Getting a subpoena: What is an expert witness?

Well, it's an inevitable part of working in an Emergency Department. I got a subpoena recently and now have to go in to testify on a trauma patient. I've gotten a few subpoenas before on trauma patients, but fortunately most cases were settled out of court.

First of all, I think it's an ethical responsibility of emergency physicians to describe what we saw and did in the care of the injured patient in the legal system. However, I have found that the few lawyers I have interacted with slowly expand their scope of questions to cover things NOT in the medical chart. Has this happened to anyone else? They essentially start to ask me things which an "expert witness" should answer. Expert witnesses receive expert witness fees.

• "What is a typical expected course for..."
• "Do patients with this type of injury usually have pain for so long?"
• "What do you think about..."
• "Can you describe the nature/ cause/ definition of..."
• "What's the prognosis for..."

Actually ACEP has created Expert Witness Guidelines.

So I read more about our rights as emergency physicians when we get subpoenaed to testify for a patient. We are supposed to just testify about the facts on the medical chart. No opinions. If we start giving opinions, we are essentially giving expert witness testimony.

Interestingly, the California Medical Association has a recommendation on this: If asked to give expert opinion, the physician should ask if s/he is being asked for their expert opinion. If so, that they would like to receive expert witness fees. In 1995, the California legislature passed bill AB1204 that ensures a treating physician expert fee payment if asked for a medical opinion. Read more here in EP Monthly. This is becoming increasingly true in many other states.

Even better, there is a great template letter (thanks to Dr. Clement Yeh for telling me about it) that you can preemptively mail the lawyers who sent you a subpoena. It basically says that you would be happy to testify what's on the medical chart and ONLY on the chart. If they want expert opinion, you should be treated as an expert witness with "x" number of dollars/hour recompensation. It's pretty hard-core, but I think it averts many misunderstandings and potentially can you save a lot of time. All the time in court and preparing for the case takes you away from work.

Wish I had this earlier. Here is the template (download here):

Dear {name},

I was recently subpoenaed by your office. In the past, there have been several incidences where there has been a misunderstanding whether attorneys are requesting factual or expert witness testimony. In the event, you ask me to provide any response or responses that calls for an opinion or medical conclusion, that will be considered to be expert witness testimony. Receipt of this letter will confer your acknowledgement that in the event you request expert witness testimony, you and/or your agency will be responsible for bills for my time. As a courtesy, I am sending my fee schedule for your review.

My fee is $___ an hour for consultation and/or expert testimony. Expert services include review of records, telephone and or office conferences with attorney(s) or other relevant individuals, and preparation for deposition and trial if indicated. The minimum fee bill will be $____.

As is standard, all reasonable expenses incurred will be billed to your agency or firm. If travel is necessary, travel time will be billed at $___ per hour. If testimony is required the following charges apply. If I am called to testify in the morning, I assume that testimony will involve a minimum of eight hours, and you will be billed for eight hours at $___ per hour. If I am called in the afternoon, I assume that testimony will involve a minimum of four hours and you will be billed for four hours at $___ per hour. If meetings or trials are subsequently canceled on short notice your agency or firm may be billed for the time scheduled.

Article Review: Rethinking the premed requirements

Think back to your college years. Remember those premed courses that you had to take? Biology, chemistry, physics... oh my. How helpful were these in your preparation for medical school and clinical practice?

In 1981, the Association of American Medical Colleges assembled a group, the General Professional Education of the Physician and College Preparation for Medicine (GPEP) to relook at these premed requirements. In 1984, the published a report "Physicians for the Twenty-First Century". They advocated that the intensive premed requirements overly skews students' education towards a "narrow objective of medical school admission". Education is not balanced to include broader liberal arts learning, which may teach students more about humanistic values and communication skills.

Despite these recommendations, not much has changed. Medical schools are still using high MCAT scores (which test the premed requirements) to determine admission.

Actually this is only mostly true. Mount Sinai medical school established a Humanities and Medicine Program (HuMed) in 1987. Innovatively, the school offers college sophomores and juniors majoring in the humanities or social sciences a GUARANTEED medical school spot upon completion of college.

Admission does not require the traditional premed requirements, except just only 1 semester each of biology and general chemistry. Nor does it require taking the MCAT. Admission requirements only include 2 essays, SAT scores, 2 interviews at Mount Sinai, and a minimum GPA of 3.5 throughout college.

Interestingly, accepted HuMed students are required to attend a 8-week summer program at Mount Sinai after junior year to get a crash course in Medicine. This includes clinical exposure in various specialties and an intensive introduction to chemistry and physics -- as they related to medicine.

Furthermore, in the summer before matriculation, Mount Sinai offers a Summer Enrichment Program (SEP) to help HuMed students to get acclimated to the medical school learning environment and upcoming curriculum. About 75% of the HuMed students participate in this. The curriculum covers the biochemistry, anatomy, embryology, cell physiology, and histology.

This publication reports the outcomes of the HuMed students (n=85) during 2004-2009 as compared to the traditional, non-HuMed students (n=606) during that same time. In other words, are the traditional premed requirements necessary to ensure success in medical school and beyond?

Results

Interestingly, there were no differences found in the following outcome measures:

• USMLE Step 1 failure rate
• Honors grades in clinical clerkships (In fact, 46% HuMed students got honors in Psychiatry compared to 23% for non-HuMed students)
• AOA distinction
• Rank in the top 25% of the class
• Medical Student Performance Evaluation (a.k.a. Dean's Letter) final descriptors

Also, HuMed students were more likely to:

• Dedicate a year to scholarly research (28.2% vs 14.1% non-HuMed students)
• Pursue a career choice in primary care and psychiatry

On the flip side, HuMed students were also more likely to:

• Have a slightly lower USMLE score (221±20 vs 227±19 non-HuMed students)
• Take a leave of absence because of personal, academic, or psychiatric difficulties (11% vs 3% for non-HuMed students)

Quoting the authors, they hypothesize that HuMed students gain a lot from their more broad liberal arts college education:

• Enhanced communication skills and a more humanistic approach to the patient, as evidenced by HuMed students’ better performance in psychiatry
• Greater interest in pursuing broader medical school experiences, as evidenced by HuMed students’ greater participation in scholarship and research"
• A heightened interest in fields that provide greater interpersonal connections between patient and physician, as evidenced by HuMed students’ trend toward residencies in primary care and psychiatry.

The Mount Sinai program really challenges the concept of the traditional premed requirements and MCAT examination. It is time to rethink why the premed requirements are there.

Thanks to Fred Wu for letting me know about this publication.

Reference

Muller D, & Kase N (2010). Challenging traditional premedical requirements as predictors of success in medical school: the Mount Sinai School of Medicine Humanities and Medicine Program. Academic medicine : journal of the Association of American Medical Colleges, 85 (8), 1378-83 PMID: 20671464

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Paucis Verbis card: TIMI risk score

How do you risk-stratify undifferentiated chest pain patients in the Emergency Department? There are a multitude of causes for chest pain. We are always taught to think of the 5 big life-threats: ACS, PE, aortic dissection, tension pneumothorax, and pericardial tamponade.

So how do YOU risk-stratify your patients for unstable angina (UA) and non-ST elevation myocardial infarction (NSTEMI)? STEMI's are usually obvious. UA and NSTEMIs -- not so much.

Fortunately a 2000 JAMA article and a followup Academic Emergency Medicine 2006 study have solidified the TIMI risk scoring system as a reasonable risk-stratification tool for all-comer ED patients with chest pain requiring an ECG.

Generally there is an upslope in risk at a TIMI score of 3 and greater.

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

[MS Word] [PDF]

See other Paucis Verbis cards.

References
Antman EM, Cohen M, Bernink PJ, McCabe CH, Horacek T, Papuchis G, Mautner B, Corbalan R, Radley D, & Braunwald E (2000). The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision making. JAMA : the journal of the American Medical Association, 284 (7), 835-42 PMID: 10938172

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Pollack, C., Sites, F., Shofer, F., Sease, K., & Hollander, J. (2006). Application of the TIMI Risk Score for Unstable Angina and Non-ST Elevation Acute Coronary Syndrome to an Unselected Emergency Department Chest Pain Population Academic Emergency Medicine, 13 (1), 13-18 DOI: 10.1197/j.aem.2005.06.031

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EM-RAP Educator's Edition: How to give an insanely great talk

Hot off the press!

Dr. Rob Rogers (University of Maryland) gives tips on How To Give An Insanely Great Talk on the EM-RAP Educator's Edition website. In this 40-minute podcast, he hits on such topics as:

• For many speakers, Powerpoint turns out to be the enemy.
• Don't be afraid to repeat your take-home points.
• Check out TED talks. Personally, I have a hard time modeling my talks from TED talks because teaching advanced medical concepts (eg. specifics of acute limb ischemia, PERC scoring system for PE) is a little different than giving motivational/layperson level talks about your passion. Still, a good goal to strive for.
• Know your audience.
• Be a closer. Have a great ending to your talk.
• Don't be a "audience carnival duck" (listen to around 26:25 mark). Great term!
• Be a storyteller.

It's amazing how much I agree with Rob on many levels. Take a listen to this free podcast.

Trick of the Trade: Increasing students responses to the differential diagnosis

Anyone who teaches medicine asks students to list their differential diagnosis when discussing a new clinical case. It's also part of several models for education including the One-Minute Preceptor and SNAPPS.

For the most part, students are good at coming up with answers to the differential, but what do you do when they strike out? Or what if the answer is always the same, i.e. chest pain = myocardial infarction?

Educator's Trick of the Trade:
Enter the game SPIT. This is an acronym for:

• S erious
• P robable
• I nteresting
• T reatable

I keep a handy supply of 3x5 cards in my pocket and will hand them to the learner when they stall or just to make things interesting. The rules are simple. One answer to each category and each category must have a different answer. I'll then go through the categories with the students and probe for their reasoning. Its amazing how something so simple creates so many teachable moments.

Work in progress:Translating videos into Vietnamese

Sometimes you just have to be lucky to get projects done.

In anticipation of our Vietnam trip in October to teach clinical decision software to pediatricians (KidsCareEverywhere), we are kicking preparations into high gear. One of my tasks is to create new KCE-PEMSoft training modules not only in English but also Vietnamese. And no, I do NOT speak a lick of Vietnamese.

Luckily a friend referred me to Dr. Phuc Nguyen, who is a retired physician from Moncrief Radiation Oncology Center/UT Southwestern Medical School. We still haven't spoken in person yet, but he is my new best friend! It's rare to find a physician, who speaks fluent Vietnamese, is computer saavy enough to record voice audio, generous with his time, and able to volunteer on short notice.

In less than 2 weeks, he has translated our modules and recorded his own voice to overlay the videos. Each sentence was recorded separately into individual audio files so that I would know where to insert the sentences.

Check out the videos below. How COOL is that?

Article Review: Use of Effective Questioning

Asking effective questions is a valuable skill for any teacher. As a junior faculty member working to improve my teaching, I'm often in awe of my more experienced colleagues when I have the chance to watch them teach. At times, it's quite easy to pick out the skills that they put into action but occasionally, their expertise is much more subtle.

Effective questioning falls into this category.

It is fair to say that educators use questioning skills in every teaching encounter. Problem is, we often ask questions poorly. Too often, we ask factual, low level questions in an environment that isn't conducive to learning. This is supported by other studies which found that only 17% of time spent speaking was in asking questions and 81% of questions asked were directed at low order thinking!

Effective questions:

• Arouse learner curiosity
• Stimulate interest in the topic at hand
• Clarify concepts
• Reinforce key points
• Promote the learner to think at higher levels of cognition
  

Properly asked questions also allow the teacher to diagnose the learner. The answers provided can become a framework for teacher feedback at the end of the encounter.

So, I know it's important, but how do I improve my questioning skills?

First and foremost. Take the time to evaluate the taxonomy of thinking skills. Probably the best known is Bloom's. Bloom's taxonomy divides thinking skills into 6 distinct levels:

1. Knowledge: recall information and repeat it
2. Comprehension: Explain topics, review items, and discuss issues
3. Application: Apply previously learned knowledge and apply it to new situations
4. Analysis: Break material into its component parts and use a systemic process to reach a logical conclusion
5. Synthesis: Hypothesize, predict, and use available information to arrive at a generalization
6. Evaluation: Use specific criteria to assess situations or to justify a previous response; defend positions, evaluate information, and appraise situations
   

Similar to Maslow's Hierarchy of Needs, learners ascend the ladder from knowledge to evaluation as they gain expertise with the topic of study. Some example questions:

1. Knowledge: What is the most common cause of meningitis in a child?
2. Comprehension: What study would you order to rule out a pulmonary embolism in a patient with cancer?
3. Application: A patient presents with DKA. Labs include a glucose of 550, sodium of 130, and potassium of 3.8. What type of fluid would you use to resuscitate this patient?
4. Analysis: A 90 year old female a history of lung cancer and hypertension presents with tachypnea, hypoxia, and tachycardia. What are some possible causes of her illness?
5. Synthesis: During an IJ central line placement, you inadvertently cannulate the carotid in a patient on warfarin. How would you proceed with the procedure?
6. Evaluation: Given the presenting history of this patient, did you complete an appropriate workup?
   

In addition to asking questions within a taxonomy of cognitive skills, questions can fall into a spectrum of "types" which further help the student to develop critical thinking skills.

• Factual Questions: Recall information
• Investigative Questions: Comprehend content, apply information, analyze situations, or synthesize information
• Hypothetical Questions: Synthesize information to consider other hypothetical possibilities. This is the classic "What if" question.
• Evaluative Questions: Assess or appraise a situation, judge, or defend a position
  

Questions can also be categorized as convergent and divergent. Convergent questions guide learners towards closure of a discussion. Divergent questions focus on higher order thinking as they require learners to consider alternatives, justify, and defend. This type of question often involves departing from the original case.

Pitfalls in Questioning:

• Beware of body language. A disgusted look, frown, or negative verbal response will shut down discussion quickly.
• Avoid Sarcasm. How many times have you heard, "Don't they teach you ______ in medical school anymore?"
• Avoid yes-no and trick questions. Students can guess an answer without really understanding why it is right or wrong while trick questions frustrate learners.
• Beware of cueing. Cueing gives away the answer and prevents the development of critical thinking.
• Address groups not individuals. When picking a learner by name, the rest of the group tunes out. By asking the group, everyone thinks about the question and has an answer by the time the facilitator picks a student to answer.
• Don't forget the non-volunteers. Make sure to involve all learners, not just the overly enthusiastic ones.
• Adapt questions to the needs of the learners. Make sure to evaluate the answers. Questions need to be challenging to learners but not so far up the taxonomy that they fail to understand the reasons for the correct answer. Using the students responses, you need to be able to ask more or less difficult questions.
• Wait long enough for an answer. The average wait time between asking a question and answering it has been found to be as short as 1 second!!! By waiting 3-5 seconds, the students will gain increased analytics and problem solving skills. One study cited in the paper found that students will increase the length of their answers, increase the number of unsolicited responses that are correct, and increase questions from the students! It only takes 2 more seconds to reap all of these valuable benefits!
  

My Take:
When I first read this article I was blown away by the breadth and depth of questioning skills but with a little practice, it gets pretty easy. I like to start with low level questions and move up the ladder. Its easy to encourage higher level thinking by asking "why" and "what if" questions as a followup to your initial question. What other creative tricks are people using to ask effective questions?

Reference
Sachdeva AK (1996). Use of effective questioning to enhance the cognitive abilities of students. Journal of cancer education : the official journal of the American Association for Cancer Education, 11 (1), 17-24 PMID: 8777151

New guest blogger: Dr. Robert Cooney

Welcome to new superstar guest blogger, Dr. Robert Cooney! Today's post is his first (of hopefully many).

Paucis Verbis card: Croup

The most common cause of stridor in pediatric patients is croup, or laryngotracheobronchitis. The distinct high-pitched, seal-like,"barky" cough can be heard from outside the patient's room often.

Check out the clip above that I randomly found on YouTube. Go to the 1:15 mark (near the end) to hear the barking cough. Poor but cute kid.

What is the current treatment regimen? Did you know that the traditional treatment with cool mist or humidified air have shown to be of no added benefit?

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

[MS Word] [PDF]

See other Paucis Verbis cards.

Incorporating debriefing into clinical practice

Plus - - - Delta

I'm in the middle of an intense weeklong course on debriefing for medical simulation here in Cambridge, MA. One of the goals many of the participants share is our desire to improve our skills in the art of debriefing after clinical simulations. Although the course focuses on "Debriefing with Good Judgement"* today the faculty also offered a simple tool to structure a brief debrief when time is very limited.

The Plus/Delta Chart seems like a good structure for after-action debriefing in the ED where we are always pressed for time. There is debate on the origins of this tool; some posit that it arose in the aviation industry while others claim that it originated in a 3rd grade class room.

Could I bring the Plus/Delta to the Emergency Department?

After an intense or stressful case such as a trauma activation or cardiac arrest I find that many members of the team want to talk about what happened, how the team performed, and what could be done to improve the care we provide in the future. I have found that gathering everyone is often difficult but taking 5 to 10 minutes to talk among most of the people involved is probably feasible.

To create your own form, take a blank piece of paper and draw two straight lines in the shape of a "t". Label the first column with a plus-sign and the second with the symbol Delta. Once we've recreated the tool, we might follow these three steps:

1. Set the stage for debriefing by gathering the team, describing the exercise, and stating a time limit i.e.: "we will end at 10:45".
2. Inquire about your team's thoughts on the case eliciting first many of the POSITIVE aspects of the resuscitation. This is an opportunity to highlight things that went well such as the availability of uncross-matched blood at the bedside or the fact that the paramedics were able to give their report without interruption.
3. Move on to the Delta side of the chart and record aspects of the event that team members wish had gone better and that they hope to improve on the next time they are faced with a similar situation. An action plan such as: "I'll ensure that the ultrasound machine in the room next time we he hear that we are getting a critically ill patient" (one of mine from last friday) could make those "Deltas" concrete, explicit, and shared.

I have used this tool in debriefing teams in the simulation lab and found it useful to organize the collective thoughts of a group. I think it is a really helpful tool because as caring, highly trained and skilled emergency nurses, doctors, surgeons, paramedics etc., our default mode is to focus on all the things that went wrong or could have gone better. Surfacing those positive aspects first not only recovers team and individual morale but also records and displays behaviors worth repeating and sets goals for the future.

• Have you used this tool in similar or different ways?
• Have you found it useful or easy to apply in the clinical setting?
• Who usually runs these debriefings in your institution?
• Do you use another strategy?

Demian

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*Rudolph et al. There's no such thing as "nonjudgmental" debriefing: a theory and method for debriefing with good judgment. Simulation in healthcare : journal of the Society for Simulation in Healthcare (2006) vol. 1 (1) pp. 49-55 [PMID]

Trick of the Trade: Modified HAT trick revisited

I finally tried the Modified HAT (Hair Apposition Technique) trick for the closure of scalp lacerations. I have used the traditional HAT trick multiple times but not the modified technique.

What's the difference?

Instead of using your fingers, the modified approach involves the use of two instrument clamps to help twist and pull the hair strands taut. It turns out that this makes a huge difference, especially for short hairs. The clamps allow you to grab the hair strands so much more securely, before instilling a tissue adhesive at the twisting points.

The nice added benefit was that my chubby fingers were now out of the procedural field. This allowed my assistant to more easily see and reach the hair twisting points with the Dermabond applicator.

Check out the finished product of this 2.5 cm laceration on the scalp vertex.

Bottom line:

The simple addition of two instrument clamps provides significantly superior control, stronger tensile strength, and better exposure when twisting hair strands together. Try it.

Real-time lecture input using Google Docs

As a lecturer, I constantly struggle to optimize audience engagement while teaching to the level of the learners. What added value does my lecture provide beyond the learner simply reading a textbook chapter on the topic? Am I covering topics that are too basic or too advanced?

What's been done?

• I have seen a few multi-day CME conferences end each day by answering anonymous slips of paper with questions from the audience. Great idea, but more engages audience AFTER rather than DURING the talk.
• I have used the audience-response system (ARS) that allows audience members to vote on multiple-choice questions. Cool engaging concept, but requires some tech setup and equipment.
• I have heard of people using Twitter feeds in the background on a second projector keeping track of audience conversations and questions. I can imagine that this can be quite distracting, especially not managed well.

A nifty trick: Use Google Docs in realtime

Recently at our residency conference, I gave a talk on Acute Limb Ischemia. Since our EM residents are so easy-going, super-smart, vocal, and ready to try anything, I felt safe trying out a new teaching approach.

After presenting a brief sample case of a patient with acute leg pain, I displayed a URL link to a public Google Docs page that I created the night before. To eliminate technological barriers, I made this page completely public. That means you don't need a login to view or edit the document. I then asked the residents to input either a burning question that they had or an important learning tip about acute limb ischemia.

See the page:

http://bit.ly/apHhJ7

What happened after I gave out the link? You could see the residents immediately typing away on the screen (see below). Each user had a different cursor bar color. Letters were flying across the screen throughout the document in real-time. It was totally amazing. For instance, there were 5 users on this screenshot.

At the upper right corner of the screen, you could see how many people were actively viewing the document.

At the end of the talk, I read aloud the questions and launched into my talk. I specifically referenced the questions when I got to the appropriate areas in my lecture and spent an extra minute more than I had planned focusing on the issue. And finally, at the end of the talk, I returned to the questions on the Google Docs page to make sure that all questions were answered.

Overall, I think this approach went over surprisingly well.

Some reflective thoughts:

• This real-time, free-form approach requires audience members to be online.
• Only 50 people can edit simultaneously.
• This approach is a great way to engage the learners and for me to assess their baseline knowledge. Because the questions can be submitted anonymously, no one has to feel shy or stupid for asking what they might consider a novice question.
• The approach is a little risky, as a speaker, because you may not be able to answer the questions. Fortunately, there was always a resident or faculty member with the answer.
• There is definitely the uncomfortable feeling of not being able to plan exactly how your talk is going to turn out. As a speaker, you have to be flexible.
• You have no control of what the audience writes. If you are really concerned about this, you can have a "patroller" to watch for inappropriate comments. In this case, the residents policed themselves.
• Caution: This document is at risk of being deleted by any user. Because document access doesn't require a login, anyone with the link has total administrative control of the document.

Has anyone else used Google Docs or other interactive feature in their talks?

Article Review: Online professionalism

A recent editorial nicely summarized the challenges that the medical profession faces with the popularity of social media platforms.

As physicians and other medical providers are coming to realize, whenever you post something to Facebook, Twitter, YouTube or a blog, you are creating a "digital footprint". In essence, think of yourself as "treading" through the World Wide Web and every action that you take leaving a lasting "footprint".

There are definite potential landmines for physicians who engage in the use of social media. Interesting questions posed and points made included:

1. Do public postings of unprofessional content (eg. your being intoxicated) also apply to when you are not working?
2. There is some degree of detachment when posting online content, because you are merely typing on a screen and not engaged with a face-to-face conversation. This may give users a sense of disinhibition when publishing material. This may then lead to inadvertent, lasting consequences (i.e. not getting a job, violating patient confidentiality, looking unprofessional).
3. Whether you intent to or not, when you post anything online, unprofessional content reflects poorly not only on you but the entire medical profession.

However, social media is not all bad for the medical profession. In fact, quite the contrary. Web 2.0 technologies have enabled a huge culture shift with incredible possibilities. For example:

• Physicians are now able to serve as credible resources for medical information.
• Digital communication is more streamlined and in real-time.
• There is more transparency between public health and hospital organizations and the public.
• These tools are paramount in providing a more reflective-based and personalized learning experience for our medical students and residents.

Great quote from the paper:

"Much like a mirror, social media can reflect the best and worst aspects of the content placed before it for all to see."

Social media is here to stay and has impacted how physicians interact with the public. This paper was a nice reminder that we are still in our infancy when it comes to defining what medical professionalism is within the social media arena.

Reference
Greysen SR, Kind T, & Chretien KC (2010). Online Professionalism and the Mirror of Social Media. Journal of general internal medicine PMID: 20632121

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Paucis Verbis card: Acute limb ischemia

Acute limb ischemia (ALI) is a true vascular emergency. It doesn't occur as frequently as the more high-profile conditions as cerebrovascular accidents and acute myocardial infarcts, but it portends similarly high morbidity and mortality risk.

• How do you stage a patient with ALI, based on the Rutherford classification system?
• What is the ED treatment plan?
• Should this patient go to Interventional Radiology or the Operating Room for more definitive management?

Here is the Rutherford Classification table in higher resolution (click to enlarge):

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

[MS Word] [PDF]

See other Paucis Verbis cards.

Poll: What other specialties were you considering?

I can not imagine working in any other specialty except Emergency Medicine. During medical school, however, I was torn between various specialties. These included Vascular Surgery (had an inspiring attending on-service and the VA patients were hilarious) and Interventional Radiology. Fortunately, I saw the light.

I am curious, as a medical student, what specialties were you considering before deciding on EM? It would be interesting to see if there were a trend.

Trick of the Trade: Email attachment etiquette

In academia, I find that .edu accounts have limited email storage capacity. Every months or so, I need to move some emails to my hard drive and empty my Sent Items and Trash folder.

What takes up SO much space in my inbox?

• Ginormous powerpoint files
• Videos
• PDF documents
• Photos

Trick of the Trade:

As an email etiquette, I send LINKS to large files. These files are housed elsewhere. This minimizes jamming up people's inboxes. It also allows the recipient to easily send the link to others.

Several options:

Google Sites

• A free Google Sites account allows you to upload a file up to 10 MB in size. Choose "Copy Link Address" and paste the URL link into your email. This might look like:

https://sites.google.com/site/academiclifeinemfiles/

home/articles/Wenrich_ExpectationsMSSkills.pdf

Box.net

• For larger files, you can use various third-party companies, such as www.box.net. It allows you to create folders and personalize which files/folders you want to share. File size limit is 20 MB (for free account).

Dropbox

• For much larger size files (>20 MB), I use www.Dropbox.com. With a free account, you get 2 GB of total storage space. The nice thing about the cloud-based Dropbox is that your files are automatically sync'd between your hard drive Dropbox folder, your online Dropbox account, and your mobile computer device app (iPhone, eg). Plus, you can share any files/folders with others.
• I minimize using Dropbox, especially for the one-time sharing of files, because I use Dropbox as my primary repository of files. I'm getting close to the 2 GB storage limit.

As an aside, if you decide to sign up for a free Dropbox account, could you use this referral link?

• https://www.dropbox.com/referrals/NTUyNDc2MTE5.
• For every referral, I get 250 MB of additional space.

Do you have any tricks or tips on emailing large files?

Work in progress: iShowU HD software

Have you ever needed to create a video that required screen-capture recording? As an educator, I have managed to do this using Quicktime Player's "New Screen Recording" option. This allows you to record everything on your screen. Unfortunately, this includes recording the area of interest (good!), plus your messy folders and an embarrassing background photo on your desktop (bad).

There are a few free video-capture tools out there, but I find that the resolution is poor, especially if you want to zoom up on particular aspects of the screen.

Recently, I discovered a relatively affordable software called iShowU. Although I am not intentionally a Macintosh-snob, this software is only for Macs. There are three tiers of functionality: iShowU ($20) , iShowU HD ($30) , and iShowU HD Pro ($60). I bought the middle one. Demo versions are available for free, but they have a subtle watermark on them.

What do I love about iShowU HD?

1. You can select what part of the screen you want to video-capture.

2. If you have watched training videos before, the mouse and mouse-clicks can be difficult to appreciate and follow. This software automatically creates a "click" noise and animates the click with an expanding green circle halo. These audio and video cues are critical to keep the viewer's eyes focused on your teaching point. Go to the 00:45 mark in Training Module #1 below to see the mouse-click feature in action!

3. When you type anything on the keyboard, the software automatically displays these letters/numbers simultaneously at the bottom of the screen for emphasis.

4. The resolution of the videos are amazing.

I am in the process of creating English-language and Vietnamese-language training videos on using a medical decision software PEMSoft. In case you were curious, here's how they were made:

• Video captured using iShowU HD
• Audio captured using Quicktime Player ("New Audio Recording" feature) - Each sentence is a separate audio AIFF file.
• Matched video with audio on iMovie
• Exported video without audio into Flash CS4 - to create simple animations and overlay text
• Re-imported Flash-edited video back into iMovie where it was re-matched with the audio
• Uploaded into Youtube from iMovie

These updated videos are up at our KidsCareEverywhere website and the PEMSoft website as well.

Training Module:

An Introduction

Training Module #1:

Basic Navigation and Utilization of PEMSoft

Training Module #2:

Phoenix Resuscitation Calculator

Disclaimer: I do not have any financial ties with this software company. Just a fan.

Article Review: Expectations of medical student clinical skill

Traditionally in U.S. medical schools, the first 2 years focus on book-learning and the last 2 years focus on clinical experience. This follows the Flexner model of medical training.

A growing trend in U.S. medical schools is the early integration of clinical experience into the first 2 years of medical school. Successful longitudinal integration depends on setting clear goals for basic clinical skills competency. Not much is known about what basic clinical skills medical students should have upon entering their traditional clinical clerkship rotations.

This survey-based study from the University of Washington assessed 3 populations:

1. Third-year medical students, who have completed 3 months of clerkships
2. Preclinical faculty who provide second-year medical students early clinical teaching and exposure
3. Clerkship directors of required 6 clerkships (IM, FM, Surgery, Psych, Peds, Ob/Gyn)

Response rates ranged from average to excellent. Generally a survey response of >70% is reasonable.

• Students: 62% (115 of 185)
• Preclinical faculty: 91% (30 of 33)
• Clerkship directors: 58% (56 of 97)

Outcome Measures

Skills assessed were divided into 3 categories. Each subject was asked to rank what level of preparation was expected for 3rd year students beginning their clinical clerkship. The rating scale ranged from 1 to 5 (1=none, 5= considerable preparation).

1. Basic Clinical Skills

• Communication skill
• Taking a comprehensive history
• Complete review of systems
• Performing a full physical exam
• Comprehensive oral case presentation
• Complete write-up
• Working as a team member
• Receiving feedback

2. Advanced Clinical Skills

• Focused history
• Focused physical exam
• Focused oral presentation
• Preparing SOAP notes
• Clinical reasoning
• Preparing assessment and plan
• Differential diagnosis

3. Knowledge-Related

• Basic science knowledge

Results

There were some interesting statistically-significant findings.

• Preclinical faculty and students had higher expectations than clerkship directors when it came to most basic clinical skills preparation.
• Students, as a whole, expected greater preparation for all of the 7 advanced clinical skills prior to starting clerkships.
• Interestingly, clerkship directors had higher expectations for only 1 item when compared to preclinical faculty. That was in "preparing SOAP notes". I totally agree. Clinical students notoriously do not appreciate the importance of documentation.

Bottom Line

In the upcoming age of vertical integration of clinical experiences throughout medical school, there should be more open communications about expectations of the 3rd year clerkship student. This is similar to the concept of handing off patients from one provider to another for further care. In this case, preclinical faculty are "handing off" students to clerkship directors for further education. We need to make sure that both parties are on the same page.

Reference

Marjorie Wenrich1, Molly B. Jackson, Albert J. Scherpbier, Ineke H. Wolfhagen, Paul G. Ramsey, & Erika A. Goldstein (2010). Ready or not? Expectations of faculty and medical students for clinical skills preparation for clerkships Medical Education Online, 15 : 10.3402/meo.v15i0.5295

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Paucis Verbis card: Procedural sedation and analgesia

From time to time, our patients need moderated and deep sedation in order to tolerate painful procedures such as joint reductions or incision and drainage procedures. There are many medications available to us including some newer ones such as Ketofol and Dexmedetomidine.

This week's Paucis Verbis is a reference card to remind us of the importance of Airway Assessment and help us calculate the medication doses.

If you want to learn more about these medications and some strategies for different types of patients and procedures I recommend the EMCRIT Podcast PSA Lectures 1 and 2.

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

[MS Word] [PDF]

See other Paucis Verbis cards.

Your to-do list: Reactive vs proactive tasks

Do you make to-do lists for yourself?

Scott Scheper is the author of a book "How to Get Focused". One excerpt that I read from his blog "How to Get Focused" really made sense to be on a personal and professional level. It discussed the the secret behind building and accomplishing your to-do list. Read the article.

Briefly, the secret lies in labeling your to-do list items as Reactive or Proactive tasks.

• Reactive Task: A task which is driven by others
• Proactive Task: A task which is driven by your long-term goals and passions

Whenever I feel overwhelmingly busy, I often find it is because my list of reactive tasks has completely overshadowed any proactive tasks that I have planned. There's just no time left for proactive tasks, when you are inundated by emails, social media forums, phone calls, and administrative deadlines.

The goal towards a successful balance is to spend 20% of your time doing reactive tasks and 80% doing proactive tasks. It is much easier said than done, but this provides a nice target to strive for. I used to be 95% reactive and 5% proactive. Over the past year, I have drastically shifted to about 30% reactive and 70% proactive... and it feels totally right.

To borrow from a great quote in the article:

Reactive tasks will make you a living. Proactive tasks will make you successful.

Note: I do not have any financial ties with the author or the book.

Trick of the Trade: Prescribing opiates

As emergency physicians, we are experts in pain control. We frequently write opiate prescriptions for patients being discharged home. Unfortunately, an occasional patient tries to forge my prescription. At times, I get a call from pharmacy for prescriptions that were suspiciously written. For instance several years ago, I had someone try to forge 100 tablets of "Mophine".

Trick of the Trade:

When writing opiate prescriptions, you might consider developing a system. Some people dispense these medications in increments of 10's. Some choose increments of 10, but starting with 8 (8, 18, 28, or 38 tablets). In fact, I have heard of one attending use only prime numbers!

I used to write "Do not drive while taking medications" on the prescriptions, and so when prescriptions didn't have this additional recommendation, I knew that I did not write them. I'm unfortunately not as consistent doing this and so now it's not a helpful screening approach for me.

What system have you used or heard of?