Budding EM

EM is still a budding field in India and I see many of our non-EM colleagues (who have never even worked in an ED) lecture during EM summits. While there is no doubt about their subject specific knowledge, there is often a disconnect felt when they try and teach EM or Critical Care. So this was one of the poll created recently:

Q - Should we be inviting non-EM physicians at EM conferences to lecture about Emergency Medicine?

1. Yes - 62%
2. No - 30%
3. Yes, but only after they go thru an EM induction program - 8%

My thoughts on this..

Some more thoughts from the FOAMed world:

Steve Carroll I think non-EM specialists certainly have something to offer when it comes to their specialty and how they would manage something or what they prefer that we do in the ED- but, for example, if a trauma surgeon wants to tell me how to do airway management (with the exception of a trach) then they should immediately close their mouth because they think they know what they are talking about but in reality they have no idea...

Justin Hensley Different specialties can offer some interesting perspectives. You have to watch what they're going to say though, because sometimes they're too specialty oriented.
Justin Hensley More like, asking the stick manufacturer to comment on ice hockey. They might not play the game, but they can offer insight to the tools.
Justin Hensley We do a feature called "ask the expert" where we bring in other people and them ask them EM specific questions. Makes it a bit more emergency oriented.

MC Gill One who never worked ER will not add any value. It is like asking a cricket player to give opinion about ice hockey.

Bishan Rajapakse Great question Lakshay (and interesting results and discussion that is emergency from the question) - I guess it all depends on which non-EM people you ask. EM is not an island, and to develop, even in mature systems, requires interdisciplinary action - especially policy makers, public health, pre-hospital, nursing, allied health, health minister etc. Even having different specialities attend EM can be very helpful - after all, we work in integrated hospitals. ------------------------------My experience of attending different IEM conferences since 2007 is that I think it is quite advantageous to have multidisciplinary conferences. A well facilitated forum with multiple disciplines is usually very productive. For example, I recently attended a high profile social media and critical care conference in Dublin, which was a true international collaboration, and interdisciplinary collaboration (doctors, nurses, paramedics, and even surgeons, and social workers were plenary speakers) - the results were good. There was an productive IEM track where people from all backgrounds were sharing ideas.-------------------------------- MC Gill I can hear your frustrations. I remember at one of the early conference hearing the question from an ex-president of college of physicians which went something like "so what is the difference between an intensivist and and emergency physician exactly?" - but I think this was a great question and great opportunity to educate those who still don't know what EM is all about - after all we are one of the most dynamic specialities that exist and it is important to keep others in the loop if we are to progress sustainably. Justin Hensley - i agree offering insight in ways that may cover our own blind spots. If people are invited and discussion is facilitated appropriately they will only offer benefit, and useful discussion. --------------------------------The key in my opinion is good facilitation at conferences, which is sometimes lacking. Using newer mediums such as twitter allow for a range of discussion to occur from the delegates, rather than just the loudest most prominent people in the room.

Praveen Chenna Invite .
They can lecture on their subject n it's importance or relevance to the field of emergency , is always acceptable.

Hashmat Faheem Emergency Medicine is comparatively newer branch as a speciality in India.. Protocols, Diseases generally varies from places where speciality is established... it might be useful to get some inputs from Non Emergency Medicine Faculties

Linda Dykes ‏@mmbangor  Jul 21

@umanamd @EMDidactic of course we should... But they should invite EPs to speak at their conferences too #abolishsilos

Manrique Umana ‏@umanamd  Jul 21San Jose, Costa Rica

Manrique Umana Retweeted Lakshay Chanana

Yeah, we work in teams (PH, EM, CC, Anesth, surg, etc) so I don’t see why not. Just need to have good communication

Feel free to share your comments.

Author:

              

     Lakshay Chanana

     @EMDidactic

                                                        

Gathering Info: ED Medical Interview (Part II)

This part forms the core of the interview. In the ED, this should take about 10-15 minutes typically.

1) Encourage patients to tell the story: Give them about a minute without any interruptions. Within a minute you will have a good idea about their chief complaint. If there are too many chief complaints then ask them what is bothering them the most and focus on that complaint. Often there are 2/3/4 chief complaints and then you need to prioritise them and set them in order. Of course we all come across patients who take us all over the map, do not lose your patience with them and very gently bring them back to the track. It is important to use words like we/us/together rather than I/me/you during the conversation.

What brings you here today?

How are you doing?

2) Use open ended questions first: It is recommended to start with an open ended question in the beggining and set them free to express symptoms and concerns. If they miss something important then use closed ended questions to clarify your doubts and best some specific info. As you actively listen to them, make neutral utterances and give them non-verbal cues to encourage them to tell more. If you ask a specific question, give them a few seconds to think. Avoid giving them a list of options to pick up one, unless they are unable to explain. If you come across a guy with shoulder pain for 6 years and now he is in the ED, it is important to ask about the triggers that made him come to the ED. 

Say: Tell me more about the chest pain (open-ended)

How long you have been having this pain (closed-ended)

Don't say: Is the pain burning, heavy, sharp? 

Avoid giving them a list of options.

3) Be attentive, sensitive, supportive

As they are telling you their story, listen attentively, facilitate the process if they have issues with something. Body language (speech, expressions, voice tone) and non-verbal cues play a major role here. Once again, if you are taking notes as you are talking to them, make frequent eye contact. Give them non-verbal cues, pick up their verbal and non-verbal cues. If you are not clear about something, paraphrase that and clarify. Acknowledge their agony. When talking about sensitive issues, once again ask for their permission.

Say: I can imagine how difficult it is.

So you are saying that the pain started around the umbilicus and then moved to the lower abdomen. Is that right?

4) No Jargon
Despite out best efforts to stay away from it, we still use jargon. It is best not to use medical jargon during the interview. The way you communicate can be gauged with the educational status/ occupation of individual patients. What I do is, I tell them beforehand that I will try my best to avoid using medical jargon, if there is anything they are free to interrupt and ask me.
Patients might think that they will sound stupid if they ask a question or if they ask us the exact meaning of a word (say Resuscitation). Therefore, it is recommended to avoid jargon as far as possible.

Say: I am going to ask you a few questions regarding the chest pain to find out exactly what is happening. I will try my best not to use any medical jargon, in case I do that unknowingly, please feel free and interrupt me. Is that okay?

5) Understand their perspective and don't be judgemental
Understand how patients look at an illness and what are their beliefs. Sometimes they tell us the diagnosis right away. Nevertheless it is important to always work with an open mindset, when you are doing the work up (because patients with meningitis can have SAH too!). Few key questions that can provide us invaluable info are:

• What are you concerned about? (highlights the chief complain again)
• What do you think is the reason for the knee pain? (Tells us about their beliefs or sometimes "the diagnosis")
• Is there anything else that you think I should know? (Often this question gives us the most important piece of history)

6) Summarise and check accuracy
When you are done with the history, present a brief summary to them to make sure that you got it right or if they want to add anything to it. Don't overdo this. Just a 15-30 seconds summary to check the accuracy of the history.

So, you have got this chest pain that has bothered you a couple of times during the last week. It comes on exertion and gets better when you rest. Do you want to add anything? 

Key points for gathering info:

• Start with open ended questions and then get specific with close ended questions
• Be attentive, sensitive and supportive 
• Ask for the triggers
• Avoid using medical jargon 
• Understand the patient's perspective and don't be judgemental 

William Osler: Listen to the patient, he is telling you the diagnosis

The first 60 seconds - ED medical interview (Part I)

As physicians, we encounter a variety of individuals everyday. Establishing relationships and building a rapport with people is something that we all should be expert at. These communication skills are undoubtedly crucial to gather the right information, ensure patient comfort and better patient care, but these skills represent one of the most overlooked aspects of medicine at least in this part of the world. 

Learning how to do a "medical interview" takes time. It is a process that is learned over years where we try to quickly develop a supporting relationship, gather information and offer information at the same time. 

We are going to cover this in three parts:

Part I: Initiating the session (First 60-seconds)
Part II: Gathering Information 
Part III: Explanation, Planning and the Closing the session

Initiating the Session (The first 60 seconds)

The first few minutes that we spend with the patients sets the foundation for the interview as well as for our relationship with them.  

1. Welcome 

• Appearance: Patients find cleanliness, conservative dress and name tag reassuring. Always have your ID displayed.
• Hand Hygiene (No excuse for this!)
• Greeting: Shaking hands is fine but be sensitive and look for the non-verbal cues because cross gender hand shakes are considered inappropriate in some cultures. At the same time, keep a watch on the non-verbal cues like facial expressions, posture, body language (throughout the interview). Remember that the patient is also observing you and reading your nonverbal cues. So be attentive, maintain a good eye contact, smile, be polite and respectful. Demonstrate your concern and make them feel important. 

If the family is around, be sure to acknowledge and greet each one of them, enquiring their names and relationship with the patient. (Maintain confidentiality when family is around). Ask the family respectfully, to leave before you start the interview unless the patient  wants them to stay.

2. Using the patient’s name

Some patients like to be addressed by their first name when they are greeted; but others prefer either their last name. So it is always better to be formal to start with (Use Mr./Mrs. or Ms. if you do not know a woman’s marital status) and address them using their last name in your initial greeting. After formally greeting the patient, ask how do they prefer to be addressed and use the preferred title/name the next time. It is easier to go from more formal to less formal terms of address than the reverse. If the patient's name sounds unusual to you, then ask them how to pronounce it.

"I am afraid of mispronouncing your name. Could you say it for me?" Then repeat their name.

3. Introduce your self and identify specific role

Use both your first and last names when introducing yourself. Avoid saying, “Hey Philip, I’m Dr. Chandy” or “Welcome Mr. Philip, I’m John.”  
After you introduce yourself, mention your official role, for example, "attending, resident or medical student”. Occasionally at the beginning but more often after some time, a relationship on first-name basis may develop.

"Mr. Philip.. Hello, I’m Dr. John Chandy. I’m the resident physician here who will be looking after you. How do you prefer to be called?"

4. Ensure patient readiness and privacy

Be courteous, make sure they are ready for it before you start the interview. Once ready, then you can ensure privacy by shutting the door, pulling a curtain (with their permission) around the hospital bed or respectfully excusing the family members. 

5. Remove Barriers to Communication
Make every possible effort to remove the barriers that hinder communication. When dealing with elderly, they should be able to see the your mouth in order to speech-read. If there is any question, ask the patient whether she or he can hear you well. Patients experience that you have spent more time with them if you sit, so do so whenever possible. Communication is optimal if you and the patient are at the same eye level. Attention to the nonverbal aspects of communication is important. 

If possible, Avoid taking notes when you are doing the history. At times, we do need to take the notes for comprehensive documentation. When doing this, do make some eye-contact and put down your pen intermittently.  

6. Ensure comfort and put the patient at ease 

These efforts are always worth the time  Determine if anything at the immediate time is interfering with the patient’s comfort. Questions like, “Are you comfortable?” or “Is the light bothering your eyes?” or “Can I raise the head of the bed for you?” are essential. Take their permission before you start the interview. Pay constant attention to patient’s comfort as you proceed. Show your care, compassion and concern. In short, treat them the way you would like to treated!!

Engaging in a little social conversation is another good way to put the patient at ease (if they are stable and have a minor illness). This breaks the ice and allows the patient to get more comfortable with you. 

If you are ever in any doubts, step into the patient's shoes and you will almost always come up with the right answer!!

Stay tuned for Part II: "Gathering information" that forms the core of the interaction.

References:

1. http://onlinelibrary.wiley.com/store/10.1046/j.1525-1497.12.s2.7.x/asset/j.1525-1497.12.s2.7.x.pdf;jsessionid=64F85FD04AEF5D03A8946EC4B3BC025D.f03t01?v=1&t=igywaxdv&s=ec03fdf5028bee52b6da44a9918f90683ceaa79f
2. Makoul,G.,A.Zick,andM.Green,An evidence-based perspective on greetings in medi- cal encounters. Arch. Intern. Med., 2007; 167(11): 1172–1176.
3. Frankel,R.M.andT.Stein,Getting the most out of the clinical encounter: the four habits model. J. Med. Pract. Manage., 2001; 16(4): 184–191.
4. Kahn, M.W., Etiquette-based medicine. N. Engl. J. Med., 2008; 358(19): 1988–1989. 
5. Mast, M.S., On the importance of nonverbal communication in the physician-patient interaction. Patient Education & Counseling., 2007; 67(3): 315–318.
6. Roter, D.L., et al., The expression of emotion through nonverbal behavior in medicalvisits. Mechanisms and outcomes. J. Gen. Intern. Med., 2006; 21(Suppl 1): S28–S34.
7. Gladwell,M.,Blink:The power of thinking withoutt hinking,1 the dition.2005, New York: Little, Brown and Company.
8. Frankel, R. and T. Stein, Getting the most out of the clinical encounter: the four habits model. Permanente Journal., 1999; 3(3): 79–92.

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.