashtag has built a large and active membership (visit FOAMfeeds for the latest posts).  It’s been great for the EM/CC conversation.  The hashtag continues to gain momentum and it stands to reason that other specialties might also benefit from creating a continuous, asynchronous educational conversation vis-a-vis FOAMed.

In the spirit of #EMconf, Salim Rezaie of Academic Life in Emergency Medicine and Knowmedge, came up with the idea of #IMconf.  As a fellow EM/IM doc I think it’s brilliant.  The world of IM FOAM desperately needs a boost.  Hopefully, Internal Medicine residents and residencies from around the world will join the party by tweeting from traditional activities: Morning Report, Noon Conference, Journal Club, Grand Rounds, etc…

IMconf, like EMconf, appears to be gaining traction.  In the past 3 days, the hashtag has produced 198 tweets from 87 participants with more than 135,ooo impressions.  For those who are not yet on Twitter, we’ve added an #IMconf page to FOAMfeeds.

Below is the first paragraph from Salim’s introductory post.  Click on the link at the end to read the entire article, and be sure to share this with your IM colleagues!

Introducing #IMConf Twitter Hashtag

Recently the EM community found a way to spread education amongst programs globally by creating the hashtag #EMConf. Residents, students, as well as programs tweet live from their didactics using this hashtag so that others can learn from each other virtually. Although IM conferences are not a half-day, once a week event, we do have morning report, grand rounds, noon conference, as well as other types of education including question/answer, journal club, etc. Why not tweet this information out and share it with each other?

New Hashtag #IMConf 

The purpose of this hashtag is to unite IM education through the use of social media.  We can all learn from each other, and ask questions allowing all of us to contribute to the learning process of…

Commenting on the proposed FOAM Charter

This is a response to the excellent discussion on LITFL around Chris Nickson’s post questioning whether it is “Time for a FOAM Charter?”  Technicalities prevented me from submitting directly to the conversation (too wordy?), so have done below.  Please do not respond to this post. If you would like to jump in on the convo, go to the original post here
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1) This is a great initiative.  Thanks, Chris, for putting it out there.  But to answer some of the questions raised we need to decide what the charter is trying to accomplish.  A charter/code of honor can serve to strengthen the scientific quality of published content.  It can also increase users’ faith in FOAM by maintaining a certain minimum professionalism and ethical standard.  Furthermore, as stated, it would be great for community building and branding.  My feeling is that the role of a charter, etc would not be scientific critique per se. That should be left to the community. After all, the beauty of FOAM is that it provides writers and consumers with unfettered access to an enormous range of educational materials. It is up to the end user to read these materials with a critical eye and assess how reliable a certain source is. This task, however, is impossible without some basic assumptions.  And this is where the charter comes in.  It should be a set of values that all participants (writers and consumers alike) adhere to. In this way, any user who sees the FOAM logo would know that the author is providing their materials in good faith, free of COI, and that the content is as accurate as possible.   I like the wording as outlined above, with 3 changes (see below).
2) Enforcement – On the one hand, I completely agree with Minh in that a committee would be the best way to ensure standards and to provide a degree of content review.  That said, I think we should avoid the idea of pre-publication review.  This is what we are trying to get away from.  FOAM contributors should be able to publish their materials free from unseen biases. Also, as one commenter wrote, these groups tend to be selected, not elected, and users and contributors may lose faith by questioning selection by whom, for how long, and what specifically is the group’s role, etc.  Creates a non-inclusive atmosphere.  On balance, would avoid a group/committee. But now we’re left with enforcing standards; who gets to remove the logo from sites that violate the charter, and how?  I think it’s best left to one or two people from the largest EM/CC websites (LITFL, ALiEM, etc) who would serve as moderators for the larger FOAM community and who would take action after public discussion, perhaps on a dedicated website that would also link to all the sites that carry the FOAM logo.  Would emphasize that the role of the charter/code is not content review or any kind of content control or editorial control, only an assurance of ethical and professional standards, as this concern could turn off some users.
3) Privacy – Patient privacy is obviously of critical importance to this entire venture and must be emphasized.  It is easy to see how, in the US at least, hospitals may be quick to ban/block certain resources if they believed they exposed the institution to any kind of legal risk.  So, would add to the privacy item wording that would indicate that privacy standards differ from country to country and that users must review their own local regulations before using any patient images.
4) COI – As noted by others, FOAM should strive to be free of conflict of interest. Sites with any kind of pharmaceutical or medical device connection should not be able to display the FOAM logo.  Alternatively, if people felt strongly about it, perhaps there would be a (very) different logo for sites that otherwise met all other criteria – as long as it is clear to users that the materials are, by definition, biased.  Would also expect writers to disclose any connections (even non-financial) to materials they are discussing. For instance, if discussing a study in which they were involved (again, even if not financially) this information should be clearly disclosed.
5) References – All writing should be referenced, when available, to allow for further reading and critical appraisal by users.
6) I like Scott’s suggestion of a logo that links to the charter. Clean and simple.  Ideally this would be hosted on an independent site dedicated to the charter which would also link to all sites that carry the logo, host conversations of users’ concerns over non-adherence, and also host a universal disclaimer to be used by FOAM contributors. This way every new writer would not have to reinvent the wheel and would be able to link to it.  To critics of disclaimers I would suggest that it can’t hurt to have these in place.  The plain truth is that FOAM has yet to be tested in court.  Hopefully it never will, but given our current practice environment it is very possible that somebody will try to claim that the FOAM charter or the writers are liable for something. Now, I don’t know that disclaimers even work, but they at least provide a backing if they are worded to indicate that materials are for educational purposes only, need to be verified, are not aimed to treat any specific patient, and that some subjects are controversial and will not represent the local standard of care, etc etc etc…
7) Agree with Creative Commons theme/attribution

A Thought on Teaching and Feedback in the ED

“Keep Reading”

Yesterday, during yet another excellent session at the ACEP Teaching Fellowship (#ACEPTF14), Dr. Rob Rogers (@EM_Educator) spent some time reviewing feedback techniques with the goal of teaching us many different ways to provide more effective feedback to students and residents.  You know, something better than the usual “Strong work” or “keep reading”.  We recently ran a similar module with the incoming EM interns at our shop as part of a Resident-as-Teacher workshop, so I was particularly interested in seeing where this would go.  Thanks to a great group of folks in the room we had an amazing discussion that really got us all thinking.

Yum!shitsandwich_rogers

One of the more common feedback techniques is the Shit Sandwich (S.S.).  This method has become so ubiquitous that, after receiving input from faculty using the S.S., one student reportedly responded to his attending, “Nice Sandwich!”  Not that feedback is any big secret. If anything, it is important to state explicitly that the learner is receiving “feedback” (see ALiEM review of Yarris et al, below).  But still, there is something wrong with that interaction.

Urban Dictionary teaches us that the Shit Sandwich is:

A way of giving crappy news to someone.The news is dressed up as, first a positive statement then the bad news, and then a positive statement to take the edge off things.

In a way, the Shit Sandwich just makes sense.  You disarm the learner by starting off with a nice soft, chewy, sweet slice of hamburger bun.  Mmmm.  Everybody feels warm and fuzzy, and you’ve bought yourself some good will. Then you bring on the meat/grilled veggies: “Here’s what you’re doing wrong…”  Finally, to make sure nobody’s feelings are hurt, at the end of it all you remind them just how great they are by giving another positive remark.

Learners are savvy to this so you’re not surprising anyone.  They know exactly when to start paying attention.  While you might think they’re enjoying that first slice of bread, they’re just bracing themselves for the bad news to come.  And then, when you’re wrapping up that second positive reinforcement, they’re actually still stuck on whatever deflating comment you’ve just given them.  All the learner hears is the negative, the two positives just fly right by.

Furthermore, by placing the negative component in such a prominent position – isn’t it the ‘meat’ of the matter? – educators have conditioned learners to think of feedback either as negative reinforcement or as punishment.  It is never associated with anything positive.  Pulling someone aside for feedback immediately sets them on the defensive.  How can we ever reinforce positive behaviors if the mere mention of feedback closes people off?

Finally, it leaves out a component that is essential for adult learners: “Where to from here?”  The adult appreciates that their actions have been sub-optimal, but they also need to know what to do better next time.

A Different Way

S.S. has its merits, and I’ve used it and will continue to use it when appropriate.  But consider incorporating a new tool into your armamentarium: S-FED.  This method, promoted at our institution by several EM educators and by Faculty Development, is based on a paper by Dr. Hershey Bell that appeared in Family Medicine in 2007 (see below).

S-FED:

  • S – Self Assessment (What do you think went well during that resuscitation?  What do you think you need to improve on?)
  • F – Feedback (Open faced sandwich! Split evenly between positives and negatives, build off of ‘S’.)
  • E – Encouragement (Empathizing with the learner and taking their side, while simultaneously pushing him or her just beyond “the limits of their knowledge and skills.”  See examples in the article.)
  • D – Direction (As in what direction should the feedback be taken.  How to use the feedback in a productive manner and what concrete steps to take.)

This is a tool that can be used in a variety of settings, including periodic formative evaluations and to give feedback following a classroom lecture.  S-FED can even be incorporated into bedside teaching.  Take, for example, the 1-Minute Preceptor and its five microskills: Get a Commitment, Supporting Evidence, Teach, Reinforce, Correct.  Now let’s modify it.  The last two skills – Reinforce and Correct – essentially mean “give feedback”.  So, when you are done with the Teach segment (microskill #3), simply transition to S-FED: “How do you think you did managing that cardiac arrest?”, and keep going from there.

The final bedside teaching construct could look something like this:

  1. Get a commitment
  2. probe for Evidence
  3. Teach
  4. self assesment
  5. Feedback
  6. Encouragement
  7. Direction

How ’bout we call it: GETs FED?

I’d love to hear your thoughts on S-FED, GETsFED, and on any other ways you’ve found to give both positive and negative feedback without “ruining the moment.”  Leave your comments below.

For further reading, check out the following resources:

A Remembrance, Dedicated to Dr. Anne Kastor

I opened Facebook the other day to a post that, at first glance, appeared to be a self written obituary: “I, Anne Kastor, died on July 5th of Ovarian Cancer at age 49.” Though I never knew her to be particularly active on Facebook, it seemed like something she might write. Perhaps an act of activism in the name of cancer awareness? Clicking the link I was driven to tears as I read that she was the one who had, in fact, succumbed to ovarian cancer at such a tragically young age. The “I” was nothing more than a Facebook formatting quirk.

Some way to find out.

Dr. Kastor was a primary care physican and a faculty member of the SUNY Downstate College of Medicine. Of the four years I spent at Downstate, Anne and I interacted for only three. But that short period has had a lasting personal and professional impact on me.

In 2006 I was a member of a group of Downstate students that organized around the idea of opening the first student-run free medical clinic in Brooklyn, NY. We kind of knew what we wanted to do, but we didn’t have a plan. We also knew that students couldn’t open a clinic alone. A physician and faculty champion was needed. Asking around, it became obvious that Anne was exactly the person for us. She had a reputation for caring deeply about her patients (imagine that) and for being a passionate advocate for universal access to health care.  As her obituary said, she was a “life-long advocate for justice.” (See also this 2010 news item from Cornell)

No other names even came up. Downstate is a large medical school that is part of an even larger inner city medical center.  But still, every single person we asked – medical students, faculty, and administration – referred us to Dr. Anne Kastor.

The beginning was tough. We couldn’t reach her. She couldn’t find us. Multiple emails and phone calls, appointments that had to be postponed, scheduling conflicts.  Then, at some point, it just clicked.  When we finally got together for the first time, I knew she was perfect.  Anne was blunt and compassionate, and obviously had no patience for the B.S. politicking that public institutions are notorious for.  That said, she also understood how the system worked, and knew how to work it to her advantage.

Anne met with the group regularly, and from the first moment she insisted we call her by her first name, not Dr. Kastor.  She was the first physician I have ever known by their first name.  This may not seem meaningful to some, but in such a formal environment it was like a beacon of compassion and practicality.  We all complied, of course.  All of us, that is, except HL (who I hope will read this) who, for three years, insisted on calling her Dr. Kastor, despite his own generally casual personality.  I think this was driven by a deep respect and admiration that we all felt for her.

She always made herself available to us, arranged for meetings with hospital leadership, and generously gave from her wisdom.  She gave us the freedom to explore all of our ideas while keeping close tabs on our work, and she never hesitated to rein in the group when our visions for the clinic bordered on delusional.  Then, when the Brooklyn Free Clinic (BFC) finally opened its doors after 18 months of hard work, she become its first, and for several months its only, preceptor.  That’s when all the other volunteers finally also got to experience the amazing teacher and compassionate physician that she was.

Anne was key to the development of the BFC.  I know there was much more to her than this simple, minor act.  But this is how we knew her.  She was an amazing mentor to the leadership group.  She was an inspiring clinician to all of the volunteers.  And she reminded us that primary care is not dead.  Even in this difficult practice environment, Dr. Kastor showed us, and taught us, the essential role that the primary care physician plays in her or his patients’ lives.

Her approach to medical care was hard-wired into the BFC’s operations manual and lives on in the generations of students who have grown in to physicians under her care, and in the weekly clinic sessions that continue to provide comprehensive, high-quality medical care to the uninsured in Brooklyn.

Thank you, Anne.  I will miss you.  We will all remember you.

(And sorry, Anne, I imagine you might have found this a little too sentimental)

Is there a doctor on board?

6a00d8341d843653ef0133f34a5c04970b-800wiWas just reading a review of outcomes of medical emergencies on commercial flights by Peterson et al published earlier this year in JAMA.  I’ve got a particular interest in this topic since my life is divided between two continents and I’ve been involved in several of these cases over the years.  It’s basically a summary of observational data from an emergency call center that contracts with major airlines.  Nothing earth shattering of course, though I was surprised to read that the youngest in-flight death they recorded was a baby only 1 month old.

One handy piece of information included in their appendices was a list of the supplies and meds contained in the Emergency Medical Kits (EMK) required by the FAA.  This has always been a popular topic of discussion and conjecture amongst my friends.  Now, we can debate why or why not to get involved, and to what extent.  But, assuming you choose to put your most beneficent foot forward, read on to see what kind of goodies you should  find on board (this paper by Sand et al demonstrates plenty of variability despite regulation).

For background, the Air Transport Medicine Committee of the Aerospace Medical Association (AsMA) has developed it’s own recommendations, a last iteration of which seems to have come out in 2007.  Here are the actual FAA guidelines.  And finally, for your reference, here is what you will find during your next in-flight emergency (see bottom for elective supplementation), per Peterson et al:

1) Required contents of EMK

  • Airways, oropharyngeal
  • Adhesive tape, 1-inch
  • Alcohol sponges
  • CPR mask
  • IV administration set
  • Needles
  • Protective gloves
  • Sphygmomanometer
  • Stethoscope
  • Syringes
  • Tape scissors
  • Tourniquet
  • Manual resuscitation device with 3 masks
  • Basic instructions on use of the kit
  • Analgesic, non-narcotic
  • Antihistamine, 50 mg, injectable
  • Antihistamine tablets, 25 mg
  • Aspirin tablets, 325 mg
  • Atropine, 0.5 mg, 5 cc
  • Bronchodilator, inhaled
  • Dextrose, 50% / 50 cc, injectable
  • Epinephrine 1:1000, 1 cc, injectable
  • Epinephrine 1:10,000, 2 ml, injectable
  • Lidocaine, 5 ml, 20 mg/ml, injectable
  • Nitroglycerine tablets
  • Saline solution, 500 cc

2) Additional contents of enhanced EMKs (airline specific)

  • Burn dressings
  • Cord clamps
  • Disposable scalpel
  • Endotracheal tubes
  • Emergency tracheal catheter
  • Glucometer
  • Laryngoscope blade
  • Steri-strips
  • Thermometer
  • Tourniquet
  • Urinary catheter
  • Calcium chloride
  • Diazepam
  • Digoxin
  • Glucose gel
  • Furosemide
  • Lorazepam
  • Haloperidol
  • Hydrocortisone
  • Meclizine
  • Methylprednisolone
  • Metoprolol
  • Morphine
  • Nalbuphine
  • Naloxone
  • Promethazine
  • Sodium bicarbonate

Catching or Tubing

And with that began a debate that might have deteriorated into an all out brawl had the participants been standing face to face.  This came on the heels of yesterday’s excitement around the question of stopping clinical studies early for harm, but not for benefit (see Seth Trueger’s final thoughts on this at MDAware).  Ah, FOAM, how I love thee.

Catch a baby or intubate?  Two generally unrelated skills, unless one is intubating a neonate (not at all unlikely in the EM world, yet unrelated to the current discussion).  The real question here is whether AW management via endotracheal intubation trumps baby-catching, or vice-versa, given the constraints of medical education.

In the onslaught of tweets that followed, Minh Le Cong, Steve Carroll, Seth Trueger, Taylor, Nicholas Chrimes, RivkaMD, Crystal Upshaw and I duked out the merits of each procedure.  The discussion wandered, as Twitter debates often do, lost context, went off on a tangent, and then returned to the initial question.  I don’t think we came to any conclusions, but Minh has promised us a poll.  He has also kindly Storified most of the conversation here.

People’s comments really helped me reflect.  And I’ll admit, I wavered for about a minute and a half.  But if one must choose, I still think that delivering babies should be preferred to intubation for medical students.  The reasoning doesn’t fit into 140 characters so I hope to spell it out a little better here, and perhaps to buy some converts.

  1. Catching babies is easy – My Ob/Gyn colleagues will (hopefully) forgive me.  The delivery of a low risk pregnancy could be handled by virtually anybody with minimal training.  Not that it should be, but it could be.  A high risk delivery is an entirely different story, and immaterial to this discussion as it requires high levels of expertise that will not be available to the student anyway.  It is possible, within the constraints of an ObGyn rotation, to teach a medical student to handle a simple delivery.  Furthermore, maintaining proficiency does not require frequent repetition and practice.  There are no complicated pieces of medical equipment to be handled, no special dexterity is required, and the common technique is generally a simple one.  In the end, all we are doing is facilitating an entirely natural process.
  2. Catching babies is practical – It doesn’t happen every day, but on occasion babies are delivered on the street, in taxis, trains, buses, offices and other unexpected places.  Our valets generally host 1-2 curbside deliveries per year.  It is helpful, and rarely harmful, to have a physician around who may be able to help ease a woman’s stress in a very challenging time.  Even minimal knowledge will bolster the doc’s confidence.
  3. Society expects it – If there is one thing society expects physicians to do, it is to be able to deliver a baby.  Yes, we must be able to resuscitate in accordance with standard protocols, and everyone thinks we should auscultate hearts and lungs, hold hands, and be good listeners.  But between intubation and delivery, intubation seems to be expected only of master resuscitationists while delivering a baby appears to be within the bounds of any purview (anecdotal, I do not have any data for this).
  4. Most students will never intubate again – Resuscitationists intubate.  Some surgical specialties intubate.  The vast majority of doctors will never need to perform invasive airway management.  It is a procedure that should be demonstrated, and can be taught, but is in no way essential to a student’s medical education.
  5. Intubation is hard – Forget about RSI for a minute.  I concede that we could standardize RSI to a degree that would allow any physician certified in ACLS to appropriately administer sedatives+paralytics.  The problem is the manual skill.  Laryngoscopy and intubation both require a level of dexterity obtained over time and maintained only by constant practice.  A student can be taught how to intubate.  He or she might even attain a level of proficiency over the course of a few weeks in the OR or the ED.  And yet, once that student puts down the laryngoscope the skill fades and is eventually lost.  To expect that student to pick up a laryngoscope five years down the road and successfully intubate a patient while maintaining expected safety standards is unreasonable. It may even directly harm the patient.  How many unsuccessful tubes have you seen?  Disaster, no? And then, going down the road of failed intubation, should this same student also be able to complete the VORTEX?
  6. You need equipment to intubate – Most of us do not carry scopes, tubes, suctions and BVM’s in our cars.  Those of us that do are probably docs and medics who intubate on a regular basis anyway.
  7. Intubation is non-essential -Endotracheal intubation must be separated from general AW management which is an essential skill.  If you are a doctor you must know how to assess, clear, and maintain an airway.  But this can all be done via positioning, manual manipulation, insertion of oro-pharyngeal and naso-pharyngeal airways, and the use of laryngeal-mask airways.  These techniques, together with appropriate ventilatory management, are almost always able to maintain adequate oxygenation/ventilation at least until the next level of care is available.  Why risk killing a patient, or significantly impeding the advanced practitioner’s ability to intubate a patient, due to the clumsy efforts of an inexperienced provider?
  8. Intubation can be learned later – I wholly agree with the notion that earlier training allows for more practice and hence increased proficiency.  And yet this logic only works for those who are going into fields of medicine that require advanced airway management.  Exposing students to intubation is beneficial, but it does not replace formal AW training as a resident/fellow, etc. (including the entire continuum of contingencies).

In the end we are merely debating an interesting hypothetical whose answer won’t have implications for most of us.  But the underlying question of which skills to teach in the short time we have with medical students is an important one.  By way of generalization, perhaps answering the following questions can help guide future decisions:

  1. Is the skill easily learned, practiced and assessed during the rotation?
  2. Is the skill relevant to the rotation and is it part of the common practice?
  3. Is skill-specific proficiency retained or rapidly lost over time?
  4. Will this skill be useful to a broad set of medical students?
  5. Does this skill require specialized equipment not available outside common medical settings?
  6. Will teaching this skill expose patients to unacceptable risk?
  7. Would partial knowledge or inappropriate implementation confer significant risk to patients?
  8. Will this skill improve patient care in any way?

Medical school should prepare the student for further learning as a physician.  It cannot teach every future doctor everything they need to know.  The trick is to find the cut-off.  It’s a balancing act between what’s cool and fun, what we (educators) love to do and think is important, and what students need to know in order to decide on a career path.  Intubating is cool and fun, it’s essential for those of us who frequently deal with critically ill  patients and it could influence a student’s choice of specialty.  But, in the end, it is not a critical part of a student’s training since alternate AW management techniques abound, and the skill will be lost by all but a few.  Catching babies, on the other hand, is also cool and fun, and can influence a choice of specialty.  No, it’s not a critical skill, but it is one that everyone thinks doctors should be able to perform.  And if you’re not going to learn it in medical school, you’ll not get another chance until that baby is ready to drop into your hands.

2013 NSLIJ Pediatric Emergency Medicine Symposium

Today we attended the PEM Symposium organized by the North Shore LIJ Health System at the NY Academy of Medicine. Usually I don’t enjoy shlepping into the city unnecessarily, but this conference was different. Great speakers, fascinating topics, and I think we all learned a lot from our Pediatric colleagues.  Here is the conference flier: Pediatric Emergency Medicine Symposium.

Several fellowships and residencies were in attendance, and Allison Harriott of King’s County/SUNY Downstate was also live tweeting from the NYAM.

To read a Storified version of our notes, and to get some excellent pointers about current and upcoming practices in Pediatric EM, visit this link.

And by the way, for all you FOAMites out there, don’t forget to follow EMPEM.org for PEM pearls, procedures, and podcasts.

Updates, Updates, Updates

Working on some new posts, but in the mean time have updated the Conferences and Conference FOAM pages.  Newly added dates and location for the next SMACC, The Crashing Patient, IEMTC, Developing EM, and a boatload of new conference hashtags that have popped up over the last few months.  The Conference FOAM page now includes links to new SMACC resources as well as an IEMTC teaser.

All past meetings have been moved to the Conference Archive, and links remain active.

If you know of any other conferences that should be included, or of any other conference related FOAM resources, please let me know so I can add them to the list!

Addendum – 

  • The next conference to go online will be CAEP13 from Vancouver.  Hoping that many FOAMites will be there.  BoringEM’s Brent Thoma will be live tweeting on behalf of Academic Life in EM as @ALIEMconf

A Lull in the Action

beach-scene-wallpaper-2It’s been pretty quiet here and on my Twitter feed for the last few weeks.  In fact, turns out I haven’t done much writing, or even reading, over the last month.  The absurdly long hours of a wonderful MICU month melted into a much needed vacation so that now I feel completely out of the loop and also quite behind on my studies.  Will be catching up on both, soon.

We are in fact still on vacation, but production will resume in a few weeks.  First, will get back to the conclusion to “Let the Junior Intubate?” And then I hope to be adding some more FOAM and conference resources.

Thanks to everyone who continues to check-in.  Please keep an eye on the Twitter feed, subscribe to the blog, or just visit again in a little while…

David