Paucis Verbis card: Vasopressors and Inotropes for Shock

The treatment of shock should focus on correcting the underlying pathophysiology. With persistent hemodynamic instability, a vasopressor and/or inotrope should be selected. Reviewing receptor physiology can help you select the best-fit agent for the patient's clinical condition. There is an especially useful table on medication selection in the reviewed 2008 EM Clinics of North America article.

This installment of the Paucis Verbis (In a Few Words) e-card series reviews Vasopressors and Inotropes for the Treatment of Shock. Note that this is a 2-carder.

(click for a larger image)

Feel free to download this card and print on a 4'' x 6'' index card.

[MS Word] [PDF]

See other Paucis Verbis cards.

2010 SAEM Meeting: Free drink coupon!

The Society of Academic Emergency Medicine (SAEM) has joined the Web 2.0 community! They created a "New Media Task Force" this year, led by Dr. Nick Genes (Mount Sinai/Elmhurst Hospital), to keep SAEM members updated about the organization, academics, and the specialty emergency medicine.

SAEM's Facebook account has a lot of useful and frequently updated information about regional and national events. If you have a Facebook account, "become a fan" of SAEM. If you don't have a Facebook account, it's finally time to join... and become a fan of SAEM.

Hot off the press:
If you are attending the 2010 SAEM Meeting in Phoenix, RSVP to the meeting to GET A FREE DRINK.

Trick of the Trade: Radial Gutter Splint

Fracture of 3rd metacarpal base

How do you splint 2nd or 3rd metacarpal fractures? A short arm volar splint is usually applied, because a fracture should be immobilized one joint distal and proximal to the injury. This splint, however, unnecessarily immobilizes the 4th and 5th fingers. It makes gripping things with your hand difficult.

Trick of the Trade: Radial Gutter Splint
This splint is the equivalent of the ulnar gutter splint, except that is placed along the radial aspect of the wrist and "sandwiches" the 2nd and 3rd fingers. The radial gutter splint provides both volar and dorsal splint immobilization of these metacarpal injuries.

1. Cut out a 3- or 4-inch splint material to the length necessary to immobilize the wrist and MCP joint.
2. Bisect the splint longitudinally from the fingertips to the wrist.
   
3. Insert a dry gauze or cotton material between the 2nd and 3rd fingers.
   
4. Fold the splint "tails" so that it sandwiches the volar and dorsal aspects of the 2nd and 3rd metacarpal.
5. Secure the splint in place using bias wrap or an ace wrap.

The radial gutter splint provides optimal immobilization of the 2nd and 3rd metacarpals, while allowing for maximal mobility of the unaffected digits.

ICRE Meeting: Abstract deadline Apr 30 for "What Works" in Residency Education

Thanks to Dr. Stella Yiu (Univ of Toronto), who just informed me that the International Conference on Residency Education in Ottawa just extended its abstract deadline on "What Works" to April 30, 2010. The abstracts should focus on educational innovations in residency education and assessment. The conference is going to be held during Sept 23-25, 2010.

The theme of the ICRE 2010 conference is "Residency Education, Reimagined". Sounds like a great conference. Check it out!

Article review: Academies of Medical Educators

What are Academies of Medical Educators?
As defined by Dewey et al [1], Academies are "a formal organization of academic teaching faculty who have been formally (or specifically) recognized for excellence in their contributions to the education mission of the medical school, and who serve specific functions on behalf of the institution . . . . A functioning organization, not simply a group of recognized faculty."

The overarching purpose of Academies is to bring education back as the central focus of academic medicine. They are supposed to have [2]:

1. a mission that advances and supports educators
2. a membership composed of distinguished educators
3. a formal schoolwide organizational structure with designated leadership
4. dedicated resources that fund mission-related initiatives

In 2003, there were only 21 Academies in existence in the United States. Since then, Academies are becoming increasingly popular. This paper describes their survey of all 127 U.S. medical schools to determine the state of Academies as of 2008, specifically in the areas of membership, benefits, and funding.

Results
With an impressive 96% response rate (122 or 127 schools), the authors noted several interesting findings. Although there were tons of interesting descriptive data from the study, here are the main take-home points:

• There are 36 Academies as of 2008 (year of survey), with 21 created on or after 2004.
• Surprisingly, less than half of the Academies (16 of 36) required a teaching or educator's portfolio in the application process. These portfolios are an educator's way to show value to all the teaching and educational scholarship that they do, which traditional CV's don't convey.
  
• Membership benefits primarily are nonmonetary and include: schoolwide recognition (92% of Academies), networking opportunities (78%), participation in faculty development events (50%), importance in promotions and advancement (50%), and mentorship (39%). Faculty development is a central focus of Academies.
  
• Members were selected based on standards or criterion-referenced methods (69%) versus a norm-reference where applicants are measured against each other.

This article is interesting because of it introduces the concept of Academies in medical schools.

The UCSF Academy of Medical Educators was created in 2000 and is going strong. Just sent my application in today. Wish me luck.


References
[1.] Dewey CM, Friedland JA, Richards BF, Lamki N, Kirkland RT. The emergence of academies of educational excellence: A survey of U.S. medical schools. Acad Med. 2005;80:358 –365.

[2.] Irby DM, Cooke M, Lowenstein D, Richards B. The academy movement: A structural approach to reinvigorating the educational mission. Acad Med. 2004;79:729 –736.

Article Reviewed
Searle, N., Thompson, B., Friedland, J., Lomax, J., Drutz, J., Coburn, M., & Nelson, E. (2010). The Prevalence and Practice of Academies of Medical Educators: A Survey of U.S. Medical Schools Academic Medicine, 85 (1), 48-56 DOI: 10.1097/ACM.0b013e3181c4846b

Paucis Verbis card: Skipping the CT prior to LP for meningitis

With increasing awareness of CT's irradiation risk, I thought I would review a classic 2001 article from the New England Journal of Medicine. Head CT's previously were commonly performed prior to all lumbar punctures (LP) to rule-out meningitis. When can you safely go straight to an LP without imaging?

Caveat: This review only applies to those patients in whom you suspect meningitis. This does not apply to those being worked up for subarachnoid hemorrhage.

This installment of the Paucis Verbis (In a Few Words) e-card series reviews Skipping the Head CT Prior to LP for meningitis.

Feel free to download this card and print on a 4'' x 6'' index card.

[MS Word] [PDF]

See other Paucis Verbis cards.

Great TED video advocating for open education

Every once in a while you watch a video and the concepts really make you stop and go "hmm". A thought to ponder on for the day.

Dr. David Wiley is an Associate Professor of Instructional Psychology and Technology at Brigham Young University. He speaks about the big-picture future of education and how it should be completely open and unrestricted. He challenges the use of course management systems (i.e. Blackboard, Moodle, and Sakai).

We are moving towards an age in "Open Education Resources" (OER). Dr. Wiley was recently quoted in an interesting article in the NY Times about OER.

How can we apply this to medical education?

Trick of the Trade: A "handy" ruler

How long is this neck laceration?

In the Emergency Department, it is important to be able to accurately estimate the length of wounds, abscesses, and cellulitis. Additionally, billing for wound closure is directly related to the length of the laceration.

The problem for me is that I personally hate carrying too many things in my pocket on a shift. This includes a ruler. Can you imagine stopping the resuscitation and evaluation for the patient above because you want to find a ruler and measure the bleeding neck laceration?

Trick of the trade: Use your "handy" ruler.
Measure parts of your hand. You now have a reasonably accurate ruler with you at all times (hopefully). For me, I know that my left hand can only reach a maximum of 20 cm. The width of my left palm is 8 cm. And my pinky DIP is 1 cm wide.



Using these landmarks, I estimated the neck laceration above as 1 palm + 3 pinkies = 8 cm + 3 cm = 11 cm.

Thanks to Sandi Ma, my Visual Aid Project photographer, who consented the patient and captured the top picture.

Hot off the press: FreeEmergencyTalks.net

Dr. Joe Lex (Temple) is constantly recording lectures from national EM conferences and compiling them into an amazing respository of free audio (MP3) files. The 2009 AAEM Scientific Assembly lectures will be added in the next few weeks.

Website:
FreeEmergencyTalks.net

The slogan is "Emergency Medicine education for everyone". This searchable, catalogued, open-source website is a big leap into the world of Web 2.0. What a great idea.

Article review: Career in Academics

What should I do after finishing residency training? What, there's no more training?!

Traditionally, graduates enter one of four traditional areas -- academia, community practice, industry, and the military. With the increased financial and research pressures of academic medicine, a study reviewed why physicians pursue a career in academia.

Specifically, the authors conducted a literature search of the term "career academic medicine". Articles published during 1986-2006 were included. From the 480 relevant articles, there were 41 identified, which were highly relevant. The following themes were noted in the literature:

Opinion and editorial pieces
One editorial commented on the decline of the academic physician pool and that efforts should focus on medical students, who should be encouraged to pursue academia.

Issues and obstacles
There are many obstacles that residents face when considering a career in academia. Issues include:

• Competition for decreasing pool of funding sources
• Long patient care hours
• Heavy administrative responsibilities
• Busy teaching schedules
• Lower salary
• Medical school and residency debt payments
  
• Uncertainty for success
• Number of years of training necessary to join academia
• Lack of effective mentoring and role modeling
• Undesirable location and practice environment
• Challenging work-life balance especially for women in academia

Financial considerations
Because of the general lower pay of academic faculty compared to community and private practices, personal debt may negatively incentive residents from academia.

Role models and mentoring
There are not enough great role models for students and residents interested in pursuing academic medicine. Without strong mentors, especially for women and under-represented minorities, it is a leap-of-faith for undifferentiated residents to choose a career in academics.

Academic physicians as teachers and/or researchers
Gone are the days of the "triple-threat" academic physician, who excels in patient care, teaching, and research. Now there are two academic models: clinician-educator and clinician-scientist. The clinician-educator has a niche in teaching and scholarship. The clinician-scientist has a niche in research.

Publication and research activities
Exposure to research experiences during medical school is associated with medical students pursuing academia as a career choice. Exposure to research during residency is also worthwhile to help foster continued interest in research and publications.

Gender
As a broad generalization, two studies suggest that men and women select an academic career for different reasons. Female physicians chose academia for the "perceived quality of life, earnings potential, and organizational reward". Being recognized nationally and being perceived as a leader are less important than for the male physicians. Both genders, however, value the intellectual challenges in academia.

Career development/choice
Students from research-intensive medical schools and those with advanced degrees tend to pursue an academic career more than other students. Those with mentors comment that mentors played an important role in their career decision to enter academics.

Values
Intellectual stimulation is a major factor in a physician's decision to pursue a career in academia. Generating and translating new knowledge is an extremely attractive draw for many physicians (including myself!). Future research will have to to determine exactly how individual and generational values differ for the Baby Boomers, Generation X, and Generation Y physicians and how they affect the decision to pursue an academic career.

The authors propose a call to action to the Association of American Medical Colleges (AAMC) and Society of Directors of Research in Medical Education (SDRME) to build a structured approach towards understanding who enters academic medicine and why.

For me, I kind of fell into academia. I attended Harbor-UCLA for EM residency, which is one of the powerhouses of EM academia. My role models were doing academics, and I just assumed that I was going to do it as well. I felt that I easily fit into the clinician-educator model, because of my interest in teaching. Boy, am I lucky to have had such strong role models.

Question to the reader:
Why did or didn't you pursue a life in academia?


Borges NJ, Navarro AM, Grover A, & Hoban JD (2010). How, when, and why do physicians choose careers in academic medicine? A literature review. Academic medicine : journal of the Association of American Medical Colleges, 85 (4), 680-6 PMID: 20354389

Paucis Verbis card: Early goal directed therapy

One of the landmark studies in sepsis was conducted by Dr. Manny Rivers (Henry Ford) and published in the New England Journal of Medicine in 2001. By managing patients with severe sepsis and septic shock with an "early goal directed therapy" approach, there was an absolute risk reduction of 16%. Furthermore, the number needed to treat to save a life was 6 patients!

This installment of the Paucis Verbis (In a Few Words) e-card series reviews Early Goal Directed Therapy algorithm. The layout is borrowed from a Cleveland Clinic Foundation (CCF) flowchart.

(click to view larger version)

Feel free to download this card and print on a 4'' x 6'' index card.

[MS Word] [PDF]

See other Paucis Verbis cards.

Handouts from CORD 2009 Academic Assembly

For those of you who weren't able to make it to the high-yield 2009 CORD Academic Assembly in Orlando a few months ago, the handouts are now available for download on the CORD website. If you are an educator in EM, these are fantastic resources. Handouts are available from each track:

• Best Practices
• Clerkship Directors in Emergency Medicine (CDEM)
• Emergency Medicine Association of Research Coordinators (EMARC)
• Medical Education Research Certification (MERC)
• Navigating the Academic Waters
• New Program Directors
• ... and many others

Enjoy!

Trick of the Trade: Retracting Swollen Eyelids

Eyelids can become edematous from blunt trauma and local inflammation, making it difficult to visualize the orbit. How do you retract the eyelids, if you don't have the fancy ophthalmology eyelid retractors?

Trick of the Trade: Use a Q-tip
I thought of this idea when I was rolling up a projector screen in a conference room. Why can't we use this rotational concept on the upper eyelid to retract it? Rest the Q-tip on the surface of the upper eyelid and slowly rotate the Q-tip to "roll" the eyelid out of the way.

Below are a series of photos of a woman with eyelid swelling from conjunctivitis. This technique provides a relatively painless way to retract the eyelid without placing pressure on the orbit itself. Although the images look like I am merely lifting the eyelid using the Q-tip, I am actually twirling the Q-tip.

Consent and photographs taken by Lourdes Adame
(Visual Aid Project member)

Embedding Powerpoint slides into website using Picasa

Have you ever wanted to post your powerpoint slides onto your blog or website? It's actually easier than you think. You'll need:

1. Your Powerpoint file
2. A free Google Picasa account
3. Your target website or blog

Steps:

• Within your Powerpoint file, select "Save As..."
• Save your files in PNG format. This will convert each slide into a PNG image file.
• From your network browser, open your Picasa account.
• Upload the individual PNG files into a New Album (see below for example).

• Select "Embed Slideshow" (bottom right of browser page).
• A new window will pop up. Choose what size slideshow you want and copy the HTML text provided.

• Paste the HTML text into your website or blog.
• This will create a Flash-based slideshow.
  

Below are slides from my talk at the 2010 UCSF Education Day conference on the negative impact of ED crowding on education.

Article review: Internal Medicine team redesign

The Institute of Medicine has re-sparked discussions about limiting and further reducing resident duty hours in the United States (IOM's Duty Hours Report from Dec 2008). In response to this, the Brigham and Women's Internal Medicine residency program created an innovative inpatient team model, which was published in this month's New England Journal of Medicine.


Study Design

Setting:

• Faulkner Hospital, an affiliated community hospital with 72 inpatient medicine beds

Control team = General Medical Service (GMS) team

• A single attending drawn from a "faculty pool"
• 1 resident, 2 interns
• A different attending drawn from a "faculty pool" to teach 3 times weekly
• Intern call was every 4th night until 10 pm
  
• Resident stays until 7 pm and then night float resident
  

Experimental team = Integrated Teaching Unit (ITU)

• 2 attendings with each covering half of patients on team
• One attending is hospitalist and the other is an internist or specialist
• Attendings were selected based on excellent teaching evaluations.
• Addition of multidisciplinary team members
  
• 2 residents, 3 interns
  
• Both attendings participated in daily morning rounds for 2 hours
• One attending was available all day for teaching and clinical care
  
• Intern call was every 6th night and leaving by noon next day
• Resident supervised all interns every 4th night until 10 pm, and then night float resident
• Team census cap = 15 patients

Methodology
Patients were randomized onto one of 4 teams over a 12-month period. There were 2 GMS and 2 ITU teams each month. An independent observer recorded intern activity on these 4 teams.

Results
Results for the GMS team are shown in blue and ITU team in red.

• Average patient census per intern = 6.6 patients vs 3.5 patients
• Overall trainee satisfaction (83% response rate) = 55% vs 78%
  
• Intern time spent with learning activities = 10% of total time vs 20% (p=0.01)
  
• Intern time spent with teaching activities = 2% of total time vs 8% (p=0.006)
• Duration of patient hospital stay = 4.61 days vs 4.10 days (p=0.002)
• There was no difference in time spent with patient care, patient outcome, and patient satisfaction.
  

The authors noted through qualitative responses, that having a dual-attending team was an important factor in greater trainee and attending satisfaction with the ITU team model. Trainees and attendings on the ITU teams enjoyed the increased exchange of ideas and debate, feedback, and different teach styles.

Bottom Line
The ITU team is a novel pro-education model which promotes greater attending supervision, a lower patient census, and more time for both self-reflective and structure learning on inpatient Medicine services. This study demonstrates that changes which prioritize education can be implemented without negatively impacting on the quality of clinical care.

How is this relevant for Emergency Medicine?
There are some fascinating findings from this study which are directly relevant to the field of EM. To me, this study seems to suggest:

• There should be greater resident and attending staffing in the ED so that the ratio of providers-to-patients is lower. This is especially relevant given that our ED's are so often crowded and overwhelmed with clinical demands. This may help move education up on the priority list for residents and attendings on shift.
  
• For residency programs with ED teaching attending shifts, where an attending physician's sole responsibility is to teach without clinical responsibilities, preference should be given to attendings who are stellar educators. This was the model used in this study.
• Future studies should look at the ideal patient load in balanced learning for EM residents.
  

Reference McMahon, G., Katz, J., Thorndike, M., Levy, B., & Loscalzo, J. (2010). Evaluation of a Redesign Initiative in an Internal-Medicine Residency New England Journal of Medicine, 362 (14), 1304-1311 DOI: 10.1056/NEJMsa0908136

Paucis Verbis card: Anticoagulation in Atrial Fibrillation

Occasionally, patients present to the ED with new onset, rate-controlled atrial fibrillation. It's an incidental finding. Do you have to anticoagulate these patients because of the risk for a stroke?

This installment of the Paucis Verbis (In a Few Words) e-card series reviews Anticoagulation for Atrial Fibrillation from the Cardiology Clinics series. The article goes over lots of literature about the risk of stroke. I find the CHADS2 scoring system and the 2006 AHA/ACC/ESC Guidelines most helpful.

Note: Patients with persistent and paroxysmal atrial fibrillation should be treated the same when it comes to deciding about anticoagulation. They have an equivalent risk of stroke.

Feel free to download this card and print on a 4'' x 6'' index card.

[MS Word] [PDF]

See other Paucis Verbis cards.

Amazing video: Awake endotracheal intubation

Videos are priceless when trying to teach procedures. This amazing teaching video by Dr. Michael Bailin at Mass General demonstrates a novel way of anesthetizing the airway during an awake intubation.

1. Inject 3 cc of lidocaine using a small butterfly needle through the cricothyroid membrane. This causes coughing, which spreads the lidocaine throughout the upper airway.
2. Inject 5 cc of atomized lidocaine through the fiberoptic scope port to anesthetize the posterior oropharynx and vocal cords.
3. Slide the endotracheal tube over the fiberoptic scope.
   

Seeing is believing.
Great video.

(The video really gets started around the 1:17 mark.)

Thanks to Dr. Demain Szyld (Simulation Education Fellow at Brigham and Women's Hospital) for letting me know about this crazy/amazing teaching video.

Trick of the trade: Eye irrigation setup

Morgan lens are placed to irrigate eyes splashed with foreign substances. Whenever I place them, images of horror and torture movies arise. Especially for patients who aren't used to having something touch their eyes like contact lens, the Morgan lens gives them the heeby-jeebies.

For the past several years, I've stopped using Morgan lens and have started using something that all Emergency Departments have -- nasal cannulas for oxygen administration. They are perfect for high-volume eye irrigation.

• Instead of attaching the nasal cannula to an oxygen port, attach it to the end of IV tubing, which in turn is attached to a 1 liter normal saline bag. The IV tubing fits snuggly into the nasal cannula tubing.

• Rest the nasal cannula prongs over the patient's nasal bridge to irrigate the eyes.
• Then open up the flood gates!
  
• To avoid a huge deluge of fluid onto the patient and floor, be sure to have a way to catch the fluid. Some place multitudes of towels around the patient's head to absorb the fluid.

• As an alternative solution to towels, I like Dr. Stella Yiu's (Univ of Toronto) adaptation of my cut-out basin approach for irrigating scalp wounds. To avoid overflow spillage, she rests a Yankauer suction tip at the bottom of the basin to collect the irrigation fluid.

Joining the Research Blogging community

Yesterday, I posted a review of an Academic Medicine education article on how to prepare medical students for their clinical clerkships, based on the Kolb learning cycle model. My blog post is now also linked and searchable from the Research Blogging network at http://researchblogging.org. Thanks to Life in the Fast Lane, who told me about the site.

What is Research Blogging?
It is a website, which aggregates blog posts that write about peer-reviewed articles. These articles span the entire spectrum of academic research and not just Medicine. My post about the education article is now linked and searchable from this website.

Here is a review of the website from Wired Magazine.

What a great idea to build an aggregator website with a focus in peer-reviewed academic research. It is a perfect bridge between the two worlds of traditional academic research and the Web 2.0 era of blogs and interactivity. I wish I had thought of this idea.

Article review: Preparing for clinical clerkships during medical school

Do you remember the sheer terror you felt, when you first started your medical school clinical rotations? Your first two years were probably spent in classrooms and small-group labs discussing anatomy, pharmacology, pathology, etc.

Then BAM! You are thrown into the deep end of the pool. You are now on a clinical team of medical professionals taking care of actual patients!

Some students fare better than others during this abrupt transition period. This commentary in Academic Medicine provides a framework to help students adapt to this change, by understanding adult learning literature. Specifically, the authors review the concept of Kolb's learning cycle.

Kolb initially proposed that learning occurs in a 4-stage cycle. This consists of:

1. Concrete Experience (experiencing an event)
   
2. Reflective Observation (reflection on that concrete experience)
   
3. Abstract Conceptualization (generation of new approach or style based on reflection)
4. Active Experimentation (test the new approach or style in reality)
   

The authors of this article propose a 5-stage modified Kolb cycle to adapt to the new challenges of the clinical years of medical school:

1. Prepare for the clinical setting
2. Experience the clinical setting
3. Reflect on the experience
4. Conceptualize new approaches
5. Testing new approaches

1. Preparing for the Clinical Setting

• As a student, identify what your roles and responsibilities are on the team. The clerkship director should tell you this, but if not, seek out the answer. What should your presentations be like for new and established patients? Do you write notes in the chart, and if so, what is the format preferred?
• Remember to do no harm. As a student, be sure not to give definitive answers to patients or families if you are not sure of the answers. Tell them that you will find out the answer. Also, do not perform procedures with which you are unfamiliar. Let the resident or attending know that you are uncomfortable with the new procedure and would like to observe at this time.
  

2. Experiencing the Clinical Setting

• Keep a log of patient encounters, framed within goals and objectives in the medical school curriculum. Such objectives might include: communication with a consultant, dealing with a difficult patient, practicing cost-effective medicine when deciding on prescribing discharge medications.
• Learning should be driven by the student. Read more about conditions or symptoms from your patient encounters. For me personally, I retain information more when it's contextually based.
• Share what you have learned by teaching your fellow team members. Teaching reinforces what you've learned.
• Move beyond "reporter" status. Medical students are traditionally perceived as data gatherers. Go one step further and think about a broad differential diagnosis list, based on your gathered data, without prompting from your resident or attending.
  
• Build collaborative relationships with your team members. In team-based clinical work, it is crucial to understand the importance of collaboration. Unit secretaries, mid-level providers, nurses, and other professionals in the health care system are all part of the greater team.
• Set a high professionalism standard. Sometimes students may witness unprofessional behavior. Think about how you would have handled the scenario differently, so that you don't fall into that trap in the future. Emulate those who exhibit humanistic behavior towards their patients and colleagues.
• Develop habits that promote mental health and physical and social well-being.

3. Reflecting on Experience

• A critical component in the "learning cycle" is the reflective piece. For self-reflection to improve your learning, seek out frequent feedback on how you are performing from residents and faculty. Be specific in what you are seeking feedback on -- "Can you tell me how I did in taking this patient's history?" or "Any feedback about my venipuncture procedure?"
• During your reflection of your clerkship experiences, think about what you like and don't like about that specialty. Start developing a pros/cons list of factors which will play into your decision-making about selecting a career choice. Clearly, the specialty of Emergency Medicine is the best, but I suppose I'll let you come to that decision yourself.

4 and 5. Conceptualizing and Testing New Approaches

• Based on self-reflection, think of how you might improve upon yourself or what you are doing. This might be how you approach a difficult patient, how you ask sensitive questions, troubleshooting a procedure, or present your differential diagnosis list.
  
• Test your new approaches.
• Repeat as new experiences arise.
  

Reference
Greenberg L, & Blatt B (2010). Perspective: successfully negotiating the clerkship years of medical school: a guide for medical students, implications for residents and faculty. Academic medicine : journal of the Association of American Medical Colleges, 85 (4), 706-9 PMID: 20354392