Great advice for your next presentation:

In order to improve teaching, he points out that we need to:

1. Structure courses to take advantage of technology:

This topic is getting a lot of airtime lately.  It even made the New England Journal of Medicine.  Blended learning, flipped learning, individual interactive instruction, asynchronous learning.  While the exact methodology employed varies, they all share an important principle: Give the learner the material on their time, at their pace.

Critics will cite difficulty with verifying completion of the material, but I think they're missing something.  Likely, they still depend on synchronous lectures to fill the valuable class time.

By putting the lectures online you take advantage of repetition, giving students the ability to master the material.  You also take advantage of adult learning by the learner the ability to skip forward if the material is too basic.

2. Rethink how we use class time effectively

Now Dr. Kim gets at the crux: we need to stop wasting learners time.  If the session fails to add value to their learning, it is wasteful.  Salman Khan, of Khan Academy fame, discusses how using video allows teachers more time with the learners in another powerful TED Talk.  By moving from the "Sage on the Stage" to the "Guide on the side" the teacher is now in the position to assess the learning and help the students master the material.

It is important to recognize that class time is now used to explore issues in greater depth.  Class time is now longer "lecture time" but is used for small groups, problem solving, or projects.  As Dr. Kim points out: learner build meaning and add a personal context to the material

The biggest threat to this type of teaching is time.  I've had the good fortune to spend the last five years teaching at a residency that utilizes this approach in a low tech fashion: assigned reading.  Each week our learners are assigned 50-100 pages of journal articles about a specific topic, such as head trauma, cardiac ischemia, or pulmonary infections.  The faculty then lead a two hour discussion every week about the topic.  We utilize many methods for leading the discussion: creating mind maps, reasoning through cases, guided discussions, role playing, etc.  It take a phenomenal amount of time to read the material and design the learning experience, but the learner engagement is phenomenal and our boards scores aren't too shabby either.

3. Make the pursuit of scholarly teaching a priority

What Dr. Kim is really getting at is the Scholarship of Teaching and Learning (SOTL), a term popularized by Ernest Boyer in his book Scholarship Reconsidered.  Educationalists view teaching as a continuum:

Teaching: routine instruction; teaching the way we were taught with little insight into how to improve education

Scholarly Teaching: Teachers who "inform" their own teaching; use pedagogy to improve practice; obtain feedback from students, outside/peer evaluators, and self-reflection to improve practice

SOTL: The actual research into what works and doesn't work in education

SOTL provides the evidence for evidence-based education, hence the need to make it a priority.  With SOTL, we can:

Improve learning outcomes
Improve instructional design
Improve teaching and faculty development

SOTL is a big topic, and I'll be writing on this more later.

So, using technology to flip the classroom, empowering students to learn, and actively investigating what works and doesn't work is the way forward?  As Dr. Kim concludes, by focusing on these three issues, "we can make informed decisions that will lead to better educational design and sound education policy."  I can't agree more!

Other References:

O'Brien, M. (2008). Navigating the SoTL Landscape: A Compass, Map and Some Tools for Getting Started. International Journal for the Scholarship of Teaching and Learning. 2(2): 1-20.

Technology is constantly advancing.  New tools arrive on the scene each year, and often we don't know whether to ignore them or incorporate them into our teaching.  The slideshow below is a compilation of 100 tools that can be used help our students understand content. Take a look and let me know what tools you use in the classroom. How do you determine whether they're tools or gimmicks?

Technology is constantly advancing.  New tools arrive on the scene each year, and often we don't know whether to ignore them or incorporate them into our teaching.  The slideshow below is a compilation of 100 tools that can be used help our students understand content. Take a look and let me know what tools you use in the classroom. How do you determine whether they're tools or gimmicks?

Technology is constantly advancing.  New tools arrive on the scene each year, and often we don't know whether to ignore them or incorporate them into our teaching.  The slideshow below is a compilation of 100 tools that can be used help our students understand content. Take a look and let me know what tools you use in the classroom. How do you determine whether they're tools or gimmicks?

I've always been a bit of a photobug.  I blame my grandmother who gave me my first camera when I was just a young kid.  Back in those days, we had this stuff called film.  The pictures were unpredictable and expensive, so I only took pictures of things I felt were important.  Fast forward 20 years, and the technology is incredible.  Digital photography is everywhere!  Cameras, phones, and maybe even glasses soon.

With the explosion in technology, it's very easy to take pictures of clinically relevant cases.  Images are a great teaching tool, but you need to get the right picture.  A few years ago, I attended the SAEM workshop on medical photography taught by Dr. Jason Thurman.  The course is great and if you have the chance to attend, I highly recommend it.  Here are some pearls I gleaned from their teaching as well as some additional hints to improve your skills.

1. It all starts with consent.  Like any procedure, to take a picture for educational purposes, you need to obtain consent.  This is likely to be institution specific.  Check with you institution to determine if you need an additional form.

2. What equipment do you need? These days, the quality of camera phones has improved dramatically.  That being said, dedicated cameras still have more functionality.  Digital SLRs offer the greatest functionality, but also cost a significant amount.  My advice would be to start small and if you think this is for you, move up to a dSLR.

3. Know the basics

Exposure: The amount of light that hits the sensor.  In photography this is controlled by the aperture and shutter speed.  These controls have a reciprocal relationship.

Shutter Speed: Simple; the amount of time that the shutter is open, expressed as a fraction of a second (1/60, 1/90).  Slow shutter speeds mean blurred motion if the subject is active.

Aperture: The opening in the lens that allows light through, expressed as the f-stop number; like gauge: bigger number = smaller opening.  Aperture is REALLY important because it controls the depth of field, which is basically the amount of the scene that is in focus. The smaller the aperture, the greater the depth of field.  This comes into play when taking close up or macro photos (like the eye above).  The closer to an object you are, the narrower the depth of field becomes.  Since you'll have to use a small aperture (f16 or smaller) your shutter speed will likely be slow, hence, you'll need a flash.

Gray World Assumption: All camera light meters try to make the detected scene 18% gray based on some light physics.  Because of this, scenes that are dark or bright end up messing up the exposure. (Think about the last time you tried to take a picture in bright sunlight or snow).  To compensate for this, watch the sensor and adjust the f-stop + or - one stop.  Fortunately with digital photography, we can view the pictures and make the adjustments on the fly (burned up a lot of good film trying to master this technique)

Lighting: There are 3 types of lighting: axial, texture, and flat.


Axial lighting involves holding the flash parallel to the barrel of the lens.  This reduces harsh shadows that might be created if the flash was placed in the shoe.  The image of the eye above was taken using axial light

Textural lighting adds dimension to an image by placed the light source at a 30-45 degree angle off to the side.

Flat Lighting produces the most accurate color.  It's accomplished by placing the flash on the side of the barrel or using a special flash called a ring flash.


4. Control the background: remove any distractions! (These, incidentally, can be an identifier)  Things like jewelry, tattoos, clothing all take away from image quality.  Place the body part in question onto a solid clean background (leftover surgical towels work AWESOME for this).  If possible, add a ruler to demonstrate scale.

5. Get the right views: Think like a radiologist.  If photographing the face, get an AP, lateral, and oblique.  Think similarly for the rest of the body.  Don't be afraid to get a standard shot and then zoom in to focus on the pathology.

Now get out there, take a camera, take lots of pictures, share them, and Vive le FOAMe
Google +1

I've always been a bit of a photobug.  I blame my grandmother who gave me my first camera when I was just a young kid.  Back in those days, we had this stuff called film.  The pictures were unpredictable and expensive, so I only took pictures of things I felt were important.  Fast forward 20 years, and the technology is incredible.  Digital photography is everywhere!  Cameras, phones, and maybe even glasses soon.

With the explosion in technology, it's very easy to take pictures of clinically relevant cases.  Images are a great teaching tool, but you need to get the right picture.  A few years ago, I attended the SAEM workshop on medical photography taught by Dr. Jason Thurman.  The course is great and if you have the chance to attend, I highly recommend it.  Here are some pearls I gleaned from their teaching as well as some additional hints to improve your skills.

1. It all starts with consent.  Like any procedure, to take a picture for educational purposes, you need to obtain consent.  This is likely to be institution specific.  Check with you institution to determine if you need an additional form.

2. What equipment do you need? These days, the quality of camera phones has improved dramatically.  That being said, dedicated cameras still have more functionality.  Digital SLRs offer the greatest functionality, but also cost a significant amount.  My advice would be to start small and if you think this is for you, move up to a dSLR.

3. Know the basics

Exposure: The amount of light that hits the sensor.  In photography this is controlled by the aperture and shutter speed.  These controls have a reciprocal relationship.

Shutter Speed: Simple; the amount of time that the shutter is open, expressed as a fraction of a second (1/60, 1/90).  Slow shutter speeds mean blurred motion if the subject is active.

Aperture: The opening in the lens that allows light through, expressed as the f-stop number; like gauge: bigger number = smaller opening.  Aperture is REALLY important because it controls the depth of field, which is basically the amount of the scene that is in focus. The smaller the aperture, the greater the depth of field.  This comes into play when taking close up or macro photos (like the eye above).  The closer to an object you are, the narrower the depth of field becomes.  Since you'll have to use a small aperture (f16 or smaller) your shutter speed will likely be slow, hence, you'll need a flash.

Gray World Assumption: All camera light meters try to make the detected scene 18% gray based on some light physics.  Because of this, scenes that are dark or bright end up messing up the exposure. (Think about the last time you tried to take a picture in bright sunlight or snow).  To compensate for this, watch the sensor and adjust the f-stop + or - one stop.  Fortunately with digital photography, we can view the pictures and make the adjustments on the fly (burned up a lot of good film trying to master this technique)

Lighting: There are 3 types of lighting: axial, texture, and flat.


Axial lighting involves holding the flash parallel to the barrel of the lens.  This reduces harsh shadows that might be created if the flash was placed in the shoe.  The image of the eye above was taken using axial light

Textural lighting adds dimension to an image by placed the light source at a 30-45 degree angle off to the side.

Flat Lighting produces the most accurate color.  It's accomplished by placing the flash on the side of the barrel or using a special flash called a ring flash.


4. Control the background: remove any distractions! (These, incidentally, can be an identifier)  Things like jewelry, tattoos, clothing all take away from image quality.  Place the body part in question onto a solid clean background (leftover surgical towels work AWESOME for this).  If possible, add a ruler to demonstrate scale.

5. Get the right views: Think like a radiologist.  If photographing the face, get an AP, lateral, and oblique.  Think similarly for the rest of the body.  Don't be afraid to get a standard shot and then zoom in to focus on the pathology.

Now get out there, take a camera, take lots of pictures, share them, and Vive le FOAMe
Google +1

I've always been a bit of a photobug.  I blame my grandmother who gave me my first camera when I was just a young kid.  Back in those days, we had this stuff called film.  The pictures were unpredictable and expensive, so I only took pictures of things I felt were important.  Fast forward 20 years, and the technology is incredible.  Digital photography is everywhere!  Cameras, phones, and maybe even glasses soon.

With the explosion in technology, it's very easy to take pictures of clinically relevant cases.  Images are a great teaching tool, but you need to get the right picture.  A few years ago, I attended the SAEM workshop on medical photography taught by Dr. Jason Thurman.  The course is great and if you have the chance to attend, I highly recommend it.  Here are some pearls I gleaned from their teaching as well as some additional hints to improve your skills.

1. It all starts with consent.  Like any procedure, to take a picture for educational purposes, you need to obtain consent.  This is likely to be institution specific.  Check with you institution to determine if you need an additional form.

2. What equipment do you need? These days, the quality of camera phones has improved dramatically.  That being said, dedicated cameras still have more functionality.  Digital SLRs offer the greatest functionality, but also cost a significant amount.  My advice would be to start small and if you think this is for you, move up to a dSLR.

3. Know the basics

Exposure: The amount of light that hits the sensor.  In photography this is controlled by the aperture and shutter speed.  These controls have a reciprocal relationship.

Shutter Speed: Simple; the amount of time that the shutter is open, expressed as a fraction of a second (1/60, 1/90).  Slow shutter speeds mean blurred motion if the subject is active.

Aperture: The opening in the lens that allows light through, expressed as the f-stop number; like gauge: bigger number = smaller opening.  Aperture is REALLY important because it controls the depth of field, which is basically the amount of the scene that is in focus. The smaller the aperture, the greater the depth of field.  This comes into play when taking close up or macro photos (like the eye above).  The closer to an object you are, the narrower the depth of field becomes.  Since you'll have to use a small aperture (f16 or smaller) your shutter speed will likely be slow, hence, you'll need a flash.

Gray World Assumption: All camera light meters try to make the detected scene 18% gray based on some light physics.  Because of this, scenes that are dark or bright end up messing up the exposure. (Think about the last time you tried to take a picture in bright sunlight or snow).  To compensate for this, watch the sensor and adjust the f-stop + or - one stop.  Fortunately with digital photography, we can view the pictures and make the adjustments on the fly (burned up a lot of good film trying to master this technique)

Lighting: There are 3 types of lighting: axial, texture, and flat.


Axial lighting involves holding the flash parallel to the barrel of the lens.  This reduces harsh shadows that might be created if the flash was placed in the shoe.  The image of the eye above was taken using axial light

Textural lighting adds dimension to an image by placed the light source at a 30-45 degree angle off to the side.

Flat Lighting produces the most accurate color.  It's accomplished by placing the flash on the side of the barrel or using a special flash called a ring flash.


4. Control the background: remove any distractions! (These, incidentally, can be an identifier)  Things like jewelry, tattoos, clothing all take away from image quality.  Place the body part in question onto a solid clean background (leftover surgical towels work AWESOME for this).  If possible, add a ruler to demonstrate scale.

5. Get the right views: Think like a radiologist.  If photographing the face, get an AP, lateral, and oblique.  Think similarly for the rest of the body.  Don't be afraid to get a standard shot and then zoom in to focus on the pathology.

Now get out there, take a camera, take lots of pictures, share them, and Vive le FOAMe

"If you fall off your horse, get right back in the saddle."

It's been too long since I last sat down to write.  I've plenty of great material to share.  I've spent the last 5 months studying medical education as part of a master's degree program, so stay tuned.  We'll be talking a LOT about medical education.

In the mean time, I wanted to share this video of Atul Gawande, author of The Checklist Manifesto, as he talks about the need to focus on becoming a medical Pit Crew instead of focusing relentlessly on maintaining our autonomy.



Great stuff to ponder as we think about needed reforms in medicine and medical education.

"If you fall off your horse, get right back in the saddle."

It's been too long since I last sat down to write.  I've plenty of great material to share.  I've spent the last 5 months studying medical education as part of a master's degree program, so stay tuned.  We'll be talking a LOT about medical education.

In the mean time, I wanted to share this video of Atul Gawande, author of The Checklist Manifesto, as he talks about the need to focus on becoming a medical Pit Crew instead of focusing relentlessly on maintaining our autonomy.



Great stuff to ponder as we think about needed reforms in medicine and medical education.

"If you fall off your horse, get right back in the saddle."

It's been too long since I last sat down to write.  I've plenty of great material to share.  I've spent the last 5 months studying medical education as part of a master's degree program, so stay tuned.  We'll be talking a LOT about medical education.

In the mean time, I wanted to share this video of Atul Gawande, author of The Checklist Manifesto, as he talks about the need to focus on becoming a medical Pit Crew instead of focusing relentlessly on maintaining our autonomy.



Great stuff to ponder as we think about needed reforms in medicine and medical education.

It's that time of year again.  The time of the year that you see the new interns scrambling through the department, eyes wide as saucers, running scared, and hungry for experience.  As an educator, it's a refreshing time to be at work!

With the start of the interns, many blogs have been providing advice to help them on their way to a successful career.  Some of the better examples are here and here.

But this is emergency medicine, and while the given advice still applies, I wanted to add a little more, just for our learners.  When I began my residency, one of our attendings handed us a copy of "The Ten Commandments of Emergency Medicine."  I still have my original copy and now and then I hand it out to my residents.  As I dusted it off this year, I realized that the article was written in 1991!  Are the commandments still relevant?  Read on. . .

Secure the ABC's

Relevance: High

We pride ourselves on being the masters of resuscitation.  Mastering the patients' ABCs should be the priority the moment you walk in the room.  Simply walking in and observing your patient can give you an amazing amount of information.  Is the patient able to speak full sentences? Are they talking at all?  Do they make sense?  How is their color, work of breathing, pulse, etc?  If you find a problem, fix it first.

The authors of the article expand the ABC's mnemonic a little ABCD2EFG2.  While most of these are familiar to us, the addition FG2 is useful to remember:

Fetal Heart tones: a needed vital sign in pregnant patients
RhoGam: Consider getting the type and Rh in pregnant trauma patients
Guardrails: Confused and elderly people fall out of bed far too often.  If you put them down or find them down, then take the 10 second and put them up!

Consider or give naloxone, glucose, and thiamine

Relevance: Glucose, high; others moderate

Any patient with altered mental status or a new neurologic deficit deserves a fingerstick glucose.  Almost every one of us has forgotten this truism once.  The embarrassment experienced by performing the stroke workup only to get the critical glucose level back from the lab is never forgotten

As for naloxone, consider it, but give it in smaller doses if you give it at all.  Remember "Priumum non Nocere."  After witnessing an addict in iatrogenic withdrawal once, I'm more likely to give 0.2 to 0.4 mg or simply intubate the patient and wait.

Thiamine is safe and potentially helpful.  While we still give it to the patient with alcoholism, the population that seems to need it the most these days are the post-gastric bypass population.

Get a pregnancy test

Relevance: Very High

I remember a story about a seasoned senior EM attending being asked what the biggest development of his career was.  The answer?  The urine pregnancy test.  Any female, age 10-55, deserves this quick test.  You'll lose count of how often your workup will be changed by the results of this test.

Assume the worst

Relevance: Very High

Amal Mattu likes to quip, "When emergency physicians here hoofbeats, we think lions, and tigers, and bears."  We aren't after the zebras.  Whatever can kill the patient we rule out first.  Only then do we move on less severe and more likely conditions.  Check your attitude at the door.  Don't get hung up on the 20/10 pain while the patient sits eating a bag of chips.  Take them at their word, do your best exam, and give them the benefit of the doubt.  You will be humbled time and time again by the seemingly stable patient who tries to die, sometimes successfully, in front of you.

Do not send unstable patients to radiology

Relevance: Moderate

This is one area that has changed in recent years.  It no longer takes as long to get studies done, and sometimes that septic elderly patient will need a CT to find the phlegmon of infection.  I would change the commandment to: Do not send unstable patients to radiology alone; you must go with them.  If conditions exist which can be fixed first then do so: secure the airway, begin fixing volume problems, etc.  If an alternative exists, such as bedside ultrasound, use it to your advantage, but don't fail to make the diagnosis simply to avoid taking the patient out of the department.  Oh yeah, and when you take them, take the right equipment too.

Look for common red flags

Relevance: High

I always get a little but of a laugh when reading this one.  It talks about FOUR vital signs!  With pulse ox and capnography and pain (really?) we have more vitals than we know what to do with!  The point is simple: look at the vitals and explain them.  Your history will gain you more than an entire battery of labs.  Ask about comorbidities.  Ask about risk factors; that patient with an IV drug addiction who has back pain and a low grade fever isn't looking to score narcotics.  Remember the extremes of age.  Pay particular attention to revisits.  These patients are giving you a second or third chance to make the correct diagnosis.  And remember, before anyone goes home, they must be able to eat and walk.

Trust no one, believe nothing (not even yourself)

Relevance: High

Anything that any tells you, in person, or in writing, might be false.  The "frequent flier" may be in the department often, but also might have real disease.  Always start with a open mind, talk to the patient, examine the patient fully, and look at every image and study yourself.  Remember, the cardiologist and radiologist aren't seeing the patient and can miss significant findings.

The same advice applies to your teachers, and to this post.  Be skeptical but not cynical.  Take the time to check the facts, read the literature yourself, and try both old and new techniques.  Did you find an absence of evidence about a treatment?  You may have just found your research project!

Learn from your mistakes

Relevance: High

I've learned far more from my mistakes than my successes.  We all make mistakes.  The important part is to learn from them.  Possibly even more important is learning OF them.  Emergency medicine is particularly prone to an absence of feedback about our mistakes.  Did you have an uncertain diagnosis?  Look into the case and follow up on the patient after discharge.  Learning about our errors is essential to improving our practice.

Since we all make them, try not to judge others by their mistakes.  Learn from their errors, but look deeper as well.  Were there any system issues, communication errors, etc, that may have contributed to the error?  Can any of these be fixed to prevent the error from occurring again?

Do unto others as you would do to your family (and that includes coworkers)

Relevance: High

You'll more often do the right thing when you follow this maxim.  Respecting our patients, colleagues, and coworkers demonstrates the caring attitude expected of a good physician.  And remember this if you decide to be rude: "The toes you step on today might be connected to the backside you need to kiss tomorrow."

When in doubt, always err on the side of the patient

Relevance: High

We see the patients that society and even healthcare tend to forget: the homeless, the addicted, the psychiatric, etc.  We need to be the ultimate patient advocate.  We strive to relieve suffering.  To do what is right for the patient, we need to consider the course of action that would minimize their suffering and keep the patient safe.  This will unfortunately put us at odds with our administrators, and at times, our peers, but if we fail to take care of our patients, then no one else will either and we will have violated our sacred oath.


As you can see, despite being 20 years old, these "commandments" still have a significant amount of relevance today.  For sure, they could be added too, but for the start of your career, paying attention to this short list will help you to save lives become a better emergency physician.

It's that time of year again.  The time of the year that you see the new interns scrambling through the department, eyes wide as saucers, running scared, and hungry for experience.  As an educator, it's a refreshing time to be at work!

With the start of the interns, many blogs have been providing advice to help them on their way to a successful career.  Some of the better examples are here and here.

But this is emergency medicine, and while the given advice still applies, I wanted to add a little more, just for our learners.  When I began my residency, one of our attendings handed us a copy of "The Ten Commandments of Emergency Medicine."  I still have my original copy and now and then I hand it out to my residents.  As I dusted it off this year, I realized that the article was written in 1991!  Are the commandments still relevant?  Read on. . .

Secure the ABC's

Relevance: High

We pride ourselves on being the masters of resuscitation.  Mastering the patients' ABCs should be the priority the moment you walk in the room.  Simply walking in and observing your patient can give you an amazing amount of information.  Is the patient able to speak full sentences? Are they talking at all?  Do they make sense?  How is their color, work of breathing, pulse, etc?  If you find a problem, fix it first.

The authors of the article expand the ABC's mnemonic a little ABCD2EFG2.  While most of these are familiar to us, the addition FG2 is useful to remember:

Fetal Heart tones: a needed vital sign in pregnant patients
RhoGam: Consider getting the type and Rh in pregnant trauma patients
Guardrails: Confused and elderly people fall out of bed far too often.  If you put them down or find them down, then take the 10 second and put them up!

Consider or give naloxone, glucose, and thiamine

Relevance: Glucose, high; others moderate

Any patient with altered mental status or a new neurologic deficit deserves a fingerstick glucose.  Almost every one of us has forgotten this truism once.  The embarrassment experienced by performing the stroke workup only to get the critical glucose level back from the lab is never forgotten

As for naloxone, consider it, but give it in smaller doses if you give it at all.  Remember "Priumum non Nocere."  After witnessing an addict in iatrogenic withdrawal once, I'm more likely to give 0.2 to 0.4 mg or simply intubate the patient and wait.

Thiamine is safe and potentially helpful.  While we still give it to the patient with alcoholism, the population that seems to need it the most these days are the post-gastric bypass population.

Get a pregnancy test

Relevance: Very High

I remember a story about a seasoned senior EM attending being asked what the biggest development of his career was.  The answer?  The urine pregnancy test.  Any female, age 10-55, deserves this quick test.  You'll lose count of how often your workup will be changed by the results of this test.

Assume the worst

Relevance: Very High

Amal Mattu likes to quip, "When emergency physicians here hoofbeats, we think lions, and tigers, and bears."  We aren't after the zebras.  Whatever can kill the patient we rule out first.  Only then do we move on less severe and more likely conditions.  Check your attitude at the door.  Don't get hung up on the 20/10 pain while the patient sits eating a bag of chips.  Take them at their word, do your best exam, and give them the benefit of the doubt.  You will be humbled time and time again by the seemingly stable patient who tries to die, sometimes successfully, in front of you.

Do not send unstable patients to radiology

Relevance: Moderate

This is one area that has changed in recent years.  It no longer takes as long to get studies done, and sometimes that septic elderly patient will need a CT to find the phlegmon of infection.  I would change the commandment to: Do not send unstable patients to radiology alone; you must go with them.  If conditions exist which can be fixed first then do so: secure the airway, begin fixing volume problems, etc.  If an alternative exists, such as bedside ultrasound, use it to your advantage, but don't fail to make the diagnosis simply to avoid taking the patient out of the department.  Oh yeah, and when you take them, take the right equipment too.

Look for common red flags

Relevance: High

I always get a little but of a laugh when reading this one.  It talks about FOUR vital signs!  With pulse ox and capnography and pain (really?) we have more vitals than we know what to do with!  The point is simple: look at the vitals and explain them.  Your history will gain you more than an entire battery of labs.  Ask about comorbidities.  Ask about risk factors; that patient with an IV drug addiction who has back pain and a low grade fever isn't looking to score narcotics.  Remember the extremes of age.  Pay particular attention to revisits.  These patients are giving you a second or third chance to make the correct diagnosis.  And remember, before anyone goes home, they must be able to eat and walk.

Trust no one, believe nothing (not even yourself)

Relevance: High

Anything that any tells you, in person, or in writing, might be false.  The "frequent flier" may be in the department often, but also might have real disease.  Always start with a open mind, talk to the patient, examine the patient fully, and look at every image and study yourself.  Remember, the cardiologist and radiologist aren't seeing the patient and can miss significant findings.

The same advice applies to your teachers, and to this post.  Be skeptical but not cynical.  Take the time to check the facts, read the literature yourself, and try both old and new techniques.  Did you find an absence of evidence about a treatment?  You may have just found your research project!

Learn from your mistakes

Relevance: High

I've learned far more from my mistakes than my successes.  We all make mistakes.  The important part is to learn from them.  Possibly even more important is learning OF them.  Emergency medicine is particularly prone to an absence of feedback about our mistakes.  Did you have an uncertain diagnosis?  Look into the case and follow up on the patient after discharge.  Learning about our errors is essential to improving our practice.

Since we all make them, try not to judge others by their mistakes.  Learn from their errors, but look deeper as well.  Were there any system issues, communication errors, etc, that may have contributed to the error?  Can any of these be fixed to prevent the error from occurring again?

Do unto others as you would do to your family (and that includes coworkers)

Relevance: High

You'll more often do the right thing when you follow this maxim.  Respecting our patients, colleagues, and coworkers demonstrates the caring attitude expected of a good physician.  And remember this if you decide to be rude: "The toes you step on today might be connected to the backside you need to kiss tomorrow."

When in doubt, always err on the side of the patient

Relevance: High

We see the patients that society and even healthcare tend to forget: the homeless, the addicted, the psychiatric, etc.  We need to be the ultimate patient advocate.  We strive to relieve suffering.  To do what is right for the patient, we need to consider the course of action that would minimize their suffering and keep the patient safe.  This will unfortunately put us at odds with our administrators, and at times, our peers, but if we fail to take care of our patients, then no one else will either and we will have violated our sacred oath.


As you can see, despite being 20 years old, these "commandments" still have a significant amount of relevance today.  For sure, they could be added too, but for the start of your career, paying attention to this short list will help you to save lives become a better emergency physician.

It's that time of year again.  The time of the year that you see the new interns scrambling through the department, eyes wide as saucers, running scared, and hungry for experience.  As an educator, it's a refreshing time to be at work!

With the start of the interns, many blogs have been providing advice to help them on their way to a successful career.  Some of the better examples are here and here.

But this is emergency medicine, and while the given advice still applies, I wanted to add a little more, just for our learners.  When I began my residency, one of our attendings handed us a copy of "The Ten Commandments of Emergency Medicine."  I still have my original copy and now and then I hand it out to my residents.  As I dusted it off this year, I realized that the article was written in 1991!  Are the commandments still relevant?  Read on. . .

Secure the ABC's

Relevance: High

We pride ourselves on being the masters of resuscitation.  Mastering the patients' ABCs should be the priority the moment you walk in the room.  Simply walking in and observing your patient can give you an amazing amount of information.  Is the patient able to speak full sentences? Are they talking at all?  Do they make sense?  How is their color, work of breathing, pulse, etc?  If you find a problem, fix it first.

The authors of the article expand the ABC's mnemonic a little ABCD2EFG2.  While most of these are familiar to us, the addition FG2 is useful to remember:

Fetal Heart tones: a needed vital sign in pregnant patients
RhoGam: Consider getting the type and Rh in pregnant trauma patients
Guardrails: Confused and elderly people fall out of bed far too often.  If you put them down or find them down, then take the 10 second and put them up!

Consider or give naloxone, glucose, and thiamine

Relevance: Glucose, high; others moderate

Any patient with altered mental status or a new neurologic deficit deserves a fingerstick glucose.  Almost every one of us has forgotten this truism once.  The embarrassment experienced by performing the stroke workup only to get the critical glucose level back from the lab is never forgotten

As for naloxone, consider it, but give it in smaller doses if you give it at all.  Remember "Priumum non Nocere."  After witnessing an addict in iatrogenic withdrawal once, I'm more likely to give 0.2 to 0.4 mg or simply intubate the patient and wait.

Thiamine is safe and potentially helpful.  While we still give it to the patient with alcoholism, the population that seems to need it the most these days are the post-gastric bypass population.

Get a pregnancy test

Relevance: Very High

I remember a story about a seasoned senior EM attending being asked what the biggest development of his career was.  The answer?  The urine pregnancy test.  Any female, age 10-55, deserves this quick test.  You'll lose count of how often your workup will be changed by the results of this test.

Assume the worst

Relevance: Very High

Amal Mattu likes to quip, "When emergency physicians here hoofbeats, we think lions, and tigers, and bears."  We aren't after the zebras.  Whatever can kill the patient we rule out first.  Only then do we move on less severe and more likely conditions.  Check your attitude at the door.  Don't get hung up on the 20/10 pain while the patient sits eating a bag of chips.  Take them at their word, do your best exam, and give them the benefit of the doubt.  You will be humbled time and time again by the seemingly stable patient who tries to die, sometimes successfully, in front of you.

Do not send unstable patients to radiology

Relevance: Moderate

This is one area that has changed in recent years.  It no longer takes as long to get studies done, and sometimes that septic elderly patient will need a CT to find the phlegmon of infection.  I would change the commandment to: Do not send unstable patients to radiology alone; you must go with them.  If conditions exist which can be fixed first then do so: secure the airway, begin fixing volume problems, etc.  If an alternative exists, such as bedside ultrasound, use it to your advantage, but don't fail to make the diagnosis simply to avoid taking the patient out of the department.  Oh yeah, and when you take them, take the right equipment too.

Look for common red flags

Relevance: High

I always get a little but of a laugh when reading this one.  It talks about FOUR vital signs!  With pulse ox and capnography and pain (really?) we have more vitals than we know what to do with!  The point is simple: look at the vitals and explain them.  Your history will gain you more than an entire battery of labs.  Ask about comorbidities.  Ask about risk factors; that patient with an IV drug addiction who has back pain and a low grade fever isn't looking to score narcotics.  Remember the extremes of age.  Pay particular attention to revisits.  These patients are giving you a second or third chance to make the correct diagnosis.  And remember, before anyone goes home, they must be able to eat and walk.

Trust no one, believe nothing (not even yourself)

Relevance: High

Anything that any tells you, in person, or in writing, might be false.  The "frequent flier" may be in the department often, but also might have real disease.  Always start with a open mind, talk to the patient, examine the patient fully, and look at every image and study yourself.  Remember, the cardiologist and radiologist aren't seeing the patient and can miss significant findings.

The same advice applies to your teachers, and to this post.  Be skeptical but not cynical.  Take the time to check the facts, read the literature yourself, and try both old and new techniques.  Did you find an absence of evidence about a treatment?  You may have just found your research project!

Learn from your mistakes

Relevance: High

I've learned far more from my mistakes than my successes.  We all make mistakes.  The important part is to learn from them.  Possibly even more important is learning OF them.  Emergency medicine is particularly prone to an absence of feedback about our mistakes.  Did you have an uncertain diagnosis?  Look into the case and follow up on the patient after discharge.  Learning about our errors is essential to improving our practice.

Since we all make them, try not to judge others by their mistakes.  Learn from their errors, but look deeper as well.  Were there any system issues, communication errors, etc, that may have contributed to the error?  Can any of these be fixed to prevent the error from occurring again?

Do unto others as you would do to your family (and that includes coworkers)

Relevance: High

You'll more often do the right thing when you follow this maxim.  Respecting our patients, colleagues, and coworkers demonstrates the caring attitude expected of a good physician.  And remember this if you decide to be rude: "The toes you step on today might be connected to the backside you need to kiss tomorrow."

When in doubt, always err on the side of the patient

Relevance: High

We see the patients that society and even healthcare tend to forget: the homeless, the addicted, the psychiatric, etc.  We need to be the ultimate patient advocate.  We strive to relieve suffering.  To do what is right for the patient, we need to consider the course of action that would minimize their suffering and keep the patient safe.  This will unfortunately put us at odds with our administrators, and at times, our peers, but if we fail to take care of our patients, then no one else will either and we will have violated our sacred oath.


As you can see, despite being 20 years old, these "commandments" still have a significant amount of relevance today.  For sure, they could be added too, but for the start of your career, paying attention to this short list will help you to save lives become a better emergency physician.

My daily commute to work takes me through the hills of western Pennsylvania.  It takes me 40 minutes to make the trip so I've really come to love podcast and audio based education.  Mel Herbert and the crew at EMRAP do a great job of putting on a quality show.  

My daily commute to work takes me through the hills of western Pennsylvania.  It takes me 40 minutes to make the trip so I've really come to love podcast and audio based education.  Mel Herbert and the crew at EMRAP do a great job of putting on a quality show.  

My daily commute to work takes me through the hills of western Pennsylvania.  It takes me 40 minutes to make the trip so I've really come to love podcast and audio based education.  Mel Herbert and the crew at EMRAP do a great job of putting on a quality show.  

The recent Society for Academic Emergency Medicine Annual Meeting just concluded after several fun and learning filled days in Boston.  I was fortunate to be able to attend and learn from the best and the brightest.

One of the presentations that stands out in my mind was a panel discussion about the "Academic Practice of Wilderness Medicine."  Wilderness medicine probably got me into medicine to begin with.  In my teen years, I was a member of a Venture Crew and spent many hours learning to climb, kayak, and haul a pack.  Our leader was a former paramedic and encouraged several of us to pursue training as EMTs to be better prepared for handling emergencies in the outdoors.  Thus began my love of emergency and wilderness medicine.

Being in a community academic site, I've always put wilderness medicine onto the back burner thinking that I didn't have the skills or resources enough to make it into a viable niche.  This presentation, given by Sanjay Gupta, N. Stuart Harris, and Michael Millin, was a nice summary of the growing field and has rekindled my interest in wilderness medicine.

First, what is wilderness medicine?

At its most basic, it is the practice of medicine in austere environments.  While generally thought to represent the out-of-doors, this can encompass military settings, event medicine, disasters, and other less than ideal settings.

How do you start in wilderness medicine?  

There are many ways to get started.  As an academic, we're always looking to cement our niche.  Probably the most basic way to do this is training.  Fellowships now exist in many places that are dedicated to wilderness medicine or wilderness medicine and EMS.  For those who have already graduated, there are any number of courses, seminars, and experiences available to build your expertise.  The Wilderness Medical Society even has a fellowship track for physicians to demonstrate a level of expertise within the field.

But what makes it Academic?

Here is where the presentation got interesting.  I've always thought of academic practice within this field as being research based; high altitude medicine, tropical diseases, etc.  Like many academic pursuits, there is so much more to practicing wilderness medicine.  You can, for example:

• Become the faculty mentor for a wilderness medicine interest group
• Teach at medical schools, residencies, or CME courses
• Become a military, expedition, or event consultant
• Serve as a medical director for a search and rescue team
• Serve as a travel medicine consultant
• Actually become a researcher
• Participate in the leadership of Wilderness Medicine oriented committees, interest groups, or the WMS

At SAEM, we became a fully fledged interest group at the meeting.  We even were able to head to the nearby quarry for an afternoon of learning the basics of high angle rescue.  The excitement on the participants faces as they took that first uncertain step into the air during their rappel was a priceless reminder of why I love teaching and emergency medicine.

Having had my assumptions challenged and realizing that there are opportunities for developing an academic niche in wilderness medicine even at a community site, you can expect to see more on various topics related to Wilderness Medicine in the future!



I would like to thank N. Stuart Harris for his leadership over the last year, his vision to start the interest group, and his willingness to share his rope, local crag, and experience with us this past week.

The recent Society for Academic Emergency Medicine Annual Meeting just concluded after several fun and learning filled days in Boston.  I was fortunate to be able to attend and learn from the best and the brightest.

One of the presentations that stands out in my mind was a panel discussion about the "Academic Practice of Wilderness Medicine."  Wilderness medicine probably got me into medicine to begin with.  In my teen years, I was a member of a Venture Crew and spent many hours learning to climb, kayak, and haul a pack.  Our leader was a former paramedic and encouraged several of us to pursue training as EMTs to be better prepared for handling emergencies in the outdoors.  Thus began my love of emergency and wilderness medicine.

Being in a community academic site, I've always put wilderness medicine onto the back burner thinking that I didn't have the skills or resources enough to make it into a viable niche.  This presentation, given by Sanjay Gupta, N. Stuart Harris, and Michael Millin, was a nice summary of the growing field and has rekindled my interest in wilderness medicine.

First, what is wilderness medicine?

At its most basic, it is the practice of medicine in austere environments.  While generally thought to represent the out-of-doors, this can encompass military settings, event medicine, disasters, and other less than ideal settings.

How do you start in wilderness medicine?  

There are many ways to get started.  As an academic, we're always looking to cement our niche.  Probably the most basic way to do this is training.  Fellowships now exist in many places that are dedicated to wilderness medicine or wilderness medicine and EMS.  For those who have already graduated, there are any number of courses, seminars, and experiences available to build your expertise.  The Wilderness Medical Society even has a fellowship track for physicians to demonstrate a level of expertise within the field.

But what makes it Academic?

Here is where the presentation got interesting.  I've always thought of academic practice within this field as being research based; high altitude medicine, tropical diseases, etc.  Like many academic pursuits, there is so much more to practicing wilderness medicine.  You can, for example:

• Become the faculty mentor for a wilderness medicine interest group
• Teach at medical schools, residencies, or CME courses
• Become a military, expedition, or event consultant
• Serve as a medical director for a search and rescue team
• Serve as a travel medicine consultant
• Actually become a researcher
• Participate in the leadership of Wilderness Medicine oriented committees, interest groups, or the WMS

At SAEM, we became a fully fledged interest group at the meeting.  We even were able to head to the nearby quarry for an afternoon of learning the basics of high angle rescue.  The excitement on the participants faces as they took that first uncertain step into the air during their rappel was a priceless reminder of why I love teaching and emergency medicine.

Having had my assumptions challenged and realizing that there are opportunities for developing an academic niche in wilderness medicine even at a community site, you can expect to see more on various topics related to Wilderness Medicine in the future!



I would like to thank N. Stuart Harris for his leadership over the last year, his vision to start the interest group, and his willingness to share his rope, local crag, and experience with us this past week.

The recent Society for Academic Emergency Medicine Annual Meeting just concluded after several fun and learning filled days in Boston.  I was fortunate to be able to attend and learn from the best and the brightest.

One of the presentations that stands out in my mind was a panel discussion about the "Academic Practice of Wilderness Medicine."  Wilderness medicine probably got me into medicine to begin with.  In my teen years, I was a member of a Venture Crew and spent many hours learning to climb, kayak, and haul a pack.  Our leader was a former paramedic and encouraged several of us to pursue training as EMTs to be better prepared for handling emergencies in the outdoors.  Thus began my love of emergency and wilderness medicine.

Being in a community academic site, I've always put wilderness medicine onto the back burner thinking that I didn't have the skills or resources enough to make it into a viable niche.  This presentation, given by Sanjay Gupta, N. Stuart Harris, and Michael Millin, was a nice summary of the growing field and has rekindled my interest in wilderness medicine.

First, what is wilderness medicine?

At its most basic, it is the practice of medicine in austere environments.  While generally thought to represent the out-of-doors, this can encompass military settings, event medicine, disasters, and other less than ideal settings.

How do you start in wilderness medicine?  

There are many ways to get started.  As an academic, we're always looking to cement our niche.  Probably the most basic way to do this is training.  Fellowships now exist in many places that are dedicated to wilderness medicine or wilderness medicine and EMS.  For those who have already graduated, there are any number of courses, seminars, and experiences available to build your expertise.  The Wilderness Medical Society even has a fellowship track for physicians to demonstrate a level of expertise within the field.

But what makes it Academic?

Here is where the presentation got interesting.  I've always thought of academic practice within this field as being research based; high altitude medicine, tropical diseases, etc.  Like many academic pursuits, there is so much more to practicing wilderness medicine.  You can, for example:

• Become the faculty mentor for a wilderness medicine interest group
• Teach at medical schools, residencies, or CME courses
• Become a military, expedition, or event consultant
• Serve as a medical director for a search and rescue team
• Serve as a travel medicine consultant
• Actually become a researcher
• Participate in the leadership of Wilderness Medicine oriented committees, interest groups, or the WMS

At SAEM, we became a fully fledged interest group at the meeting.  We even were able to head to the nearby quarry for an afternoon of learning the basics of high angle rescue.  The excitement on the participants faces as they took that first uncertain step into the air during their rappel was a priceless reminder of why I love teaching and emergency medicine.

Having had my assumptions challenged and realizing that there are opportunities for developing an academic niche in wilderness medicine even at a community site, you can expect to see more on various topics related to Wilderness Medicine in the future!



I would like to thank N. Stuart Harris for his leadership over the last year, his vision to start the interest group, and his willingness to share his rope, local crag, and experience with us this past week.

Do you believe in patient satisfaction?  For the majority of my training, I had my doubts.  As an impressionable intern, I remember a conversation between 2 seniors discussing a patient complaint about the wait.  The conclusion was something like this: "This isn't Burger King.  In the ED, you don't get it your way, right away."  For a long time, I believed that good care comes first and satisfying the patient comes second.

I'll also admit that my opinion was further skewed by the wealth of poor data collected by various "satisfaction" surveys that using a sampling that would be laughed at by any respectable researcher.  We see  more than 200 patients per day.  One month our sample was derived from a sum total of 14 patient responses.  Hard to make valid conclusions with data that is derived from <1% of total patients.

Needless to say, as I mature in my practice, I have come to realize that there is a lot of truth to the statement, "They don't care how much you know until they know how much you care."  With that in mind, I want to share some key points from a nice review of customer satisfaction that I stumbled upon from the Emergency Medicine Clinics of North America.

So why pursue a goal of having more satisfied patients?

There are multiple demonstrating benefits from hospitals which perform better:

-Staff morale improves
      (Turnover decreases, work is more enjoyable)
-Malpractice risk decreases
     (Happy patients sue less frequently)
-Patients respond better to treatment
     (Patients follow instructions when they believe that they received good care)
-Hospital finances improve
     (Patients recommend the facility and will come back)

The list is pretty impressive.  I'd be happy with improvement in one of those categories!  So we know that happy patients can bring us happiness, but how can we improve the current quagmire that is emergency medicine?

Obviously, you know your local environment best.  Each department will need to tailor a program to its needs.  The first step is figuring out those needs: what is the goal you want to strive for?  If you already have a program, great!  Hopefully you've been keeping tabs.  The data gleaned from your surveys can highlight areas in need of immediate attention.  What if you haven't kept tabs?  Look at complaints, get staff input, administrative input, and use good ol' common sense.

Leadership will be vital.  You'll be attempting to change something fundamental about emergency care: our culture.  First, get the key players on board: administrative, nursing, and physician leaders.  Don't forget the "leaders" within the ranks who may not formally hold a title.

As the leader, you'll be tasked with the following:
-Setting goals
-Modeling and insisting on specific behavior
-Monitoring the behavior and progress towards the goal
-Delivery of rewards and recognition for good performance

Goals take on two forms: philosophic and specific.  The philosophic goals helps set the vision for the change, the specific gives the down and dirty expectations and guidance for attaining the vision.  Remember to involve the staff.  Using goals that they create will help promote buy-in.

Some specific examples:
-Answer all phone calls within X rings
-Door to Doc of X minutes or less
-Door to discharge of X hours or less
-Door to bed of X hours or less
-Each patient will be re-evaluated by a provider every X minutes

Once you choose your goals, it will be up to the leadership to hold people accountable.  Some people will resist.  Giving that person an exemption will deep six any cultural change before it even has a chance.

Educating the staff will be important.  Everyone will need to learn to modify their behavior: physicians, nurses, registration, techs, transporters, housekeeping, etc.  The success of your program will depend on universal participation.

Remember to reward the people who contribute.  Publicly acknowledge them, give bonuses, a parking spot, etc.

Remember the need for a scoreboard.  Even if you missed the first half of a game, you know who's winning by looking at the board.  So it is with the staff: they need to know where they're at in order to improve.  Publish your results widely: newsletters, emails, bulletin boards, etc.  Let patients know too.  Success is contagious.

Invariably, there will be some people who choose not to come on board.  Once they become obvious, they will need to be removed.  Letting them stay within the department will create a division amongst the staff and hurt your chances of success.

There are tools available to help you succeed:

Scripting: developing specific comments for registration, nursing, and even docs can help diffuse anger and demonstrate an attitude of caring.

Patient advocate: This person can make sure that patients who are waiting are up to date with an explanation.  They can also help keep the patient comfortable while waiting.

Surveys: You can't change without data.  Develop your own, and distribute them widely.  The more the merrier.  Don't forget to allow family members to fill them out as well.

Call Back System: This tool can help to salvage what may have been a negative impression.  You can target specific conditions: Against Medical Advice discharges, left without being seen, etc.

Patient Satisfaction is a worthy goal to persue.  It's not easy, that is obvious from our day to day practice. Start by being honest with yourself.  Would you want your mother, father, spouse, or child to receive the same care given to the majority of the patients waiting in your waiting room.  If you answered no, then step up, become a leader, and promote the improvement that is within your reach.

Reference:
K Worthington. Customer Satisfaction in the Emergency Department. Emerg Med Clin N Am. 22; 2004: 87-102. PMID: 15062498

Do you believe in patient satisfaction?  For the majority of my training, I had my doubts.  As an impressionable intern, I remember a conversation between 2 seniors discussing a patient complaint about the wait.  The conclusion was something like this: "This isn't Burger King.  In the ED, you don't get it your way, right away."  For a long time, I believed that good care comes first and satisfying the patient comes second.

I'll also admit that my opinion was further skewed by the wealth of poor data collected by various "satisfaction" surveys that using a sampling that would be laughed at by any respectable researcher.  We see  more than 200 patients per day.  One month our sample was derived from a sum total of 14 patient responses.  Hard to make valid conclusions with data that is derived from <1% of total patients.

Needless to say, as I mature in my practice, I have come to realize that there is a lot of truth to the statement, "They don't care how much you know until they know how much you care."  With that in mind, I want to share some key points from a nice review of customer satisfaction that I stumbled upon from the Emergency Medicine Clinics of North America.

So why pursue a goal of having more satisfied patients?

There are multiple demonstrating benefits from hospitals which perform better:

-Staff morale improves
      (Turnover decreases, work is more enjoyable)
-Malpractice risk decreases
     (Happy patients sue less frequently)
-Patients respond better to treatment
     (Patients follow instructions when they believe that they received good care)
-Hospital finances improve
     (Patients recommend the facility and will come back)

The list is pretty impressive.  I'd be happy with improvement in one of those categories!  So we know that happy patients can bring us happiness, but how can we improve the current quagmire that is emergency medicine?

Obviously, you know your local environment best.  Each department will need to tailor a program to its needs.  The first step is figuring out those needs: what is the goal you want to strive for?  If you already have a program, great!  Hopefully you've been keeping tabs.  The data gleaned from your surveys can highlight areas in need of immediate attention.  What if you haven't kept tabs?  Look at complaints, get staff input, administrative input, and use good ol' common sense.

Leadership will be vital.  You'll be attempting to change something fundamental about emergency care: our culture.  First, get the key players on board: administrative, nursing, and physician leaders.  Don't forget the "leaders" within the ranks who may not formally hold a title.

As the leader, you'll be tasked with the following:
-Setting goals
-Modeling and insisting on specific behavior
-Monitoring the behavior and progress towards the goal
-Delivery of rewards and recognition for good performance

Goals take on two forms: philosophic and specific.  The philosophic goals helps set the vision for the change, the specific gives the down and dirty expectations and guidance for attaining the vision.  Remember to involve the staff.  Using goals that they create will help promote buy-in.

Some specific examples:
-Answer all phone calls within X rings
-Door to Doc of X minutes or less
-Door to discharge of X hours or less
-Door to bed of X hours or less
-Each patient will be re-evaluated by a provider every X minutes

Once you choose your goals, it will be up to the leadership to hold people accountable.  Some people will resist.  Giving that person an exemption will deep six any cultural change before it even has a chance.

Educating the staff will be important.  Everyone will need to learn to modify their behavior: physicians, nurses, registration, techs, transporters, housekeeping, etc.  The success of your program will depend on universal participation.

Remember to reward the people who contribute.  Publicly acknowledge them, give bonuses, a parking spot, etc.

Remember the need for a scoreboard.  Even if you missed the first half of a game, you know who's winning by looking at the board.  So it is with the staff: they need to know where they're at in order to improve.  Publish your results widely: newsletters, emails, bulletin boards, etc.  Let patients know too.  Success is contagious.

Invariably, there will be some people who choose not to come on board.  Once they become obvious, they will need to be removed.  Letting them stay within the department will create a division amongst the staff and hurt your chances of success.

There are tools available to help you succeed:

Scripting: developing specific comments for registration, nursing, and even docs can help diffuse anger and demonstrate an attitude of caring.

Patient advocate: This person can make sure that patients who are waiting are up to date with an explanation.  They can also help keep the patient comfortable while waiting.

Surveys: You can't change without data.  Develop your own, and distribute them widely.  The more the merrier.  Don't forget to allow family members to fill them out as well.

Call Back System: This tool can help to salvage what may have been a negative impression.  You can target specific conditions: Against Medical Advice discharges, left without being seen, etc.

Patient Satisfaction is a worthy goal to persue.  It's not easy, that is obvious from our day to day practice. Start by being honest with yourself.  Would you want your mother, father, spouse, or child to receive the same care given to the majority of the patients waiting in your waiting room.  If you answered no, then step up, become a leader, and promote the improvement that is within your reach.

Reference:
K Worthington. Customer Satisfaction in the Emergency Department. Emerg Med Clin N Am. 22; 2004: 87-102. PMID: 15062498

Do you believe in patient satisfaction?  For the majority of my training, I had my doubts.  As an impressionable intern, I remember a conversation between 2 seniors discussing a patient complaint about the wait.  The conclusion was something like this: "This isn't Burger King.  In the ED, you don't get it your way, right away."  For a long time, I believed that good care comes first and satisfying the patient comes second.

I'll also admit that my opinion was further skewed by the wealth of poor data collected by various "satisfaction" surveys that using a sampling that would be laughed at by any respectable researcher.  We see  more than 200 patients per day.  One month our sample was derived from a sum total of 14 patient responses.  Hard to make valid conclusions with data that is derived from <1% of total patients.

Needless to say, as I mature in my practice, I have come to realize that there is a lot of truth to the statement, "They don't care how much you know until they know how much you care."  With that in mind, I want to share some key points from a nice review of customer satisfaction that I stumbled upon from the Emergency Medicine Clinics of North America.

So why pursue a goal of having more satisfied patients?

There are multiple demonstrating benefits from hospitals which perform better:

-Staff morale improves
      (Turnover decreases, work is more enjoyable)
-Malpractice risk decreases
     (Happy patients sue less frequently)
-Patients respond better to treatment
     (Patients follow instructions when they believe that they received good care)
-Hospital finances improve
     (Patients recommend the facility and will come back)

The list is pretty impressive.  I'd be happy with improvement in one of those categories!  So we know that happy patients can bring us happiness, but how can we improve the current quagmire that is emergency medicine?

Obviously, you know your local environment best.  Each department will need to tailor a program to its needs.  The first step is figuring out those needs: what is the goal you want to strive for?  If you already have a program, great!  Hopefully you've been keeping tabs.  The data gleaned from your surveys can highlight areas in need of immediate attention.  What if you haven't kept tabs?  Look at complaints, get staff input, administrative input, and use good ol' common sense.

Leadership will be vital.  You'll be attempting to change something fundamental about emergency care: our culture.  First, get the key players on board: administrative, nursing, and physician leaders.  Don't forget the "leaders" within the ranks who may not formally hold a title.

As the leader, you'll be tasked with the following:
-Setting goals
-Modeling and insisting on specific behavior
-Monitoring the behavior and progress towards the goal
-Delivery of rewards and recognition for good performance

Goals take on two forms: philosophic and specific.  The philosophic goals helps set the vision for the change, the specific gives the down and dirty expectations and guidance for attaining the vision.  Remember to involve the staff.  Using goals that they create will help promote buy-in.

Some specific examples:
-Answer all phone calls within X rings
-Door to Doc of X minutes or less
-Door to discharge of X hours or less
-Door to bed of X hours or less
-Each patient will be re-evaluated by a provider every X minutes

Once you choose your goals, it will be up to the leadership to hold people accountable.  Some people will resist.  Giving that person an exemption will deep six any cultural change before it even has a chance.

Educating the staff will be important.  Everyone will need to learn to modify their behavior: physicians, nurses, registration, techs, transporters, housekeeping, etc.  The success of your program will depend on universal participation.

Remember to reward the people who contribute.  Publicly acknowledge them, give bonuses, a parking spot, etc.

Remember the need for a scoreboard.  Even if you missed the first half of a game, you know who's winning by looking at the board.  So it is with the staff: they need to know where they're at in order to improve.  Publish your results widely: newsletters, emails, bulletin boards, etc.  Let patients know too.  Success is contagious.

Invariably, there will be some people who choose not to come on board.  Once they become obvious, they will need to be removed.  Letting them stay within the department will create a division amongst the staff and hurt your chances of success.

There are tools available to help you succeed:

Scripting: developing specific comments for registration, nursing, and even docs can help diffuse anger and demonstrate an attitude of caring.

Patient advocate: This person can make sure that patients who are waiting are up to date with an explanation.  They can also help keep the patient comfortable while waiting.

Surveys: You can't change without data.  Develop your own, and distribute them widely.  The more the merrier.  Don't forget to allow family members to fill them out as well.

Call Back System: This tool can help to salvage what may have been a negative impression.  You can target specific conditions: Against Medical Advice discharges, left without being seen, etc.

Patient Satisfaction is a worthy goal to persue.  It's not easy, that is obvious from our day to day practice. Start by being honest with yourself.  Would you want your mother, father, spouse, or child to receive the same care given to the majority of the patients waiting in your waiting room.  If you answered no, then step up, become a leader, and promote the improvement that is within your reach.

Reference:
K Worthington. Customer Satisfaction in the Emergency Department. Emerg Med Clin N Am. 22; 2004: 87-102. PMID: 15062498

A while back a reader asked the following question:

"How do you get them to buy in? as a resident in a surgical specialty, I'd love the EM residents to give better referrals, but often they want nothing more than to sell the patient and move the meat."

This immediately made me think of a lecture given by Emergency Medicine Superstar Chad Kessler.  He actually has a research paper on the way studying the effect of his approach that I'm looking forward to reading.  In the mean time, I'll settle for listening to him lecture, repeatedly, again and again, on consultation skills.  In his lecture, he offers up some consultation pearls that we would all benefit from learning:

The Five "C's" of Consultation

1. Contact: This is where you call your consultant.  Before picking up the phone, make sure you need the consultation.  I'm currently a dedicated night doc.  When admitting a patient to a medical service, the accepting physician will often ask me to "consult" service x,y, or z.  Knowing when to simply write an order for a "routine" consultation versus calling each service in the middle of the night goes a long way towards improving your relationship with each service.  When you call appropriately, they begin to recognize that when you call, you need them.

When first making contact, make sure to identify yourself and get their identity as well.

2. Communicate: Once you've made contact, tell them about the patient.  The level of detail will vary by specialty.  Surgery often needs a one liner while medicine wants a thorough review of the patient.

3. Core Question: Here's the money issue: What do you need?  Be as specific as possible.  "I need you to admit this patient for fluids and antibiotics," or "I need you to take the patient for emergent cardiac catheterization."

4. Collaborate: Let your consultant digest the information presented and respond with their needs.  They may need you to order additional tests, call in the cath team, etc.  I've found that this are is where the consultation can quickly break down, especially with the uber-specialists.  Their plan may deviate from what you believe the patient needs.  You may need to take a quick time out and engage in some shared problem solving.  I find this to be most true when they're asking for a test to "stall" the need to see the patient.

For example:
"I have a patient with a fever, back pain, and loss of sensation in the L4 distribution who I think has an epidural abscess.  I need you to come and evaluate him for operative drainage."

"Order the MRI and call me back after the results."

Unfortunately, this behavior delays the needed evaluation.

Shared problem solving allows you to advocate for the patient and get them to the person they need to see.  For example: "How about you send your resident or PA down to get a quick baseline neurologic exam while I order the bed, the MRI, and antibiotics after a set of cultures."

5. Close the loop:  Take the time to repeat the plan back.  Letting them hear it allows for correction of errors or the addition of something that they may have forgotten.  Make sure to take the time to document the date, time, name, and nature of your conversation.

Another important point that Dr. Kessler makes is the need to practice.  Just like intubation or suturing, consultation is a skill.  To improve this skill, we need to take the time to practice.  As teachers, we can help our residents with a "practice run" so that they don't end up frustrated on the phone.  With luck, this short list will help to ease the frustration felt with difficult consultations.

A while back a reader asked the following question:

"How do you get them to buy in? as a resident in a surgical specialty, I'd love the EM residents to give better referrals, but often they want nothing more than to sell the patient and move the meat."

This immediately made me think of a lecture given by Emergency Medicine Superstar Chad Kessler.  He actually has a research paper on the way studying the effect of his approach that I'm looking forward to reading.  In the mean time, I'll settle for listening to him lecture, repeatedly, again and again, on consultation skills.  In his lecture, he offers up some consultation pearls that we would all benefit from learning:

The Five "C's" of Consultation

1. Contact: This is where you call your consultant.  Before picking up the phone, make sure you need the consultation.  I'm currently a dedicated night doc.  When admitting a patient to a medical service, the accepting physician will often ask me to "consult" service x,y, or z.  Knowing when to simply write an order for a "routine" consultation versus calling each service in the middle of the night goes a long way towards improving your relationship with each service.  When you call appropriately, they begin to recognize that when you call, you need them.

When first making contact, make sure to identify yourself and get their identity as well.

2. Communicate: Once you've made contact, tell them about the patient.  The level of detail will vary by specialty.  Surgery often needs a one liner while medicine wants a thorough review of the patient.

3. Core Question: Here's the money issue: What do you need?  Be as specific as possible.  "I need you to admit this patient for fluids and antibiotics," or "I need you to take the patient for emergent cardiac catheterization."

4. Collaborate: Let your consultant digest the information presented and respond with their needs.  They may need you to order additional tests, call in the cath team, etc.  I've found that this are is where the consultation can quickly break down, especially with the uber-specialists.  Their plan may deviate from what you believe the patient needs.  You may need to take a quick time out and engage in some shared problem solving.  I find this to be most true when they're asking for a test to "stall" the need to see the patient.

For example:
"I have a patient with a fever, back pain, and loss of sensation in the L4 distribution who I think has an epidural abscess.  I need you to come and evaluate him for operative drainage."

"Order the MRI and call me back after the results."

Unfortunately, this behavior delays the needed evaluation.

Shared problem solving allows you to advocate for the patient and get them to the person they need to see.  For example: "How about you send your resident or PA down to get a quick baseline neurologic exam while I order the bed, the MRI, and antibiotics after a set of cultures."

5. Close the loop:  Take the time to repeat the plan back.  Letting them hear it allows for correction of errors or the addition of something that they may have forgotten.  Make sure to take the time to document the date, time, name, and nature of your conversation.

Another important point that Dr. Kessler makes is the need to practice.  Just like intubation or suturing, consultation is a skill.  To improve this skill, we need to take the time to practice.  As teachers, we can help our residents with a "practice run" so that they don't end up frustrated on the phone.  With luck, this short list will help to ease the frustration felt with difficult consultations.

A while back a reader asked the following question:

"How do you get them to buy in? as a resident in a surgical specialty, I'd love the EM residents to give better referrals, but often they want nothing more than to sell the patient and move the meat."

This immediately made me think of a lecture given by Emergency Medicine Superstar Chad Kessler.  He actually has a research paper on the way studying the effect of his approach that I'm looking forward to reading.  In the mean time, I'll settle for listening to him lecture, repeatedly, again and again, on consultation skills.  In his lecture, he offers up some consultation pearls that we would all benefit from learning:

The Five "C's" of Consultation

1. Contact: This is where you call your consultant.  Before picking up the phone, make sure you need the consultation.  I'm currently a dedicated night doc.  When admitting a patient to a medical service, the accepting physician will often ask me to "consult" service x,y, or z.  Knowing when to simply write an order for a "routine" consultation versus calling each service in the middle of the night goes a long way towards improving your relationship with each service.  When you call appropriately, they begin to recognize that when you call, you need them.

When first making contact, make sure to identify yourself and get their identity as well.

2. Communicate: Once you've made contact, tell them about the patient.  The level of detail will vary by specialty.  Surgery often needs a one liner while medicine wants a thorough review of the patient.

3. Core Question: Here's the money issue: What do you need?  Be as specific as possible.  "I need you to admit this patient for fluids and antibiotics," or "I need you to take the patient for emergent cardiac catheterization."

4. Collaborate: Let your consultant digest the information presented and respond with their needs.  They may need you to order additional tests, call in the cath team, etc.  I've found that this are is where the consultation can quickly break down, especially with the uber-specialists.  Their plan may deviate from what you believe the patient needs.  You may need to take a quick time out and engage in some shared problem solving.  I find this to be most true when they're asking for a test to "stall" the need to see the patient.

For example:
"I have a patient with a fever, back pain, and loss of sensation in the L4 distribution who I think has an epidural abscess.  I need you to come and evaluate him for operative drainage."

"Order the MRI and call me back after the results."

Unfortunately, this behavior delays the needed evaluation.

Shared problem solving allows you to advocate for the patient and get them to the person they need to see.  For example: "How about you send your resident or PA down to get a quick baseline neurologic exam while I order the bed, the MRI, and antibiotics after a set of cultures."

5. Close the loop:  Take the time to repeat the plan back.  Letting them hear it allows for correction of errors or the addition of something that they may have forgotten.  Make sure to take the time to document the date, time, name, and nature of your conversation.

Another important point that Dr. Kessler makes is the need to practice.  Just like intubation or suturing, consultation is a skill.  To improve this skill, we need to take the time to practice.  As teachers, we can help our residents with a "practice run" so that they don't end up frustrated on the phone.  With luck, this short list will help to ease the frustration felt with difficult consultations.

A pre-hospital emergency anaesthesia pre-procedure checklist R Mackenzie , J French, S Lewis and A Steel from Scandinavian Update on Trauma, Resuscitation and Emergency Medicine 2009 Stavanger, Norway. 23 - 25 April 2009 Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2009, 17(Suppl 3):O26