EMRA*Cast

Dr. Jessie Werner speaks with Professor and Chair of Emergency Medicine at UC Davis, Dr. Nathan Kuppermann, about ground-breaking research in Pediatric DKA. Learn the dos and don’ts of management and learn to embrace those fluids!

In this episode, EMRA*Caster Dr. Tiffany Proffitt talks with Dr. Andy Little and Dr. Brian Milman about how to mentor junior residents and medical students as a resident. They discuss everything from small gestures that make a big impact to having difficult conversations and setting boundaries with mentees. The challenges and rewards of mentoring are broad but worth the extra effort and time. To those mentor hopefuls out there, just remember: Your mentee matters. If you decide to mentor, keep your mentee in mind; mentor with purpose and intention.

Dr Miguel Reyes sits down with Dr. Wall to discuss pediatric fellowships. Why decide to do it? How does one apply and what how do you know for sure if its the right fit for you.

In this episode, Dr. Jessie Werner and Dr. Tiffany Proffitt talk with some of the best medical podcasters in the field about the use of podcasts for teaching and learning. Can podcasts replace books? Supplement conference? Which ones are the best? Find out here.

Dr. Miguel Reyes meets with Drs. Sara Paradise Dimeo, Guy Carmelli, and Michael Shamoon to discuss medical education fellowships and all they entail.

Overview:

We sit down with three guest panelists all involved in medical education fellowships in different phases of their fellowship career to discuss its ins and outs. We talk about why they chose MedED, why their programs, what the application was like and what you can do to be best the applicant.  

Key Resources:

•  https://www.emra.org/fellowships/education-fellowships/
•  https://www.emra.org/books/fellowship-guide-book/7-education/

Key Points:

• MedEd fellowship gives you a leg up for academic positions
• Learn novel and engaging teaching techniques!
• Network with a lot of academic folk! It’s a small community
• Mentorship matters and can help your significantly career

Host: Dr. Agboola MD, MS 

Guests:  Dr. Arelene Chung MD, Dr. Chris Doty MD,  Dr. Alicia Kurtz MD 

Overview:

On this episode, Doctors Agboola, Chung, Kurtz, and Doty discuss the topic of “The Elephant in the Room: ‘Burnout’”. They spend time discussing: Defining the term of burnout, How to recognize symptoms of burnout in others,  Getting past the platitudes of “yoga & exercise”, Moral injury, The Unspoken Curriculum, and Models of Wellness.

Key Resources:

• EMRA Wellness Committee : https://www.emra.org/be-involved/committees/wellness-committee/

• EMRA Wellness Handbook : https://www.emra.org/books/emra-wellness-guide/cover/

• Airway Stories : https://airwaystories.org/author/airwaystories/

• Real Talk :  https://www.vituity.com/realtalk

Key Points:

• “Adversity is coming for all of us”
• We operate in a specialty that lends itself to “burnout”
• Moral Injury is better terminology to use than burnout because “burnout” puts the impetus on the individual rather than on the system that causes it
• It’s critical to find an outlet, whether that be in the curriculum of your program or elsewhere through modalities online. 
• Online modalities such as these include Airway Stories and Real Talk
• “Burnout” ≄ Depression 
• Recognizing burnout is often difficult because each person manifests it in different ways. Look for acute changes in a person’s behavior or mood. 
• “Burnout” is a moving target, there are a variety of different ways to approach it

References:

• Stanford Model of Wellness : https://wellmd.stanford.edu/content/dam/sm/wellmd/documents/2017-wellmd-status-report-dist-1.pdf 

• National Academy of Medicine Action Collaborative on Clinician Well-Being and Resilience : https://nam.edu/initiatives/clinician-resilience-and-well-being/ 

• Medscape National Physician Burnout Depression and Suicide Report 2019 : https://www.medscape.com/slideshow/2019-lifestyle-burnout-depression-6011056#1

Overview: In this episode of EMRA*Cast, Dr. Jessie Werner discusses medical education with researcher and educator, Dr. Jeff Riddell. We cover adult learning theory, the current state of medical education and new developments. If you’re wondering where the CCC report came from, how to give and receive better on-shift feedback, and what we can do to improve medical education, then this episode is for you!

Key Resources:

• Norman, Geoffrey R. "The adult learner: a mythical species." Academic medicine (1999).
• Gottlieb, Michael, Jeff Riddell, and Sara E. Crager. "Alternatives to the conference status quo: Addressing the learning needs of emergency medicine residents." Annals of emergency medicine 4.68 (2016): 423-430.
• Telio, Summer, Rola Ajjawi, and Glenn Regehr. "The “educational alliance” as a framework for reconceptualizing feedback in medical education." Academic Medicine 90.5 (2015): 609-614.
• Telio, Summer, Glenn Regehr, and Rola Ajjawi. "Feedback and the educational alliance: examining credibility judgements and their consequences." Medical education 50.9 (2016): 933-942.

Key Points:

• Adult Learning Theory:
• •  Malcom Knowles’ Theory of Andragogy has 5 main assumptions:
  • • Adults are self-directed learners
    • Adults learn experientially
    • Adults approach learning based on tasks and social roles (adults want to know what they NEED to know)
    • Adults approach learning as problem-solving
    • Adults are intrinsically motivated to learn
  • Geoffrey Norman argues against these ideas as being largely untested
  • Adults and kids are actually more similar than different in how they learn
• When asking a question, or “pimping,” make sure you come at it with the right intent so as not to alienate learners. That being said, emotional activation (a little fear) can help you learn, as can the practice of retrieval (remembering)
• “Flipped Classroom”: lecture material is learned at home, asynchronously, and reviewed in conference
• “Interleaving”: mixing up topics rather than blocked topics i.e. when talking about pulmonary embolism you address it in multiple ways and emphasize varying concepts so that learners remember multiple aspects about it and how it ties in with various presentations or alternate diagnoses (not all PEs present with pleuritic chest pain!) 

• Feedback:

• • Formative: designed to help the resident improve (given directly to the resident in the moment)
  • Summative: a summary of how the resident is doing overall (this is usually in your CCC report or an evaluation you see 6 months later)
• The Educational Alliance: Residents make credibility judgments about feedback in the context of a relationship (i.e. if you have a relationship with your resident then the feedback goes over better)
• Directions of Graduate Medical Education
• • Technology is going to play a big role!
  • There are a lot of resources out there now. Curating those resources will be important! Educational resources are not just in textbooks or from large academic centers. FOAMed, podcasts, blogs, etc are coming from multiple places. 

Host: Alex Kaminsky MD: PGY-3 UCSF Fresno

Guest: Jerry Hoffman MD: Professor Emeritus UCLA

Deputy Editor/Contributor: Mat Goebel MD: PGY-1 Baystate

Overview: 

In this inaugural Journal Club episode, we discuss the over-utilization of cervical spine imaging in traumatic patients via landmark papers from the NEXUS group. 

X-radiography of the C-spine has been widely replaced by CT-radiography, but the principles remain the same. Patient with low mechanism injuries are often over-irradiated due to physician fears of a statistically small percentage of true clinically significant C-spine injuries. Physicians often neglect to recognize the number needed to harm during diagnostic studies. This is particularly important in C-spine imaging as the anatomic target is directly adjacent to the radiosensitive thyroid gland.

With the Assistance of Dr. Hoffman (Primary Author), we will delve into the overall study with some advanced pearls.

Key Resources:

• Initial Paper: Hoffman JR, Wolfson AB, Todd KH, Mower WR. Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS). Ann Emerg Med 1998;32:461-469. PMID:9774931
• • https://www.ncbi.nlm.nih.gov/pubmed/9774931
• Hoffman JR, , Mower WR, Todd KH. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med. 2000;343(2):94-1. PMID: 10891516 
• • https://www.nejm.org/doi/10.1056/NEJM200007133430203?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dwww.ncbi.nlm.nih.gov

• https://www.mdcalc.com/nexus-criteria-c-spine-imaging#evidence

Key Points:

• NEXUS C-Spine is an INSTRUMENT designed to augment clinical judgement. It was designed to support common-sense practices.

Criteria – 99.6% Sensitive (If all negative, reassured no significant fracture) 

• No Focal Neurologic Deficit
• No Altered Consciousness
• No Intoxication – Requires Judgement (common sense)
• No Distracting Injury – Requires Judgement (common sense)
• Is a finger fracture? Is a corneal ulceration?
• No Midline Tenderness

Study Highlights:

>34,000 Patients over 21 hospitals in 4 geographic US regions

>800 true positive C-spine injuries identified

Sensitivity reported at 99.6%

Two clinically significant “misses” identified

• One likely chronic injury. No change in outcome at follow-up. Patient asymptomatic.

• One patient underwent surgical intervention

• Of note authors suggest patient actually did not meet NEXUS criteria as he had paresthesias

NEXUS C-spine: Overall 12.6% reduction in C-spine imaging

Host: Miguel Reyes, MD
Hackensack University Medical Center
Year: PGY-3
@miguel_reyesMD

Guest: Alicia Kurtz,MD

Assistant Medical Director at Mercy San Juan Medical 
Mercy San Juan Medical
@aliciakurtz_md

Overview: We discuss with former EMRA president, and current EMRA 45 Under 45, Dr. Alicia Kurtz about her decision and why people would choose to go into an administrative fellowship and what that entails.

Key Resources:

•    https://www.emra.org/fellowships/

Key Points:

• If interested in admin try to get involved as a resident on committees
• Look up fellowships on the EMRA website!
• Some groups don't advertise their administrative tracks well, always ask!     

Host: Tiffany Proffitt DO, MABS PGY-4 Lakeland Health

@ProMammaDoc

Guests: Dr. Anita Rohra: Assistant Professor at Baylor College of Medicine, residency at New York Hospital in Queens, Ultrasound Fellowship at Baylor, upcoming speaker at FIX 2019

@RohraAnita

 Overview: 

In this episode, Tiffany discusses gender disparities in the evaluation of female residents in the context of the 2017 JAMA study with Dr. Anita Rohra. The study compared the ACGME milestone data collected over 2 years from 8 emergency medicine residency programs across the country of male versus female residents. It demonstrated that both male and female residents started residency at a similar competency level according to milestones, however, female emergency medicine residents were evaluated 0.15 milestones, equivalent of 3-4 months of training, lower than their male counterparts at graduation.  The study further found that both male and female attendings evaluated the female residents lower, oftentimes counter to the expressed beliefs of the attendings. 

References:

1. Dayal A, O'Connor DM, Qadri U, Arora VM. Comparison of Male vs Female Resident Milestone Evaluations by Faculty During Emergency Medicine Residency Training [published correction appears in JAMA Intern Med. 2017 May 1;177(5):747]. JAMA Intern Med. 2017;177(5):651–657. doi:10.1001/jamainternmed.2016.9616October 2017 
2. Mueller, Anna S., Tania M. Jenkins, Melissa Osborne, Arjun Dayal, Daniel M. O’Connor, and Vineet M. Arora. 2017. “Gender Differences in Attending Physicians’ Feedback to Residents: A Qualitative Analysis.” Journal of Graduate Medical Education 9(5): 577–85. 
3. The Delta Factor: Overcoming Gender Disparities https://traffic.libsyn.com/secure/emracast/530117925-emresidents-overcoming-gender-disparities-with-dr-esther-choo-and-dr-tiffany-proffitt.mp3

Key Points:

• Overcoming gender bias requires constant diligent evaluation of ourselves and our behavior. 
• Change will only come with speaking out and awareness.
• The attainment of equality is an active, not a passive, process.