Trick of the Trade: How are they so smart at the Poison Control Center?

In an upcoming issue of the ACEP News "Tricks of the Trade" column, Dr. Caitlin Bilotti and I author a sneak peak into the resources that the Poison Control Center toxicologists and pharmacists have. These specialists are just plain smart, but they also have access to encyclopedic databases of everything toxicology-related.

One such database is the POISINDEX System. It contains more than 5,000 detailed management documents providing information on clinical effects, range of toxicity, and treatment protocols for the handling of exposures to specific substances listed, as well as general categories of substances. POISINDEX can be accessed via TOXNET at http://toxnet.nlm.nih.gov/.


TOXNET stands for Toxicology Data Network. Begin your navigation by first selecting the HSDB (Hazardous Substances Data Bank) database in the left column. Type the substance of interest, and click “Search”. Then in the new window, select the specific toxin name. Click on “Emergency Medical Treatment” in the table of contents sub-section on the left side of the screen. This will bring you to the POISINDEX information. Here you will find a summary of expected clinical effects by organ system, recommended lab tests, and treatment protocols including antidote information.

Below is a video demonstration of how you can navigate TOXNET to learn about:

1. The treatment for lithium overdose
2. The contraindication for physostigmine administration in benadryl overdose

Sorry for the background piano music. I'm playing around with iMovie's audio masking features. Be glad I didn't go with the banjo music...

Work in progress: Tips on finetuning powerpoint lectures

The ACEP Scientific Assembly is coming up next week in Boston. I am presenting 3 lectures.

• Acute Limb Ischemia
• Lifelong Learning and Self Assessment Review: Part 3
• Tricks of the Trade

Since I wrote the lectures a few months ago, I am starting to review what I wrote! Conferences usually have speakers submit all their lecture material months before the conference. I thought I would share some of the basic rules that I follow in building powerpoint presentations.

I find that you can be the best speaker in the world, but if you have visually distracting slides, your talk comes out only average. These are only my opinions, and you should develop your own style and preferences.


1. Font consistency and visibility

• I typically choose a sans sarif font such as Arial. I find it easier to read on a screen. Less busy than sarif fonts such as Times.
  
• Be sure that you are using the same font throughout the slides. This is a pet peeve of mine...
  
• Be sure that the font size is large enough so that audience can read the slide from over 30 feet.

2. Colors

• Choose a non-busy dark background. Notice the great speakers will have a very unobtrusive dark background. The next time you are at one of Dr. Amal Mattu's talks, check out what background he uses. I think it's just a plain black background.
• Use only only a few text colors. I use 2-3. Generally they are yellow (headers), white (main text), and light blue for emphasis. These colors pop off a black or very dark blue background.

3. Images

• Make the images large enough so that everyone can notice the details.
• Be sure images are high-resolution and not grainy. Another pet peeve of mine. It makes you look lazy if you have a fuzzy image of a xray, EKG, or clinical finding.
• Don't use an image if you don't need to. It's distracting.

4. Intra- and inter-slide transitions

• Referring back to yesterday's post about how our brain learns, the goal of teaching should be to maximize "germane load" (relevant information) and minimize "extraneous cognitive loads" (white noise which doesn't contribute to learning). To me, transitions between slides falls in the latter. This is also true for busy transitions between sentences.
• On busy slides with lots of text, I sometimes use a transition feature such that lines of text appear only when I talk about them.

If you want to be even more geeky (like myself), check out the Presentation Zen blog. The author Garr Reynolds has some really great ideas on presentation, coming from the perspective of a designer. I especially love the blog post where he compares the contrasting presentation styles of Steve Jobs and Bill Gates. No wonder Mac is kicking PC's bottom.

Article Review: Literature review of computer animations for medical education

"Animation is a series of images designed so that each image appears an alteration of the previous one, and in which the sequence of images is determined by either the designer or the user."

I came across this article evaluating the effectiveness of computer animation in learning, after having build an EM radiology animation module in a previous blog post. While I think it's cool, it would be nice to know if this approach to learning is better than showing just static images. From an instructor's standpoint, still images would be much easier to create.

There were many fascinating concepts in this article. For me, there were 4 key take-home points from:

1. There are very few (and often conflicting) studies evaluating the effectiveness of animation vs static images in medical education.
2. Allowing learner control of the animation pace improves the effectiveness of the animation.
3. Building shorter (more digestible) animation pieces improves the effectiveness of the animation.
4. There is a "cognitive load theory" which attempts to explain how people learn. The authors describe how animation fits into this framework.

Cognitive Load Theory Humans have a "working memory" center, which processes new information. Some of this information is stored in "long-term memory". There are 2 major types of information, or "cognitive loads".

• Germane load: Information that contributes to learning.
• Extraneous cognitive load: Information that takes up cognitive "space" in your working memory but does NOT add to effective learning.

Extraneous cognitive load (a.k.a white noise) wouldn't be a problem for learning except that our working memory has only a limited capacity for information. This contrasts long-term memory, which has no limits. So the goal behind teaching should be to maximize germane and minimize extraneous cognitive loads.

Cognitive Theory on Multimedia Learning
This theory builds on the "cognitive load theory" concept. It is known that people process information using visual and auditory pathways. Learning is improved if both pathways are engaged. That means both images and spoken words should be used (keeping in mind to minimize the extraneous cognitive load) to optimize teaching and learning.


So bringing this back to animation, what should we keep in mind if building animations for education?
Animations are not always superior to still images. Ask yourself, will the animation be more distracting than useful? Will this be considered a germane of extraneous cognitive load? Preliminary studies showed that building user-triggered controls, where the learner can control the animation pace or flow, improves learning comprehension.

Table 2 poses some interesting research questions, if you are interested in pursuing research in this area.

Click to enlarge table.

Reference:
Ruiz JG, Cook DA, Levinson AJ. Computer animations in medical education: a critical literature review. Med Educ 2009;43:838-46.

TGIF: Project 10 to the 100 - Vote for free online education

Google launched a call for ideas in 2008 called "Project 10 to the 100". The only criteria was that the idea would need to "help the world". They selected 16 of the best ideas and now are asking for the public to vote. Google is committing $10 million to these projects.

While all look amazing, one caught my eye immediately:

Making online educational content
available for free!

This is an incredible opportunity for those of us in medical education (and a niche in educational technologies).

Go cast your vote NOW at Voting Link.
Voting begins today and ends October 8.

Other ideas include:

• Encourage positive media depictions of engineers and scientists
• Build better banking tools for everyone
• Work toward socially conscious tax policies
• Collect and organize the world's urban data
• Create more efficient landmine removal programs
• Drive innovation in public transport
• Build real-time, user-reported news service
• Make educational content available online for free
• Create real-time natural crisis tracking system
• Make government more transparent
• Help social entrepreneurs drive change
• Provide quality education to African students
• Create genocide monitoring and alert system
• Enhance science and engineering education
• Promote health monitoring and data analysis
• Create real-world issue reporting system

Hot off the press: CDEM meeting agenda at ACEP

The agenda for the Clerkship Directors in Emergency Medicine (CDEM) meeting at the American College of Emergency Physicians (ACEP) annual meeting is set! This was just sent out by the CDEM Chair, Dr. Dave Wald (Temple). If you are going to be in Boston, MA on October 6, come join us! Some exciting and practical topics will be discussed.

Tuesday, October 6, 2009
1:00pm – 4:00pm
Room TBA
Boston, MA

1:00pm – 1:15pm
CDEM Update

1:15pm – 2:30pm
Best practices for EM Undergraduate Medical Education

2:30pm – 2:45pm
Break

2:45pm – 3:45pm
Best practices for EM Undergraduate Medical Education (Continued)

3:45pm – 4pm
Wrap up

The goal of the "Best Practices" sessions is to be interactive. Based on the size of the audience, we may break everyone up into small groups and have a team based approach. Below is a preliminary list of topics. Additional topics may be presented depending on time. It would be best to spend an hour or two thinking about some of the below topics questions and prepare some ideas coming into the sessions.



1. Educational guidelines ED–2 and ED–8 from the Liaison Committee in Medical Education (LCME) regarding standardizing the medical student experience in terms of what patient conditions (s)he must encounter before graduation.

• What types of patients, clinical conditions, procedures, tasks must students encounter during your rotation?
• How did you develop your list?
• How do you keep track of this and how to you remediate?
  

2. Educational guidelines ED–26 from the LCME, regarding the assessment of competency and evaluation of clinical skills

• What type of shift evaluation cards or other methods of student evaluation do you use?
• Do you employ any type of procedural competency checklist?
• What are your clerkship competencies?
• How do you evaluate your clerkship competencies, RIME, etc.?
• Do you employ any direct observation of clinical skills?

3. Standardized Letter of Recommendations (SLOR)

• Who writes them at your institution?
• Are the letters mandatory or voluntary?
• Bring examples of challenging letters for discussion
• Ways to improve the letter?
• How many should a student get?

4. Mentoring students with academic or other challenges, etc.

• Student’s with poor USMLE Step I scores
• When should they take USMLE step II
• How many programs should students with fair-average grades apply to?
• Couples match advice?

This agenda is to give you an idea of what we, as medical student educators, talk about on the national level. I'll be at the second half of this CDEM meeting, because I'm lecturing on "Acute Limb Ischemia" at the same time during 1:30-2:30 pm. I plan to hurry over after my talk, because I always learn lots from our discussions. Come join!

Trick of the Trade: Style points in pediatric orthopedics

With this hot summer season in California, kids have been running around and getting into all sorts of orthopedic troubles. Monkey bars are a common culprit. In treating pediatric patients in the ED, it's worth spending an extra few minutes on the subtle style points.

You should consider keeping a stash of stuffed teddy bears in the ED for those patients, whom you splint or cast. It is a nice touch to have the patient go home with a teddy bear with the same "injury" and splint/cast.

It's the little touches that will make
your patient's day a little less sucky.

Work in progress: Video production for KidsCareEverywhere

I'm not sure whether this is a wise idea, but I'm keeping with the theme of this post being a "Work In Progress."

I have been spending every waking moment (when not working) producing a video documentary for KidsCareEverywhere (KCE), a non-profit organization. I was part of a 5-person KCE team, who traveled to Vietnam last month. We distributed a clinical-decision support software called PEMSoft to pediatricians and taught an all-day conference at National Hospital of Pediatrics on how to incorporate it into real-time care.

This Saturday, KCE is having its inaugural fundraiser (download the brochure) and is going to play my 10-minute video. I have been posting the unfinished video productions on YouTube for feedback from KCE members. I've been sorting through hours of video footage and 1000's of photos, trying to distill and capture the essence of what we accomplished in Vietnam. I am learning tons about the newest version of iMovie, Quicktime, Flash, and Photoshop.

This is the most recent version of the KCE video, and will be changed out with every new version.

Final version!

Any suggestions or comments welcome. I've lost objectivity after looking so long at these images, videos, and music. I've received a lot of great ideas and the video is a result of a group effort. Thanks to Ron, Marlowe, Jamie, and Unity for their time.

Article review: Unethical practices during interview season

Residency interview season is almost upon us!

Tours, interviews, lunches... oh my.

A timely article published in Academic EM discusses unethical recruiting practices and illegal questions by the interviewing program. In 2005 and 2006, an anonymous online survey was given to all residency program directors to give to their newly matched intern PGY-1 class. The researchers collected a total of 671 survey responses.

Results

• 8.3% stated that they were asked to disclose at least one program's position on their supposedly private rank list by a program representative
• 6.6% matched at a program lower on their rank list than another program, which had told them that they were "ranked to match".
• 30% were asked an illegal question during their interview
• Survey response rate = 28%. Although this is a small proportion of the applicants, it gives a very rough estimate about the prevalence of unethical practices and illegal questions. We do know, however, that the Match practices in EM are not perfect.
  

What's the National Resident Matching Program "cardinal rule"?
The residency program and applicant can NOT ask how they are going to be ranked on each other's rank list. It is ok to express interest, but that's it.

Note: If you get a phone call or email saying that a program "plans to rank you highly", it is only expressing interest. It does NOT guarantee that you will be "ranked to match". This is totally legitimate.

What is considered an illegal interview question?
Based on Title VII of the Civil Rights Act of 1964, one can not be discriminated against for employment based on race, color, religion, sex, or ethnicity. In this study, the most commonly asked illegal question revolved around marital status. Less common infractions involved questions about having children, planning for children, religion, ethnicity, and sexual orientation.

Having been an interviewer before, there is a loop hole. If the interviewee broaches the subject first, it's fair game for discussion. If you (as an applicant), want to talk about your wife/husband, you should start the conversation first.

What do you do if you get asked an unethical question? This isn't part of the article, but I've always wondered what applicants have done in the past. As an interviewee, it's always awkward to tell the interviewer that they just asked an "off-limits" question. Two humorous techniques that I can think of:

• Don't pause and answer quickly (and vaguely if possible), followed immediately by asking the same question to the interviewer. Question: "Are you married?" Answer: "In a prior life. Are you?"
• Tell such an exaggerated lie that the interviewer knows that you are kidding. Bonus points for diverting the conversation immediately afterward. Question: "Are you married?" Answer: "Twenty times. Just can't get it right. Hey, is that a picture of Venice, Italy? My parents got married there..."

Funny food for thought
Is it wrong to answer an unethical question with a lie, knowing that it's unethical to lie? I figure two wrongs make a right...



Reference
Thurman RJ, Katz E, Carter W, et al. Emergency medicine residency applicant perceptions of unethical recruiting practices and illegal questioning in the Match. Acad Emerg Med 2009; 16:550-7. Pubmed

TGIF: Think about attending CORD Academic Assembly in March 2010

The Council of Residency Directors (CORD) in EM hosts an annual education-centric meeting. If you haven't heard of this before and you are interested in education, this is the meeting to be at. The next one is March 3-6, 2010 in Orlando, FL.



The CORD Academy Assembly has to be the most inspiring, rejuvenating, and motivational conferences in EM for educators. It's a must-go for chief residents, medical education fellows, and junior faculty in academic EM. It's a relatively smaller (and thus more personable) conference where you are surrounded by star educators, learning and teaching alongside each other. I'm talking Dr. Diane Birmbaumer, Dr. Amal Mattu, Dr. Rob Rogers, Dr. Gloria Kuhn, Dr. Sue Farrell, Dr. Wendy Coates... I'm sure I'm leaving lots of names off. You'll feel smarter and more inspired just sitting near them!

Take a look at the 2009 CORD Academic Assembly line-up at:
http://www.cordem.org/09aaa/main2009.html

New this year, however, is an additional track -- the Clerkship Directors in Emergency Medicine (CDEM) track. This track is dedicated to faculty and residents interested in medical student education and features many of my CDEM colleagues. In the CDEM track, I'll be there giving an "Education Journal Club 2009" with Dr. Sorabh Khandelwal ("The" Ohio State Univ). We will review the top 10 EM education articles from 2009.


Also, I just was invited to help mentor a group of people on the pre-day for the Medical Education Research Certification (MERC) track. I'll be looking for residents/fellows/faculty to work with, who might be interested in brainstorming about research in medical education, as it relates to technology (simulation, computer-assisted education, web 2.0). I'll be sure to blog about it in March.

Come join!

Here's the link to the CORD website: http://www.cordem.org.

Hot off the press: Birth of new journal in Emergency Medicine

Welcome to the newest member of the EM journal family:

Open Access Emergency Medicine

Thanks to a fellow faculty member Dr. Rob Rodriguez (our SFGH EM Research Director), I just heard about a new international, online-only journal in EM - Open Access Emergency Medicine. Rob is on the prestigious editorial board. Online open-access journals, I think, are going to be the way of the future.

Website:
http://www.dovepress.com/open-access-emergency-medicine-journal

Open Access Emergency Medicine is based on an open-access publication model. This new model puts the burden of cost on the author rather than on the reader. Instead of subscribing to journals, the public now has free, open access to articles in these journals. Authors, whose articles which are accepted after peer-review, front the cost. This one-time, per-article submission fee is approximately $1,200. This fee seems a bit steep to me, but I applaud the concept of an open-access EM journal. Furthermore, this journal is online only.

The submission fee for OAEM is

being completely waived for all articles
received by December 31, 2009!

I don't know about you, but I'll be digging up an article which I wrote last year and got rejected from the first journal that I submitted to. Just wanted to let people know about this amazing opportunity to help launch a new online, open-access journal.

Trick of the Trade: The key to pollution is dilution

Wound care mantra: "The key to pollution is dilution."

High-pressure irrigation best reduces the patient's risk for a wound infection. Open fractures are unique in the ED in that they require quick, high-volume irrigation before going to the operating room for more definitive wash-out. Often times a 30 mL syringe and 18-gauge angiocatheter is too cumbersome and slow for high-volume, high-pressure irrigation.



In this patient, who is being pre-op'd for operative washout and repair of a grade 1 open tib-fib fracture, high-volume irrigation should be performed quickly. This can be done by punching several holes through the plastic cap of sterile saline bottles, using an 18-gauge needle. Multiple people can help with irrigation, while the patient is being mobilized to the OR.

Photos and patient consent
obtained by Lourdes Adame,
SFGH Visual Aid Project photographer.

New EM radiology teaching idea: Wrist dislocation

What do you think is the best way to teach EM radiology?

Think outside the box.
Think beyond textbooks.
Think beyond static webpages.

I'm toying with the idea of using interactive Flash elements to teach radiology for emergency physicians. It's time intensive to build these modules, but the pay-off may be worth it. What do you think?

I've incorporated this approach to teaching radiology in a few of my past lectures, but I've never done so online. Here is my debut of a Flash-based teaching approach to reading plain films of the wrist.

Roll your mouse over the words to highlight the bones.

Image set #1: Normal xray of the wrist (AP and lateral) with key identifiable structures


Image set #2: Perilunate dislocation
For all plain films of the wrist, be sure to look at the lateral view for the 4-bone alignment (distal radius, lunate, capitate, 3rd metacarpal). Oftentimes, dislocations such as this perilunate dislocation are missed.


Image set #3: Lunate dislocation
Just yesterday, a Chicago Bears player Brian Urlacher sustained a lunate dislocation, which requires operative repair. Notice that the lunate appears abnormally as a triangle-shape on the AP view, instead of the usual cuboid shape. Furthermore, the lunate has "spilled" volarly on the lateral view. Both perilunate and lunate dislocations place the patient at risk for a median nerve injury.

Article Review: Using medical interpreters

The United States is becoming culturally and linguistically diverse. Consequently, cultural competency should play a crucial part in the medical school curriculum. Specifically, all medical practitioners should know how to properly work with medical interpreters in patient encounters. I never was trained in this skill and unfortunately learned more by just doing.

A 2007 article in the Journal of General Internal Medicine focused on building two instruments which assessed how effectively medical students use medical interpreters. To me, the most helpful part of this whole article is the list of assessment criteria for these instruments.

• Interpreter Impact Rating Scale (IIRS) - Standardized patient uses this score sheet.
• Faculty Observer Rating Scale (FORS) - Faculty, who is observing, uses this score sheet.

Pearls on using medical interpreters:

1. Look more at the patient than the interpreter during the clinical encounter. Direct eye contact with the patient builds rapport and trust.
2. Talk to the patient in the first person ("How strong is YOUR chest pain?" instead of "Can you ask the patient how strong her chest pain is?")
3. Introduce the interpreter and his/her purpose at the beginning of the interview.
4. Ask the patient one question at a time to make it easier for the interpreter to translate accurately and to allow the patient time to listen and answer.
5. Don't interrupt the patient and interpreter when listening to the answers.
6. Present information to the patient (through the interpreter) in "digestible chunks".

The study involved medical students taking a history from standardized patients with faculty observers. The standardized patients and the faculty observers completed the IIRS and FORS scoresheets, respectively. Both scores were compared to scores from a general communication skill assessment instrument - the Physician Patient Interaction (PPI) scale.

Result/ Conclusion

The itemized scores for the IIRS and FORS tools are listed in the figure below. The IIRS scores correlated well with the general PPI scores (r=0.88, p less than 0.0005). Oddly, the FORS scores did not correlate with the PPI scores (r=-0.22, p=0.32). Regardless, the authors have created two useful instruments to assess students' ability to appropriately use medical interpreters. More research should be done to determine their validity with actual (not standardized) patients.

IIRS and FORS scores (click to enlarge image)

Reference:
Lie D, Boker J, Bereknyei S, Ahearn S, Fesko C, Lenahan P. Validating measures of third year medical students' use of interpreters by standardized patients and faculty observers. J Gen Intern Med. 2007 Nov;22 Suppl 2:336-40. View entire article.

TGIF: Sharing photos using "Bump" iPhone app

The "knuckle bump" has clearly become a part of our culture as an informal means of salutation or as a high-five. It's no surprise that it's been incorporated in the "Bump" iPhone app, as a means for sharing contact information and photos. This is done wirelessly between 2 iPhone users.


You only need to gently bump fists with another iPhone user, while each person grasps his/her iPhone. This can serve as a high-tech way of swapping business cards, but instead paperlessly. I've been using this to share photos amongst my friends without having to email them. Check it out - it's a free app.

I'm closely watching to see if the company will expand on this and incorporate the sending of PDFs files. I envision bumping fists with a medical student at the end of the shift. "Nice job, dude. Now go read this article on NOT treating asymptomatic hypertension in the Emergency Department that I just bumped to you." How fun would that be?!

Video demonstrating Bump in action:

Must-know toxicology website for emergency physicians

With recent discussion about the potential closing of California Poison Control Centers due to budget cuts, I suddenly became shockingly aware of how much Emergency Departments depend on these centers for assistance. They are always so knowledgeable and helpful in managing various ingestions and poisonings.

How do the Poison Control Center folks know so much?!
First of all, they are all just plain smart. In addition, I recently discovered that they rely on the TOXNET website, which houses the Toxicology Network Database. This is a public website. Check it out!



If you click on the less-than-obvious link "HSDB" in the left column, you will enter the Hazardous Substance Data Bank. Here you can search for any ingestant or chemical. For instance, you can search for lithium, digoxin, or MDMA (ecstasy). The website provides extensive information about the hazardous substance, but if you want to get to the "meat" of the information, go straight to the section on Emergency Medical Treatment.

Although there isn't an iPhone app for this website yet (hmm idea?), you can go the TOXNET PDA website which formats the screen smaller so that it fits on your handheld device. This is the website: http://toxnet.nlm.nih.gov/pda.

Trick of the Trade: Peritonsillar abscess needle aspiration

How do you drain a peritonsillar abscess?

When evaluating a patient with a sore throat and “hot potato voice,” peritonsillar abscess (PTA) is at the top of the differential diagnosis list. As with all abscesses, the definitive treatment involves drainage of pus. This can be done either by incision and drainage or, more commonly, by needle aspiration.

Unlike surface abscesses on the skin, there are unique challenges for accessing the PTA.

• The peritonsillar area is not as easily accessed as the skin, and, for this reason, is often poorly lit.
  
• Patients with PTAs often have associated trismus which make it harder for the practitioner to even see, much less aspirate, the PTA.
  
• Vascular structures, such as the carotid artery, lie in close proximity to the peritonsillar space and add a level of complexity to the procedure.

Trick of the trade: Shed some light on the situation.
Visualization is key when aspirating a PTA. Appropriate visualization of the pharynx is made possible by abundant lighting with adequate exposure. A laryngoscope with a curved blade provides both of those elements. With the patient sitting upright and after appropriate anesthesia, gently insert the blade into the patient’s mouth, as far posteriorly as tolerated without gagging. The laryngoscope blade should be inserted, similar to the technique for endotracheal intubation.

Photo courtesy of Dr. Hagop Afarian (Fresno)

A variation on this theme is to use a video laryngoscope in lieu of a direct laryngoscope when teaching this procedure to others. It can both be used to demonstrate the procedure, and to oversee and guide the learner’s technique. Projecting the procedure on a digital screen allows multiple providers to view the pharynx, instead of just the person directly in front of the patient.

Another variation on this theme is actually to have a cooperative patient control the laryngoscope handle. Patients often can provide a great view when they pull their own tongue inferiorly. They can pull without triggering their gag reflex.


Trick of the trade: Use a long spinal needle.
Needle aspiration of a PTA can be done with a 1.5 inch needle on a syringe. However, the barrel of the syringe often can obscure the practitioner's line of sight, as shown in this photo. To optimize the view, use a 3.5 inch spinal needle so that the syringe remains outside of the patient's mouth.

Trick of the trade: When using a spinal needle, always use protection.
A worrisome concern with using a 3.5 inch spinal needle for PTA drainage is advancing the needle too deeply and inadvertently puncturing the carotid artery. A trick to help prevent this is to use a protective guide. Trim the needle’s plastic sheath so that when replaced, only 1.5 cm of the needle tip is exposed. When using the needle to aspirate the abscess, the sheath prevents the needle from over-advancing beyond 1.5 cm.


Thanks to Dr. Hagop Afarian (Fresno), who co-authored this topic with me in a recent ACEP News Tricks of the Trade column!

Work in Progress: Writing letters of recommendations

Residency application season is officially starting!

As of September 1, 2009, medical students can now apply to ACGME-accredited residency programs. This also means that EM faculty are hurrying to finish their Standardized Letters of Recommendations (SLORs). This is what I'm working on all week.

I love the fact that the Council of Residency Directors (CORD) organization created a standardized form. Having read applications, it makes it SO much easier to compare students. See CORD website for form.

Two-page SLOR form (click to enlarge image)

For students applying into EM, I highly recommend reading the template form so that you at least know what you are being evaluated on. It gives you a sense of what residency programs are looking for. In blue are my personal thoughts on some questions:

How long have you known the applicant? If the answer is less than 4 weeks, I wonder how well the letter writer knows the student.

Indicate what % of students rotating in your Emergency Department received the following grades last academic year: This is a crucial piece of information. When I was a student, I didn't even think of the fact that there might be a range of honors rates. Some rotations have a honors rate as low as 7% and others as high as 60%! Having the distribution of grades on paper gives application readers a better sense of the student's grade. For instance, a passing grade in a 60% honors/30% high pass rotation actually places the student in the bottom 10% of students for the year in the EM rotation!

• Total # students last year:
• Honors %
• High Pass %
• Pass %
• Low Pass %
• Fail %

Work ethic, willingness to assume responsibility. Coming into residency, I personally don't expect students to know much about medicine and EM. So, I try to look for teachability and potential to become a great emergency physician. I find that work ethic directly correlates with this. Anyone who isn't scored as Outstanding makes me a little wary.

• Outstanding (top 10%)
  
• Excellent (top 1/3)
  
• Very Good (middle 1/3)
  
• Good (lower 1/3)
  

Compared to other EM residency candidates you have recommended as such last academic year, this candidate is ranked as: This is nice piece of information about the letter writer habits. In the age of grade inflation and hyperboles, this allows readers to see if a writer only gives "Outstanding" global assessment rankings or a distribution of rankings. If the former, an "Outstanding" score on the applicant's SLOR holds a little less weight in isolation.

• Outstanding (top 10%)
  
• Excellent (top 1/3)
  
• Very Good (middle 1/3)
  
• Good (lower 1/3)
• Provide # Recommended as such (for each ranking) last academic year

Happy Labor Day!

Stop reading this blog!

Go out and enjoy this Labor Day weekend.
May you not be laboring today (working in the ED, pregnancy, or otherwise).

TGIF: Back from KidsCareEverywhere trip to Vietnam

Did you know that I was gone to Vietnam for the past week and a half? I wrote several of the posts ahead of time and even posted a few from Vietnam. How DID we survive before the internet?


I just returned from Vietnam as part of the KidsCareEverywhere/UCSF trip to teach a conference for pediatricians at the National Hospital of Pediatrics (NHP) in Hanoi. This is the primary pediatric hospital for the country. The KCE team consisted of Dr. Ron Dieckmann (Chairman of KCE and all-around Pediatric EM guru), Marlowe Dieckmann, Jamie Sharp, Hieu Do, and myself. I was amazed at each of our team member's versatility and creativity in troubleshooting, while also being able to serve as educators (or "intructors" as our misspelled certificates say), photographers, videographers, and ambassadors for KCE. It is incredible what you can get done with a few efficient and competent collaborators.

We were given an all-access tour of the hospital's Emergency Department and Pediatric ICU by our good friend, Dr. Tu Nguyen. As the Vice-Deputy of the Pediatric ICU, he was managing over 30 critical patients, but still was gracious enough to show our team around. He even took our team out for dinner (despite being on-call). The dinner had turtle dishes along with turtle-blood vodka shots, but that's a whole other story...



It was quite overwhelming to see so many critically ill children with sepsis, ARDS, Japanese encephalitis, seizures, and various terminal diseases. There were high-tech ventilator and monitor equipments in otherwise low-tech rooms. There were no computers in sight in the ED and very few in the Pediatric ICU. Their one-room library had reference books ranging from 1980 to early 2000's.


Because of the paucity of computers in the clinical areas, I became worried about how computer-saavy the pediatricians would be. Our conference would be teaching them how to use a new decision-support software PEMSoft (Pediatric Emergency Medicine Software). This could revolutionize how they could access real-time and reference up-to-date information. We had requested that they bring their own laptops, but we were expecting only a few of the 50 registrants to have them. We each brought laptops to loan for the day and planned for many to pair or triple-up on each computer.

Much to our surprise, we found that almost every one of the 55 attendees had relatively new PC-based laptops. The pediatricians had come from across the country and consisted of almost equal numbers of women and men. I had anticipated that Medicine was still a very male-dominated profession in Vietnam.

We introduced them to the concept of PEMSoft and administered a brief multiple-choice pre-test of their knowledge base. This test was written in both English and Vietnamese. This study was IRB approved by the NHP hospital and UCSF.



Upon completion of the pretest, the pediatricians were given the donated CD software. They immediately began to upload the software even before we began the lecture on how to install it! We had assumed that everyone would be uncomfortable with using computers. Boy, were we wrong. We had to constantly catch up with the group's forward pushing momentum! We just had to watch for the few stragglers who were a little less tech-saavy.


After a demonstration of the concept of length-based resuscitation (using an infant's length to determine medication doses and equipment sizes), we gave everyone a retractable tape measure. This drew oohs and aahs from the audience. Notice that my wild hair does not fare well in humidity... Plus I don't think my interpreter was amused by my demonstrating how to use the tape measure on him.

Ron then reviewed how to use the PEMSoft software. From the back of the room, I could see that they were exploring various features on their own. It was so inspiring to see the enthusiastic nature of the learners, despite being in a crammed, hot, and humid conference room with minimal air conditioning. They really wanted to understand everything about the software.

We then broke for lunch and ate with the National Ministry of Health, who also happens to be a pediatric surgeon in the hospital. He expressed how impressed he was with our efforts and medical software.

Back at the conference, we administered the post-test now that the participants have been taught how to use the software. This was followed by a low-fidelity simulation demonstration of how to use the software in real clinical scenarios. Since the participants were extremely engaged and actively participating, we changed our simulation plans on the fly. Instead of Ron and my demonstrating the use of PEMSoft, we asked for volunteers to navigate the software during the simulation. Ron ran through each simulation scenario, while I guided the volunteer on the LCD-projected computer.

Before we knew it, volunteers were popping up left and right wanting to navigate the computer. Ron ran through at least 9 cases! We started with a simple status epilepticus case. Ron paused every few steps and would ask the volunteer for the equipment size, drug dose, recommendations for the next action, etc. The other participants would follow along on their computer, and the volunteer eagerly would answer his questions. The cases got progressively more difficult. You could just see that they were realizing the power of a clinical decision support software at their fingertips.

Looking briefly at our conference conclusion survey, everyone had universally rated it with top scores. Many wished that it was a 2-day conference. The Ministry of Health surprised us all by announcing that PEMSoft is now being named the official software for the hospital.


What's the next step for KCE?

• Finding funds to set up laptops and desktops in the NHP hospital's ED and Pediatric ICU so that they can use the software for real-time clinical care.
• Return to Vietnam to "train the trainers" in a more advanced teaching conference, where pediatricians would learn how to formally teach PEMSoft to their colleagues.
• Continue to customize PEMSoft to Vietnamese. We already uploaded various Vietnamese manuals and resources into PEMSoft (APLS and Newborn Care textbooks).
• Publish data from pre/post tests and survey.
  

While I have never considered Global Health as my academic niche, I can now appreciate it's appeal. It takes so few people to make a substantial difference in underserved countries. In a way, Global Health is a form of medical education.