Welcome to Emergency Medicine by Rahul Patwari

Over the last decade, EM has become incredibly popular among medical graduates in India. But quite often, students begin ED rotations without a formal induction session. Here are a few quick videos to understand how things work in Emergency Medicine and how Emergency Physicians think, by Rahul Patwari. This video gives a sort of introduction to Emergency Medicine before interns/residents begin working in the ED.

Welcome to EM

         

Clinical Thinking in EM - 1

                                          

 Clinical Thinking in EM - 2

                                          

For more such videos, subscribe to Dr. Patwari's YouTube channel

Thanks to Dr. Patwari (@rahulpatwari) for supporting our site!

For more on EM induction, Check out this link on how to present a case in the ED and If you want to know Why do I keep falling in love with EM? "OVER AND OVER", click here!

Are you a good or bad PIMP?

What is pimping in Medical education?

In medicine, 'Pimping' refers to a more knowledgeable person (pimper) questioning others with less experience (pimpee) to test their knowledge. For example a students who has been questioned may say "Dr. XYZ pimped me about the Autonomic Nervous System today". 

Pimping

Pimping is a thin line between education and bullying. You can look at PIMPing as an opportunity for the seniors to humiliate the junior members of their team OR as a valid educational tool: a provocative method that might help students to think and retain the knowledge. I call that good pimping.

But trainees very often report back, complaining maltreatment by seniors (Registrars, Attendings), that too in front of patients and colleagues during the grand rounds. Some seniors make nasty comments and justify that by saying that "the trainee is going to remember that forever" and thus is unlikely to make the same error again. So they say "Pimping did not hinder, it helped"

Though pimping and socrates method look similar, there are differences between them. Pimping (or Bad Pimping) often uses the power of status to embarrass and humiliate the learner in a group environment. The goal of pimping is evaluative and thus answering questions becomes a competition. Often, rhetorical questions are asked.  Students might be asked about vague facts of certain diseases, or faculty can push students by questioning them about something challenging beyond the normal expectations. With this approach students might walk away in shame and embarrassment if the don't come up with the correct answer. Many, also consider pimping to be an abusive type of questioning. 


Socrates Method of teaching

Pimping somewhat resembles the Socratic method of teaching through questions and answers rather than a lecture kind of teaching. Socrates method of teaching involves discussion between individuals, based on questions and answers to stimulate critical thinking and to illuminate new ideas. When using Socrates method the goal of the question is known and follow-up questions lead the learner to solve the problem himself using his baseline knowledge. Its focus is on diagnosing the level of the learner and then teaching them appropriately.

Is pimping good or bad?

In recent years pimping has been looked down by some in medical education because it involves embarrassing and humiliating the medical students. Students and trainees develop negative associations with group learning methods and after start avoiding the pimp (Registrar or Attending). If they don't come up with an answer, they are made to look like "fools". However, pimpers argue saying that some amount of stress as a result of pimping can enhance the performance of learners because it gives them a fear of being put to shame and humiliation. 

If you are pimping, make sure that the questions asked are focussed, make sense, must follow up with other thought provoking questions and an explanation should be provided if no one comes up with the answer. Almost always when we ask a question as an educator, we already know if the learner knows the answer or not! So, Students do benefit from pimping, rather I should say "good pimping".

BAD/ MALIGNANT PIMPING

• Trivial facts
• Evaluative
• Rhetorical questions
• Passing humiliating comments 
• Embarrassing students
• Incessant use of questions
• Pushing the learner to his emotional as well as intellectual limits.

GOOD/ KIND/ BETTER PIMPING

• Focus is on concepts
• Connects the new knowledge with existing knowledge
• Questioning always starts from juniors, only then passed to the seniors 
• Reframes the questions
• Encouraging the learner to achieve his highest level of clinical reasoning
• Offers an explanation and emphasise important learning points
• Praise them

Surprisingly, a survey of medical students revealed that more than half like "being pimped" and even said that they would also pimp when they climb up the academic ladder though most of them made a distinction between good and bad pimping. So, Attendings and residents should feel free to pimp,  just as long as they are not demeaning or insulting. 

Key Point: It is okay to "pimp them" but don't be mean!




Further Reading:

• Brancati, FL. The art of pimping. JAMA. 1989;262(1)89 
• Detsky, AS. The art of pimping. JAMA. 2009;301(13):1379-81

Last week, one of our Trauma experts/ Prehospitalist and Resuscitationist (Dr. John Hinds) passed away in a road crash in Dublin. I never got an opportunity to meet him personally, but heard him few months back on emcrit.org and was totally amused with the kind of work he did. My heart felt condolences with his family. 

Why do I keep falling in love with EM? "OVER AND OVER"

Hi friends,

I present the first screencast this week, for the blog - in response to my friend, Nicolas Pineda's (@nfpineda) video that was released last year, #EMporelmundo. 

Before you go ahead, Please Read this : 

This video is intended for young EM Physicians, for EM Induction programs - primarily for the nations where EM is still in the developing phases. It takes us through the 10 points that we come across everyday as ED Physicians. Don't get upset if you don't agree with parts of it, these are just my own opinions. This is not an evidence based kind of talk. Please feel free to share your thoughts and comments.

I am grateful to the teaching course faculty, all my mentors and colleagues. This was not possible without their guidance and support. 

Hope you enjoy it..

Thanks!!

You can also watch the video on https://www.youtube.com/watch?v=ocvuCliVzpI or https://vimeo.com/home/myvideos.

Effective Feedback: The Heart of Medical Education!

This week, lets talk about FEEDBACK. This is something which we should do everyday, may be after every shift or may be twice/thrice on a single shift. An effective feedback can really transform learners. This is important for the attendings /consultants as well as the residents as they need to provide constant feedback to the residents/ medical students. 

So, What is feedback?

Feed- back is an essential element of medical educational that can help students/residents to reach the best of their potential. It enables the learner to achieve goals by reinforcing good performance and providing the basis for remediation whenever required. Feedback, therefore, drives learning and progress and is essential in allowing a student to remain on course in reaching a goal. Its also a good spot where learners can pause and reflect back on their own performance. 

Adult learners welcome feedback, especially when it is based on their performance and tailored to their goals.

Providing feedback is an art which can be acquired overtime with practise. Often this is ignored in medical education and teachers/ instructors are not taught on "how to provide an effective feedback". This is a really critical component and it should be a part of our training. If feedback is not provided, then poor performance will remain uncorrected which while eventually get passed on to the next generation of learners!

The Goals of Feedback:

• Encourage learners to self reflect and think how they might improve 

• To narrow down the gap between actual and desired performance 

• Lead to changes in the learner’s thinking, behaviour, and performance 

Note: Feedback is not given to make someone feel good, but for them to reflect back and improve their performance.  It is intended to change behaviour, rather than being an estimate of the students’ worth.

Characteristics of Constructive Effective Feedback 

1. Timely 
2. Specific 
3. Non Judgemental
4. Non Threatening 
5. Constructive 
6. Measurable 
7. With opportunity to respond 
8. Motivating
9. Clear summary and follow up
10. Conclude with an action plan

Often we hear feedback like "Good Job" - "Keep it up" - "Well Done" which is essentially meaning less. Feedback should be very specific mentioning about what went well and what could have been done better. So don't just say "Good job" next time - Be specific. As educators we also might find it difficult to provide negative feedback. A good way to do that is:

The Approach to Providing ‘Negative’ Feedback 

• Goal is improvement – ALWAYS 
• Relaxed environment
• Let the learner self-evaluate first (You will be surprised to know that how critical they can get about themselves) 
• Offer positive feedback, too – focus on the work, not the person
• Offer specific ways to improve
• Also you can ask for feedback from them on how you can improve as an educator

When feedback fails, it is because the process was handled poorly, causing defensiveness and embarrassment to the learner and leaving them feeling demoralised and rejected. Therefore, Attending training programmes on how to give feedback should be essential for those who teach in medicine because, in trying to give feedback, we still make remarks that have the potential to undermine the learner’s confidence completely.

Methods of Providing Feedback 

1. FAST – frequent, appropriate, specific, timely 
2. W3 – what went well, what didn’t go well, what could you work on 
3. ARCH – ask, reinforce positives, correct negatives, help move forward 
4. 360 approach – seek feedback from all team members (nurses, pharmacists, patients, etc.) 
5. Feedback Sandwich – positive → negative → positive 
6. One minute preceptor – have the learner commit to a plan, have the learner provide support/evidence for their plan, discuss general rules applied to this plan and future plans, reinforce what was done well, provide constructive feedback on areas in need of improvement, identify learning steps 
7. Pendelton: Pendleton’s rules are structured in such a way that the positives are highlighted first, in order to create a safe environment.Therefore the learner identifies the positives first. This is followed by the facilitator or group reinforcing these positives and discussing skills to achieve them. “What could be done differently?” is then suggested, first by the learner and then by the person or group giving feedback. 

 What you should never do while providing feedback! Never!

• Don’t form opinions based on what you’ve heard 
• Don’t compare to other students 
• Don’t focus only on the ‘negative’ 
• Never be sarcastic 

Don't say things like: that was awful, you are stubborn/narrow minded, I will take you for a task next time if you repeat this, better do it right next time, Are you a real doctor or a quack?

It makes me really sad and upset when I hear such comments. Residents and medical students frequently receive feedback that leaves them feeling bruised, depressed and lacking in self-worth. It is not surprising then, that medical teachers brought up in this environment, avoid giving feedback – especially if it is ‘corrective’.

Providing Feedback to the Millennial Learner (born ~1981-2000) 

• Millennial learners expect to be entertained while being educated - 
• Despite the incorporation of technology into most aspects of their lives, they actually prefer face-to-face or written feedback 
• They prefer private feedback 
• They seek immediate feedback, both positive and negative 
• Millennial learners assume positive if no feedback given 

Key Points 

• Feedback is about communication. The key skills are to listen and ask, not to tell and provide solutions. Be specific, be clear.
• Learn this with practise - See which method works out for you.
• Most important: Always Be sensitive and be NICE!

Further Reading:

1. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1496906/
2. http://onlinelibrary.wiley.com/store/10.1576/toag.6.4.243.27023/asset/toag.6.4.243.27023.pdf;jsessionid=5C493ACD23451626AC8FE1B6C5A015A3.f02t03?v=1&t=i83v9qqv&s=e2686ad66f4489b268a22429ea795c689454ea9c
3. http://sse.umontreal.ca/apprentissage/documentation/Ramani_KracKov_2012_Tips_Feedback.pdf
4. http://new.livestream.com/iTeachEM/events/2539760/videos/49556191