Wellness and Resiliency During Residency: Interprofessional Conflict

“It’s rarely the patients that hurt me. It’s my colleagues in the hospital.”

cartoon conflict pointing finger 3d

“[Interprofessional conflict] is so underappreciated as a source of stress and misery in our job. And so often in the hospital, horrible behavior is swept underneath the rug because a) there is no pathway to address this stuff and b) it’s almost seen as de rigor for certain services to act this way. “Oh it’s the surgical service, what do you expect, that’s just the way they are.” That is what ruins me … I think that is the biggest threat to wellness in my world.”

–Scott Weingart, MD

Burnout in Emergency Medicine

We get it. Emergency Medicine (EM) is tough. Depending on who you ask, EM tops the charts for burnout.1 Long nights, short holidays, critical patients, and jam-packed waiting rooms are just the beginning. Poorly handled arguments, rudeness, and lack of respect between physicians, nurses, and other hospital staff also contribute their own fair share to the burnout epidemic. EM is particularly vulnerable to this type of interprofessional conflict for at least three reasons:

  1. The “fishbowl” effect
  2. A heavy dependence on consultants for definitive care
  3. Necessary interactions with a wide range of specialties and services within the hospital.

Not only does almost every other service have the benefit of hindsight when criticizing patient care in the emergency department, our inpatient colleagues are also often in positions of power to refuse our requests for their expertise, admitting privileges, or operating rooms. Even though as professionals, we are all expected to rise above the level of our own petty emotions. On a busy night at 2 AM, it is easy to see why emergency physicians can often bear the brunt of the distinctly unprofessional wrath of consultants, nurses, techs, and other staff in the hospital.

Disrespectful Behavior and Downstream Effects

Disrespectful behavior may be one of the major contributors to the dysfunctional culture and hidden curriculum of our healthcare system.2 We see it all the time—loud and inappropriate arguments between residents and consultants, demeaning comments to nurses and prehospital providers, and the humiliation of medical students through open censure or criticism in front of others. Not only does all of this contribute to a hostile work environment, interprofessional conflict can be bad for patients too. Rudeness and incivility impairs effective communication between team members, which can then lead to patient safety issues and medical errors.2,3

So what can you do?

The best way to stop an argument is to be the voice of reason. Take a moment to breathe and step back from the situation. Be a professional and encourage your colleagues all over the hospital to do the same.

Want an even better solution?

Essentials of Emergency Medicine icon EEMIf you are an EM resident, join us on May 15, 2017 at the 16th annual Essentials of Emergency Medicine (EEM) Course where residents from all over the country will be coming together for the first-ever Resident Wellness Consensus Summit (RWCS) in order to innovate real-world solutions to resident-physician wellness issues just like this one. This Consensus Summit is jointly sponsored by EEM, Emergency Medicine Residents’ Association (EMRA), and ALiEM.

Also if your residency program has not yet sent 2 resident representatives to the Wellness Think Tank, that would be a good start because work for the RWCS will be starting soon there.

Featured podcast with Dr. Scott Weingart

Listen to Dr. Scott Weingart as he shares his own story of a central line gone horribly wrong. He reflects on the damaging nature of disruptive behavior and proposes ways that each of us can manage interprofessional conflict during our next shift.

What is coming up in the Wellness Think Tank?

On December 5, 2016 at 4 pm PST (7 pm EST) , we will be hosting a Google Hangout on Air videochat with the famous ZDoggMD, a featured strategist for the Think Tank. Hear him share his stories about why this is such a passionate issue for him. Here’s a creatively insightful video he did on physician mindfulness.

1.
Shanafelt T, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012;172(18):1377-1385. [PubMed]
2.
Leape L, Shore M, Dienstag J, et al. Perspective:  a culture of respect, part 1:  the nature and causes of disrespectful behavior by physicians. Acad Med. 2012;87(7):845-852. [PubMed]
3.
Riskin A, Erez A, Foulk T, et al. The Impact of Rudeness on Medical Team Performance: A Randomized Trial. Pediatrics. 2015;136(3):487-495. [PubMed]

Author information

Arlene Chung, MD

Arlene Chung, MD

Chief Strategy Officer,

2016-17 ALiEM Wellness Think Tank
Assistant Professor of Emergency Medicine
Assistant Program Director
Mount Sinai Emergency Medicine Residency
Editor, AKOSMED (EM wellness blog)

The post Wellness and Resiliency During Residency: Interprofessional Conflict appeared first on ALiEM.

Ultrasound For The Win! Case – 40F with Fever, Chest Pain, Shortness of Breath

Welcome to another ultrasound-based case, part of the “Ultrasound For The Win!” (#US4TW) Case Series. In this case series, we focus on a real clinical case where point-of-care ultrasound changed the management of a patient’s care or aided in the diagnosis. In this case, a 40-year-old woman presents with a fever, chest pain, shortness of breath, cough, and generalized weakness.

Case Presentation

A 40-year-old woman presents to the Emergency Department (ED) for evaluation of multiple complaints including fever, chest pain, shortness of breath, cough, and generalized weakness. She denies any known sick contacts or recent travels, and denies any significant past medical history. Her review of systems is otherwise unremarkable. On social history, she endorses intravenous (IV) drug abuse.

Vitals

  • BP 93/56 mmHg
  • P 109 bpm
  • RR 24 breaths/min
  • O2 93% room air
  • T 38.0 C

Differential Diagnosis

  • Acute Coronary Syndrome (ACS)
  • Endocarditis
  • Influenza-Like Illness (ILI)
  • Myocarditis
  • Pericarditis
  • Pneumonia
  • Pulmonary Embolism (PE)
  • Sepsis

She is placed in an isolation room. On physical examination, you find a woman who appears older than stated age. She is in moderate respiratory distress and diaphoretic. On auscultation, her heart is tachycardic and regular without murmurs or rubs. She has coarse breath sounds throughout. Examination of the skin reveals track marks on bilateral ventral forearms, with no other sores, petechiae, or lesions noted.

Fluid resuscitation is started via two large-bore IVs, and initial laboratory studies including blood cultures are drawn. While awaiting a portable chest x-ray, the emergency physician performs a point-of-care echocardiogram.

Workup

Point-of-Care Ultrasound

image-1-endocarditis

Figure 1. Apical-4-chamber cardiac view revealing vegetations on the tricuspid valves concerning for right-sided infective endocarditis.

 

image-2-endocarditis

Figure 2. Large vegetations (arrows) are identified on the tricuspid valves (*). RA = right atrium, RV = right ventricle, LA = left atrium, LV = left ventricle

image-3-endocarditis

Figure 3. Trans-thoracic echo revealing vegetations on the tricuspid valves.

image-4-endocarditis

Figure 4. Vegetation (arrow) on the tricuspid valve

Given the concern for infective endocarditis, broad-spectrum antibiotics are started. At this point, the chest x-ray is performed:

image-5-cxr-pulm-infarct-endocarditis

Figure 5. Chest x-ray revealing a new cavitary mass (3.9 cm) in the left upper lobe. Differential considerations include septic embolus, cavitary pneumonia (tuberculosis/fungal), and abscess.

Laboratory Investigations

Laboratory studies return and are unremarkable:

  • WBC 7.9 x10³/µL
  • Lactate 1.1 mg/dL
  • Hemoglobin 9.2 g/dL
  • Three (3) sets of blood cultures are sent and pending

Ultrasound Image Quality Assurance (QA)

Infective endocarditis (IE) has been historically diagnosed clinically with the aid of the Duke Criteria; however, the requirements for diagnosis are not typically met in the ED as they require a prolonged hospitalization. Thus, the Duke Criteria is largely irrelevant in the ED, making IE a particularly challenging diagnosis for emergency physicians. Fortunately, point-of-care trans-thoracic echocardiogram (TTE) is readily available in most EDs, and can be considered the initial imaging study of choice to look for vegetations.

Vegetations on echocardiogram are visualized as mobile masses on the cardiac valves that move independently from the valves themselves. Vegetations as small as 6 mm can be seen with TTE.1 The identification of right-sided vegetations in particular can be difficult to visualize with a parasternal view. A subxiphoid or apical-4-chamber view may be needed to better visualize these vegetations which highlights the importance of obtaining multiple views when performing a point-of-care echocardiogram.

Valvular incompetence can be evaluated when vegetations are identified or suspected, and has been found to be both diagnostic and prognostic.1 Assessing for tricuspid or mitral regurgitation involves the use of Color Doppler in the apical-4-chamber view. A regurgitant jet is identified with color flow moving away from the probe when the valves close. Additionally, atrial enlargement may be associated with regurgitation.

Abscesses can also be associated and identified with IE (albeit difficult with TTE) as a thickened region with an associated heterogenous echogenic area.

Is TEE sensitive enough to rule out endocarditis in the Emergency Department?

Studies comparing the test characteristics of TTE vs. TEE in the identification of vegetations reveal sensitivities of 30-65% for TTE compared with sensitivities of 87-100% for TEE.2,3 However for right-sided endocarditis, there is an improved sensitivity with TTE, and TEE may not be necessary if clear vegetations are visualized with TTE.3 Of course, the size of a vegetation is a large determinant in its ability to be visualized with TTE. One study revealed that 25% of vegetations <5 mm in size were identified by TTE, 70% of those between 6-10 mm were identified, and 84% of vegetations >10 mm were identified with TTE (Figure 6).1

Figure 6. Identification of vegetations with trans-thoracic echocardiography based on size of vegetation. Adapted from Seif et al.

The data from Figure 6 above can prove particularly useful for emergency physicians as larger vegetations (i.e. >10 mm) or vegetations with severe mobility are independent prognostic factors that are associated with a higher risk of complications (including septic emboli) and mortality.1,4 If these higher-risk patients can be identified by emergency physicians by TTE, more aggressive management and consultation can be initiated earlier, potentially decreasing patient morbidity and mortality.

Thus the utility for the use of TTE in patients with suspicion for infective endocarditis in the ED may be in the ability to risk-stratify patients who are at higher risk for complications such as embolic events and death.

Disposition and Case Conclusion

The visualization of vegetations on the tricuspid valves on point-of-care trans-thoracic echocardiogram helped confirm the diagnosis of right-sided infective endocarditis. The patient was admitted to the ICU for continued IV antibiotics and medical management, in consultation with cardiothoracic surgery during her hospitalization.

A transesophageal echocardiogram was performed during her admission the following day, which revealed:

Multiple large tricuspid valve vegetations (20 mm and 10 mm) attached to both the anterior and posterior leaflets of the tricuspid valve. Mild tricuspid regurgitation. No abscess cavity. Mitral, aortic, pulmonic valves appear normal. Normal biventricular systolic function. No pericardial effusion.

Blood cultures grew gram positive cocci, confirmed to be methicillin-resistant staphylococcus aureus (MRSA), sensitive to vancomycin.

After a prolonged hospitalization, the patient was discharged to home in stable condition with no complications.

Infective Endocarditis

Infective endocarditis (IE) is an uncommon and life-threatening disease with significant morbidity and mortality.1 There are an estimated 10,000 to 15,000 new cases of IE in the United States annually.5 The most common presenting symptoms of IE are non-specific and include fever, anorexia, weight loss, and night sweats.6 The classic physical exam findings including cardiac murmurs, petechiae, Janeway lesions, and Osler’s nodes are relatively rare and may not be evident in cases of IE.6 In fact, a study by Pathak et. al. revealed that tricuspid regurgitation could only be identified 12-33% of the time via cardiac auscultation by Internal Medicine residents and Cardiology fellows.5

Risk factors for IE include patients with prosthetic heart valves, structural heart disease, and intravenous drug use.5 As compared to left-sided endocarditis, right-sided endocarditis tends to affect patients who are younger, have a history of IV drug abuse, and tend to have larger vegetations.3

Complications from IE include septic shock and embolic events. The mortality rate of IE is high (up to 40%) with the most common causes of death being septic shock and multi-organ failure.4,6,7 Thus, a high index of suspicion with early recognition and diagnosis with aggressive early management is needed.

Treatment of IE includes aggressive resuscitation, broad spectrum IV antibiotics that cover the most common organisms (staphylococci and streptococci), which may include vancomycin + gentamicin.8 Cardiothoracic surgery consultation can be considered for potential valvulectomy.6 The indications for valvulectomy include persistent fever, large vegetations, severe right-sided heart failure, or recurrent pulmonary emboli.8

Trans-Esophageal Echocardiography (TEE) in the ED

While not yet widespread, TEE is becoming increasingly used in EDs by emergency physicians, primarily in patients with cardiac arrest. A great online resource for learning more about TEE is the Virtual Transesophageal Echocardiography Simulator by the Toronto General Hospital, Department of Anesthesia.

Take Home Points

  1. Infective endocarditis (IE) is a life-threatening disease with a high morbidity and mortality that often presents with non-specific symptoms. This challenging diagnosis requires a high-index of suspicion by the emergency physician.
  2. Trans-thoracic echocardiogram, while not as sensitive as trans-esophageal echocardiogram, can be used to risk stratify patients at high risk for complications of IE including septic emboli.
  3. Vegetations appear as mobile masses on the valves that move independently from the valves themselves. Vegetations as small as 6 mm can be visualized with TTE.
  4. Management of IE includes aggressive medical management including broad spectrum antibiotics, hospital admission, and consideration for cardiothoracic surgery consultation.
1.
Seif D, Meeks A, Mailhot T, Perera P. Emergency department diagnosis of infective endocarditis using bedside emergency ultrasound. Crit Ultrasound J. 2013;5(1):1. [PubMed]
2.
San R, Vilacosta I, López J, et al. Role of transthoracic and transesophageal echocardiography in right-sided endocarditis: one echocardiographic modality does not fit all. J Am Soc Echocardiogr. 2012;25(8):807-814. [PubMed]
3.
Reynolds H, Jagen M, Tunick P, Kronzon I. Sensitivity of transthoracic versus transesophageal echocardiography for the detection of native valve vegetations in the modern era. J Am Soc Echocardiogr. 2003;16(1):67-70. [PubMed]
4.
Thuny F, Di S, Belliard O, et al. Risk of embolism and death in infective endocarditis: prognostic value of echocardiography: a prospective multicenter study. Circulation. 2005;112(1):69-75. [PubMed]
5.
Pathak N, Ng L, Saul T, Lewiss R. Focused cardiac ultrasound diagnosis of right-sided endocarditis. Am J Emerg Med. 2013;31(6):998.e3-4. [PubMed]
6.
Nunes M, Gelape C, Ferrari T. Profile of infective endocarditis at a tertiary care center in Brazil during a seven-year period: prognostic factors and in-hospital outcome. Int J Infect Dis. 2010;14(5):e394-8. [PubMed]
7.
Kini V, Logani S, Ky B, et al. Transthoracic and transesophageal echocardiography for the indication of suspected infective endocarditis: vegetations, blood cultures and imaging. J Am Soc Echocardiogr. 2010;23(4):396-402. [PubMed]
8.
Hecht S, Berger M. Right-sided endocarditis in intravenous drug users. Prognostic features in 102 episodes. Ann Intern Med. 1992;117(7):560-566. [PubMed]

Author information

Jeffrey Shih, MD, RDMS

Director, Emergency Ultrasound Fellowship Program,
The Scarborough Hospital
Lecturer,
University of Toronto
Assistant Editor, Ultrasound for the Win Series,
Academic Life in Emergency Medicine

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IDEA Series: Partnering with Pathology to Review Deaths in the ED

idea series - team based learning

The Problem

As part of their training, Emergency Medicine (EM) residents are required to perform patient follow up. However, there is currently no universal format in place. Additionally, there is often little follow-up information available on patients who die during the course of their Emergency Department (ED) visit, or shortly after admission to the hospital.

The Innovation: Partnering with Pathology to Review Deaths in the ED

During a monthly emergency medicine conference at the University of Louisville, all deaths occurring in the ED or within 24 hours of admission are reviewed. For those patients who underwent an autopsy, a pathologist is invited to present the case in conjunction with an EM resident. Unlike traditional Morbidity and Mortality (M&M) conferences which feature in-depth analyses of all systems involved, these cases are often straight-forward and focus on the relevant pathologic and forensic findings. These sessions are also less intimidating for the providers involved, as they are not presenting a single case with a negative outcome where the spotlight is on the care they provided.

Target Learners

This review targets EM residents at all levels of training as well as EM faculty. It also has the potential to benefit trainees and practitioners from other disciplines (pre-hospital providers, nursing, pharmacy, respiratory therapy, etc.) and other fields of medicine (general surgery, orthopedics, neurosurgery, critical care, cardiology, neurology, etc.).

ACGME Milestones

Practice-based Performance Improvement (PBLI):

  • “Performs patient follow-up.” (Level 2)
  • “Participates in a process improvement plan to optimize ED practice.” (Level 4)

Patient Safety (SBP1):

  • “Describes medical errors and adverse events.” (Level 1)
  • “Participates in an institutional plan to optimize ED practice and patient safety.” (Level 4)
  • “Leads team reflection such as code debriefings, root cause analysis, or M&M to improve ED performance.” (Level 4)
  • “Identifies situations when the breakdown in teamwork or communication may contribute to medical error.” (Level 4)

Description of the Activity

Preparation

  • Emergency Medicine:
    • Each month, the PGY-3 (post-graduate year) EM resident on an administration rotation is provided with a list of all deaths in the ED and those occurring within 24 hours of admission from a single month.
    • The PGY-3 performs an in depth review of each death, including ED/hospital records, pre-hospital documentation, labs results, radiology reads, and relevant prior medical records.
    • The key data is summarized in a report detailing each case (please see below for an example).
    • Paper copies are made available to all conference attendees.
    • The PGY-3 resident is also responsible for coordinating with the presenting pathologist to determine which cases will be presented.
    • Of note, there is a two-month delay in case review. For example, deaths from September are discussed in November.
Date Expired Medical Record#, ED Resident, Attending ED Summary Procedures Follow Up/Notes
1/1/16 11223344
Dr. XXX
Dr. ZZZ
Level 1 activation PTA. 53 yo M, unrestrained driver, rollover MVA. GCS 7 on scene, intubated. Initial vitals w/ noted tachycardia and hypotension. Palpable crepitus on the L chest, needle decompressed. Obvious LLE fracture. Significant abrasions to chest, facial trauma. Lost pulse 10 mins PTA, CPR started. Epi x 3. PEA on the monitor. R tibial IO. On arrival, CPR continued. Bilateral chest tubes and central line placed. Received an additional 3 rounds of CPR, Epi x1. Aystole. TOD called.

Intubation (EMS)

 

Bilateral Chest Tubes (ED/Trauma)

 

R Femoral Cordis (Trauma)

Excellent documentation

 

  • Pathology:
    • The presenting pathologist is provided with a list of the relevant deaths and cross-matches the names with those who were autopsied.
    • This duty primarily falls to the current forensic pathology fellow; however, on occasion a pathologist from the medical examiner’s office fills in.
    • Depending on the number of qualifying cases, the pathologist may present all cases from the month in question, or choose the 3-4 of most interest or educational value. For example, if three individuals died from self-inflicted gunshot wounds to the head in a single month, all three cases do not need to be presented.
    • For each case presented, the pathologist prepares a brief PowerPoint presentation featuring forensic photographs, final lab results (including toxicology), and the final ruling on cause and manner of death.

Presentation

  • The PGY-3 EM resident functions as the moderator of the session and introduces each case, providing a summary of their ED course.
  • The pathologist follows with their slide presentation, addressing relevant teaching points and questions.
  • Following each case presentation, all faculty and residents are invited to participate in the discussion.
  • Insights from the resident(s) and faculty directly involved in the case are often solicited.

Lessons Learned/Closing Thoughts

These sessions are one of the most well-attended conferences, both by residents and faculty. Patient death affects physicians strongly and the chance to follow up post-mortem is not always readily available. Residents and faculty also benefit from learning about the processes that occurred internally that are not always apparent when treating the patient. For example, the autopsy of a victim of a motor vehicle crash with only externally visible injuries of minor abrasions/contusions may reveal a chest cavity filled with blood from an aortic avulsion. These descriptions and images leave a lasting impact.

In the cases of young patients who die unexpectedly after a long, grueling resuscitation, this activity can also provide closure by revealing the cause of death.

In addition, for the victims of violent crimes, it also serves as an excellent platform to review some of the basics of forensics and improve our documentation of gunshot wounds, stabs, and other injury patterns.

Read more about the IDEA Series.

Photo credits: Lightbulb (c) Can Stock Photo

Author information

Meg Pusateri, MD

Meg Pusateri, MD

Chief Resident
Department of Emergency Medicine
University of Louisville

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I am Dr. Catherine Varner, Emergency Physician and Clinical Scientist: How I Stay Healthy in EM

Dr. Catherine Varner is an emergency physician and clinical scientist from Toronto, Canada. Being an emergency physician and a mother to two young ones, Dr. Varner’s schedule can fill up pretty quick. But despite her busy schedule, she still takes the time to take care of herself. Whether it’s tackling a running trail in the city, or exploring the forest off the beaten path, the outdoors allow her to escape from daily life. Here’s how she stays healthy in EM!

  • Name: Catherine Varnercvarner_headshot_web
  • Location: Toronto, Ontario, Canada
  • Current job(s): Emergency Physician – Mount Sinai Hospital, Clinician Scientist – Schwartz / Reisman Emergency Medicine Institute, Assistant Professor – University of Toronto
  • One word that describes how you stay healthy: Running
  • Primary behavior/activity for destressing: Whether I am taking a long walk on Wrightsville Beach where I grew up, or running in downtown Toronto where I now live, I always think the clearest and breathe the deepest outside.

What are the top 3 ways you keep healthy?

  1. Being with family. There is nothing more relaxing than playing on the floor or going to the park with my 2 boys. Once the boys are asleep, my husband and I love a good couch cuddle.
  1. Spending time with friends. Sharing a coffee or meal with friends always reminds me to laugh and relax. Reconnecting doesn’t happen often enough, but I love picking up right where we left off.
  1. Running. Twenty minutes completely resets my mind and gets me ready to take on the next shift or research task.

What’s your ideal workout?

Running for an hour on any terrain is like a breath of fresh air. Toronto has an amazing (and surprising!) trail system that runs through forests and ravines. All of the sudden you’re underneath a gorgeous canopy of green, and feel a world away from the hustle and bustle! On the other hand, an hour run on city streets can be like a quick trip around the globe, as TO has phenomenal neighborhoods (Little Italy, Little Portugal, Chinatown, Annex, Cabbagetown, Danforth, etc). Also, finishing a run near the Parisian bakery or gelateria is particularly delightful!

Do you track your fitness? How?

I try to run 5 times a week. Most are around 30-45 minutes, and many of these runs are on my way to work. If I am not running regularly, my grumpy-meter starts alarming.

How do you prepare for a night shift? How do you recover from one?

I may or may not have a nap leading up to a night shift, but when I get home post-nights I have breakfast with a big glass of chocolate milk, take a shower, and then sleep for at least 4 to 5 hours.

How do you avoid getting “hangry” (angry due to hunger) on shift?

My colleagues laugh because I have brought the same snack to every shift for 5 years: 2 rice cakes with peanut butter and honey, almonds, and raisins. I eat while I am charting or reviewing test results several times throughout a shift.

How do you ensure you are mentally in check?

Sleep hygiene is one of the most important personal responsibilities of an emergency physician. For me, recognizing and relieving sleep deprivation are keys to maintaining good mental and physical health.

What are the biggest challenges you face in maintaining a longstanding career in EM? How do you address these challenges?

The biggest challenge is balancing shift work while being a mother of 2 young boys (3 years old and 1 year old). The blend of research and shift work is ideal, because the research hours are predictable and doing mostly night shifts gives me more day time to give the little guys a more consistent routine. My husband and I frequently reevaluate what is working and what is not, and plan our schedules many months in advance to avoid childcare gaps and ‘too tight’ pick-ups from daycare.

Best advice you have received for maintaining health?

As a 4th year medical student while assisting with a delivery, blood splashed in my eyes. I was inclined to ignore it and keep working, because it was a busy night and the exposure was low-risk. However, when my attending physician heard about it, she was insistent that I wash out my eyes, see occupational health, and have a post-exposure risk assessment. To this day, I remember her getting frustrated with my negligence and said, “In this career, only YOU will take responsibility for your own health.” I apply this advice to not only my self-care when I am on shift, but also to my personal life.

Who would you love for us to track down to answer these questions?

Nazanin Meshkat

Author information

Zafrina Poonja, MD

Zafrina Poonja, MD

ALiEM Assistant Editor,
How I Stay Health in EM series
Emergency Medicine Resident
University of Saskatchewan

The post I am Dr. Catherine Varner, Emergency Physician and Clinical Scientist: How I Stay Healthy in EM appeared first on ALiEM.

NEW: 2nd Edition of In-Training Exam Prep Book (Sets 1-5)

ALiEM In-Training Exam Prep book in Emergency MedicineHot off the press! The 2nd edition to the ALiEM In-Training Exam Prep Book in Emergency Medicine book is already out less than 6 months from the first edition. This 2nd edition book includes fixes for broken links, spelling and grammar errors, and ambiguous questions. Many thanks to the readership for their feedback. This book is released again in iBook and PDF form for free. Congratulations to the editors-in-chief Dr. Michael Gottlieb, Dr. Rochelle Zarzar, and Philippe Bierny, as well as the previous editors-in-chief Dr. Dorothy Habrat, Dr. Margaret Sheehy, Dr. Samuel, and Zidovetzki from the first edition. To clarify, these 250 multiple-choice questions are designated as Question Sets #1-5, because the 2016-17 Chief Resident Incubator team is working on publishing the next set of new questions.

Author information

Michelle Lin, MD

ALiEM Editor-in-Chief
Academy Endowed Chair of EM Education
Professor of Clinical Emergency Medicine
University of California, San Francisco

The post NEW: 2nd Edition of In-Training Exam Prep Book (Sets 1-5) appeared first on ALiEM.