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Patient Care

Artifact: ATEM Assessment

I am currently applying for my emergency medicine residency, and as such am enrolled in the Advanced Topics in Emergency Medicine course at OSU. This course has many components to prepare us for our residency, one of which is assessment shifts conducted periodically throughout our 4th year. We essentially are paired with one emergency medicine physician and will evaluate a patient in the ED from start to finish, while they oversee the encounter and provide feedback.

On my most recent shift, I picked up a patient with an elevated glucose >500 who was otherwise asymptomatic. My instructor insisted I go in “blind” as a learning experience, not having looked at previous notes for the patient. I’ve had multiple EM docs push me to try this, and I’ve come to understand that it can improve patient care by teaching you not to narrow down on a single diagnosis. When you read a patient’s chart, it’s easy to reason through it and hone in on a couple of pathologies, but you may not have the full story and this habit may cause you to forget other items on the differential. I conducted the visit, with a focus on eliciting a HOPI. This was the first patient I had seen in several months due to interviews, and I definitely felt a little rusty on my history taking. However, I felt that I had taken a pretty good focused history, making sure none of the patient’s symptoms pointed to anything dangerous.

Afterwards, me and the physician I was paired with sat down and had a discussion about the encounter. He said I did a great job taking a focused history, ruling out some of the most dangerous diagnoses. One comment is that I forgot to perform a complete review of systems, instead having only focused on the chief complaint and possibly related pathologies. The biggest point of feedback, however, was on how I established a relationship with the patient. In my student experience in the emergency department, I always felt pressured to conduct a history as quickly and accurately as possible. While I was always polite with patients, I don’t think I really went out of my away enough to build a relationship with them. The physician I was working with expounded on the benefits of this practice. He told me that patients will open up to you more if you build that trust. He also said it can help with compliance, and overall patients will have a better experience. While this all made sense to me and I had heard it before, I never had someone sit down with me and run through exactly how to do this. I’ve always been focused on the strictly medical side of patient interactions as a student, trying to hone these skills. I’ve started to realize that as I progress in my training, I should be expanding my training beyond the basic concepts of physiology and pathology. This assessment shift strongly reinforced the important social factors of patient care, and it’s something I’ve since committed to improving upon.

I found a great paper with a list of priorities for building rapport with new patients1, which is almost every patient I’ll see in the emergency department. Here are the big items from that paper:

  1. Provide reassurance to patients
  2. Tell patients it’s okay to ask questions
  3. Show patients their lab results and explain what they mean
  4. Avoid language and behaviors that are judgmental of patients
  5. Ask patients what they want [i.e., treatment goals and preferences]

I hope to apply all these concepts as best I can with each visit going forward in my training and beyond!

 

  1. Dang BN, Westbrook RA, Njue SM, Giordano TP. Building trust and rapport early in the new doctor-patient relationship: a longitudinal qualitative study. BMC Med Educ. 2017;17(1):32. Published 2017 Feb 2. doi:10.1186/s12909-017-0868-5

Interpersonal Communications

Artifact: USIV Presentation Draft

For one of my 4th year courses, I enrolled in a Global Health advanced competency. The original design of the course was to spend a month doing clinical work in another country, but travel had been restricted due to COVID. The result was a virtual global health course with a group called Foundation for International Medical Relief of Children (FIMRC). The design of the virtual course was 4 weeks, each focused on a different geographical region where they worked. We would be able to do virtual observations of their clinics during the day, and at night we would have conversations on topics we had read about, such as social determinants of health. Another important aspect of the curriculum was completing a project to help one of their clinics deliver patient care. I was paired up with a clinic in Bududa, Uganda.

To begin my project, I met with the site coordinator, who gave me an overview of the clinic and helped me formulate some possible project ideas. I then met with one of the nursing staff at the clinic, who spoke amazing English and discussed with me what some need areas might be. It was incredibly helpful talking to these people who were so integrally involved with the clinic, as they had a much better understanding of what was needed than I ever would. Through our conversations, I learned they had recently acquired a portable ultrasound probe, but were using it primarily for Ob/Gyn purposes. I also learned that they frequently dealt with dehydration. This gave me the idea to put together a virtual training on how to use US to acquire IV access in a difficult stick.

While I have some experience with this topic, I thought it’d be best to get some expert input. I reached out to a couple physicians who I know are involved with ultrasound here at OSU, and asked them how they have taught this topic in the past and what they thought were the most important aspects of this technique. They were incredibly helpful and gave me a lot of advice to help structure the training. As I began putting together this training, I realized I had forgotten to ask some key questions about how the content would be communicated. How well did the staff speak English, and what level of provider would be applying this technique? I was able to reach out to the coordinator, who let me know that the staff were all decently proficient in English, and most were working at the level of a nurse or mid-level provider. This knowledge helped me tailor the language of my training to be not overly technical and easy to understand.

Ultimately, I learned how important communication is when there are multiple players in a project, and how valuable the human resources in your life can be when trying to work on something like this. I also learned about the importance of tailoring your communication to the audience you are trying to reach. By keeping these concepts in mind, I think I will be more successful when working on future projects.

Going forward, I hope to further develop my communication skills. One big goal for me is to improve upon my communication skills during intern year. While I’m sure there are tons of resources one can access to learn more about communication, I think the biggest thing I can do to achieve my current goal is get more practice. Working as a resident will afford me plenty of opportunities to practice my communication with both patients and coworkers.

Medical Knowledge and Skills

Artifact: Ultrasound Journal Club

During my 4th year of medical school, I enrolled in an Honors Ultrasound advanced competency. I had been taking ultrasound courses since my 1st year, and felt like this would be a great capstone to my previous experience. The overall structure of the course was altered a bit due to COVID, but the fundamental content stayed the same. We would have a set number of scans we had to complete by the end of the year, and would also have a capstone project we would need to complete. On top of this, we would have monthly journal club to discuss multiple articles prepared by students in the course. This was some of my first experience reading not only academic papers focused on ultrasound, but really reading academic papers in depth. I usually opted for summaries of such papers so as to avoid the lengthy reading.

For my presentation, I chose to cover a paper discussing lung US vs radiography for pneumonia diagnosis in children. It ended up being a really interesting article, and taught me a lot about how to structure a study using US compared to the standard practice. It also expanded my views on the applications of ultrasound and how I could use it in my future practice. Beyond this, I was able to practice my presentation skills, and I believe nothing challenges you to learn a topic better than having to present it to your peers. I learned a lot about how to assess research articles and apply EBM. I know this is an important skill for a life-long learner, and will help me better analyze papers in the future to understand my practice.

My goal going forward is to get more practice reading research articles. I’ve found a document called “52 Articles in 52 Weeks”1 that covers important emergency medicine papers. My goal is to read one of these a week during my intern year.

  1. 52-Articles-in-52-Weeks

Professionalism

Artifact:

Early last year I applied and was accepted to something called the Emergency Medicine Residents’ Association Leadership Academy. This is a program aimed at medical students and residents going into emergency medicine who are looking to develop their leadership skills.

I’ve always felt that physicians are inherently leaders just by nature of their position in the hospital. They are in charge of coordinating care for the patient and have the final say over the mid-levels, nurses, etc. What I’ve come to realize in the past couple years is that

Throughout the year, we’ve had meetings with different thought leaders in emergency medicine about different aspects of leadership. We’ll usually have some readings and videos to complete beforehand, and then we meet virtually do listen to a presentation from whoever the guest is that evening. We’ll then have open conversation about the topic, along with Q&A for the guest.

Here is a list of a lot of the topics we discuss:

What it Means to be a Leader

Emotional Intelligence

Conflict Resolution & Navigating Difficult Discussions

Positivity/Energy

Focus: Setting Goals and How to Reach Them

Public Speaking

Team Dynamics

Building Your Own Brand

Personal Reflection, Deliberate Practice, Mindfulness

Through these conversations, I’ve learned a lot about what it means to be a leader. I’ve also learned that a lot of things that I thought were innate (emotional intelligence, positivity) are actually skills that can be enhanced with further practice. This course has helped me lay a foundation from which I can work to improve my leadership skills.

My goal is to become further involved with EMRA during my intern year. I plan to join a committee (EMRA Committees) before I begin residency, as well as possibly attend their Leadership and Advocacy Conference in Washington DC.

Practice-Based and Lifelong Learning

Artifact: ALIEM Bridge to EM

The layout of my 4th year of medical school has been drastically different from previous years, in that I’ve had extensive amounts of time off clinical duties. Because of the way interview season and my longitudinal courses played out, I’ve been more or less out of the hospital for ~5 months. While I’ve definitely been making the most of this time off and enjoying it before residency starts, I realized a couple months in that I had been neglecting keeping up with any studying, simply because I wasn’t being tested or being challenged in the hospital. It’s also one of the first times I’ve had no solid structure in my studying goals. Previously, I had a final or a board exam to study for, which allowed me to have a narrowed focus and learning objectives set out before me. With this realization, I decided I would need to be more intentional about my learning going forward.

The first thing I needed to do is set learning objectives for myself. Without a goal to strive towards, I wouldn’t know where to begin. I plan to go into emergency medicine, so my learning goals would need to cover a wide variety of topics. That being said, there is certainly an “emergency medicine” approach to these topics. I decided to use a textbook called “Rosen’s Emergency Medicine: Concepts and Clinical Practice”, which does an incredibly thorough review of EM topics. My plan has been to read one chapter of this book every 2-3 days, taking notes as I go along and reviewing old notes.

During one of my interviews, a physician directed me towards an amazing resource for preparing to be an intern in emergency medicine. It’s called the ALIEM Bridge to EM1, assembled by a popular emergency medicine blog. It consists of podcasts, journal articles, blog posts, and more. It’s an incredible FOAMed resource that seems very comprehensive. This resource provided me with a framework within which I can work towards my learning objectives. The whole experience taught me a lot about how important it is to take ownership of your learning and use the resources available to you in order to develop a strong learning plan.

My goal is to finish this 8-week program, and I plan to start it 2 months prior to residency beginning. This way, I’ll have further built a foundation with which I can go into intern year.

 

  1. https://www.aliem.com/bridge-to-em/

Systems-Based Practice

Artifact:

During the 4th year of medical school, we are required to take part in a QI project. I had been looking for leadership opportunities, and volunteered to lead a group of my peers through this project. We reached out to an emergency physician, and decided to focus on reducing the use of MRI in the emergency department for non-emergent back pain. The project was broken into several steps. We first got a year’s worth of data from the ED to see how many patients coming in with the chief complaint of back pain received an MRI. We then did a convenience sample to see how often these patients actually had red flags indicating advanced imaging. Afterwards, we developed an informational flyer education providers on what these red flags are and how best to refer patients. Alongside this, we have been working with physical therapy to develop a faster referral for outpatient management of this back pain.

This was a huge learning experience for me, as I had never been part of a QI project before, and had never been a sole leader among my peers as in this manner. I learned a lot about communication skills, as it was initially difficult keeping everybody on the same page as we worked through the project. I realized I needed to provide frequent updates from both the faculty and peers to keep everyone connected. I also realized how difficult it can be to keep people working on the same timeline. With the craziness of COVID, it was difficult for our attending to keep track of our deadlines and work at the pace some students wanted to. It was also sometimes difficult to keep students on track, and I found myself sometimes picking up the slack for others. On top of this, I learned a ton about how to conduct a QI project. This is definitely a useful framework I will be able to use going forward.

My goals for this project are to successfully complete the presentation we have on March 11th. I also hope to follow this project beyond these due dates and provide assistance to the physician we were working with however I am able. My resources for attaining this goal will be my past experience with the project and all the analysis we’ve completed. This puts me in a strong position to provide assistance and bring others on to the project as needed.