January 2020 Faculty Development: How do Advanced Practice Providers fit into IPE at academic medical centers?

Posted & filed under , .

How do Advanced Practice Providers fit into IPE at academic medical centers?

Angela Leclerc, PA-C

Does your service have one or more Advanced Practice Providers (APPs)?  Chances are you do, or you will!  Originally conceived in the 1960s to assist with the primary care shortage, APPs can be found in almost every specialty and subspecialty of medicine and surgery.  In addition, APPs now support a large part of the workforce at academic centers due to resident work hour restrictions, as well as the stable clinical competence a well-trained APP maintains.

APPs complete rigorous graduate programs prior to entering practice.  To be successful, the new APP requires additional postgraduate training as they are transitioning to practice.  A small percentage of APPs may complete a postgraduate residency/fellowship program in areas such as Emergency Medicine (EM), Critical Care Medicine, Cardiothoracic Surgery, Trauma Surgery or Hospital Medicine, just to name a few.  However, these postgraduate programs are not mandatory and 80% of applicants are new graduates (Maine Medical Center).  How do we leverage the current academic opportunities in your institution to incorporate and educate APPs, either through formal or informal postgraduate training, leading to improved safety, lower cost and improved retention through professional development?

Investing in the training of APPs leads to a high level of consistent competency (Figure 1) (1).

Figure 1

Clin Med 12(3):200-206 (2012)

The well-trained APP provides a consistent level of competence and beyond.  Here the graph on the left represents the PGY1-PGY3 resident while the graph on the right represents the fellow. The solid line labeled ”Physician Assistants” is the well-trained APP that has been practicing for at least 2 years on service.

Chekijian et al. aimed to describe best practices and considerations regarding the integration of APPs at four separate academic institutions in Emergency Medicine.  Yale has a postgraduate APP residency in EM that is 18 months in duration and directly parallels the medical residency for MDs with complete integration from the start date of the internship year through the 18 month program.  Expectations of review of board material also parallel the MD residency program.    At Brown, Physician Extender Development Program (PEDP) was developed for new graduate APPs for a 1 year period.  This includes 5 hours of lecture time each week with the EM residency program.  This program is overseen by the chief education APP as well as two other educational assistant APPs.  UMMS-Baystate program accepts up to two PAs a year into a 12 month residency program who are partially integrated into the physician residency program (2).

You may be curious of the impact of additional learners integrated with the residents and fellows.  Kahn et al. sent a survey to 1178 surgical residents to which 354 (30%) responded.  A large majority of the respondents were part of residencies where the APPs had been integrated into the ICU for 5 or more years (3).

Figure 2

J Surg Res 2015; 199:7-12

If you do not have a formal postgraduate training program to train your APPs, not to worry. Here are some quick tips you can incorporate now:

·         Incorporate your APP(s) into bedside teaching rounds
·         Invite new APPs to resident and medical school didactics
·         Train new APPs simultaneously with residents and medical students in simulation
·         Provide access to shared educations sites or drives for APPs (i.e. asynchronous learning)
·         Provide time for your APPs to attend Grand Rounds
·         Provide formal feedback and support for APP education in your department
·         Provide highly functioning APPs the opportunity to educate other learners on the healthcare team as well as participate ongoing professional development activities in the department
·         Put APPs in charge of the education of onboarding new APPs, have them collaborate with the department chief for incorporation of the new APPs with the medical student and resident learning activities

References:

  1. Ross N1, Parle J, Begg P, Kuhns D.  The case for the physician assistant. Clin Med (Lond). 2012 Jun;12(3):200-6.
  2. Chekijian SA1, Elia TR2, Monti JE3, Temin ES4. Integration of Advanced Practice Providers in Academic Emergency Departments: Best Practices and Considerations. AEM Educ Train. 2018 Nov 27;2(Suppl Suppl 1):S48-S55.
  3. Kahn SA, Davis SA, Banes CT, et al: Impact of advanced practice providers (nurse practitioners and physician assistants) on surgical residents’ critical care experience. J Surg Res 2015; 199:7-12.

December 2019 Faculty Development: “I heard it in a podcast” How to navigate learners’ use of non-traditional learning platforms

Posted & filed under , .

Jason Hine, MD

“I heard it in a podcast”

How to navigate learners’ use of non-traditional learning platforms

 

It is no secret that non-traditional learning platforms such as blogs and podcasts are becoming more popular among learners. This article will help guide you with a 3-step approach to the trainee who brings up such material.

 

Rather than leaf through a textbook, many current trainees will open their favorite RSS feed or podcast app to find study material. In fact, Mallin et al. found that listening to podcasts outranked textbook reading as the preferred form of study among emergency medicine residents (35% vs 33.6%).1 Regardless of your stance on blogs/podcasts, it is important to recognize that they are here and a part of our learners’ knowledge acquisition.

A trainee’s use of non-traditional learning platforms often comes to light while in our clinical work, with phrases such as “I heard X in a podcast” or “I read about Y in a blog and I would like to try it.” These statements can be off-putting, and our reflexive response is sometimes dismissive or condemning. This reaction often stems from one of the following:

  • Lack of familiarity with the podcast/blog
  • Lack of understanding in the topic matter
  • Lack of comfort implementing practice change based on non-traditional resources

When we go with our knee-jerk reaction of dismissal, we invalidate the learner and their efforts, and miss an opportunity to teach them about the use of these non-traditional materials. We must recognize what is before us: a motivated student, doing independent learning, is asking us about practical application of new medical knowledge. Our response, ideally, is structured and supportive. With this 3-step approach, it can be.

Step 1: Validation

First, it is important to recognize the independent learning of the trainee and commend them for their application of this clinically.

Example: “That is so awesome you are finding time outside of your busy medical student/resident life to study independently! Even more kudos for trying to apply that to patient care. Awesome work!”

Step 2: Structured critique

Similar to how journal club teaches trainees how to critique an article, we should be offering the same skill set on how to assess a blog or podcast. Structured approaches exist, and I recommend that published by Academic Life in Emergency Medicine. This assessment is a 5-element approach to assessing a blog/podcast’s quality (ALIEM Scoring Instrument).

Example: “I’m not familiar with that specific blog/podcast. Just like the articles we review in journal club, it’s important to have a structured approach to critiquing these pieces. Luckily, someone has created an assessment tool to help us. Why don’t you send me the material and I’ll send to assessment tool. We can then look at the material, appraise it with the tool, and reconvene on how to apply it to our clinical practice.”

Step 3: Wrapping It Up

After you and the student have done some independent learning, it is important to close the loop. This, too, can be done asynchronously if time is an issue. In this conversation topics to address include:

  • Issues with the use of the assessment tool
  • Questions regarding the individual blog/podcast’s quality
  • Content review
  • Clinical application

Example: “Thanks for bringing that podcast on stress testing to my attention. I thought it did well in 4 of the five areas in the assessment tool. The one area I had reservations was that it seemed to have a lot of expert opinion and less literature citation. We always have to be cautious there. How do you think this will affect your clinical practice?”

 

With some premeditation and structure, these challenging interactions can be turned very rewarding for both learner and teacher. For more information on learners’ views on blogs and podcasts, look at Independent and Interwoven.3

 

References:

  1. Mallin M, Schlein S, Doctor S, Stroud S, Dawson M, Fix M. A survey of the current utilization of asynchronous education among emergency medicine residents in the United States. Acad Med. 2014 Apr;89(4):598-601.
  2. https://www.aliem.com/aliem-air-pro/
  3. Riddell J, Robins L, Brown A, Sherbino J, Lin M, Ilgen JS. Independent and Interwoven: A Qualitative Exploration of Residents’ Experiences with Educational Podcasts. Acad Med. 2019 Sep 10.

November 2019 Faculty Development: Case in Point: How to Write an Effective Case Report or Series

Posted & filed under , .

Case in Point: How to Write an Effective Case Report or Series

William J. Sauer, M.D.

Case reports continue to play a critical role in the advancement of medicine, particularly with regard to new disease entities (e.g. AIDS and Kaposi Sarcoma), adverse reactions (e.g. thalidomide associated birth defects), as well as other novel observations (see Table1).  As an example, there is currently a lot of attention from the CDC and NEJM correspondence regarding vaping-associated lung injury, yet a well written case report was published over two years ago.

 

 

 

Although often labelled as low quality of evidence, the objective of these publications are entirely different from a randomized controlled trial.  Instead of directly impacting medical decision making, case reports should inspire creativity, promote engagement, and further investigations.  They function to alert clinicians of new or rare phenomena that cannot be described in RCTs.  Several specialties, including surgery, infectious disease, and pharmacology, rely on case reports to support their foundation of knowledge.

In an era of information overload, the delivery of these “clinical stories” is particularly important as the audience can quickly become un-engaged.  Several resources, including the CARE (CAse REport) guidelines and checklist, should be used to ensure accurate and intriguing presentation of the intended message.

Tips from the CARE Guidelines include2:

  • Clearly identify the message. The title should succinctly describe the primary interest the author hopes to describe.
  • Create a timeline. The patient(s) chief complaints, clinical course, and outcome should be articulated in a chronological and engaging manner.
  • Complete the remainder using specialty-specific information with references. Highlight key words as well as references (if available) to summarize findings.
  • De-Identify patient information. Informed consent needs to be obtained.
  • Follow journal-specific submission requirements/ guidelines. Unfortunately, a smaller number of journals are publishing case reports/ series.

 

1) Vandenbroucke JP.  In Defense of Case Reports and Case Series.  Ann Intern Med. 2001; 134(4):330-4 (see attached PDF for article)

2) CARE case reports guidelines.  www.care-statement.org. (see attached PDF for article)

3) Gagnier JJ, et al.  The CARE Guidelines: Consensus-based Clinical Case Reporting Guideline Development.  Glob Adv Health Med. 2013; 2(5): 38-43.

4) Riley DS, et al.  CARE guidelines for case reports: explanation and elaboration document.  Journal of Clinical Epidemiology. 2017; 89:218-235

 

Tips for Being a Mentee

Posted & filed under , .

Tips for Being a Mentee

Rebecca Hutchinson, MD

Many of us have benefited from excellent mentors who have given their time, expertise and guidance to help us develop to our fullest potential.  Please see earlier MITE tip (link here to July 2018 MITE tip) on characteristics of great mentors, which include enthusiasm for the project and mentee, tailored career guidance, dedicated time, encouraging work-life balance and serving as a role model for mentorship.  In this tip, I’d like to focus on strategies to use as a mentee to maximize your gain from your relationship with your mentor.

  1. Be the driver.1-3 Mentors are busy people who have many competing demands.  You’ll get the biggest bang for your buck if you take ownership and responsibility for determining what to discuss in the mentorship meeting.  Come prepared; identify in advance the ways in which this particular mentor might be able to help you before your meeting.1,3 It’s also important to evaluate your mentor-mentee relationship intermittently to ensure that it is helping you meet your goals; don’t stay in a relationship out of obligation.3  There are tools that can help you evaluate the utility of a particular mentor relationship.4
  2. Let yourself struggle a little – but not too much — before asking for help.3 You’ll learn and develop more if you take risks and try to solve some problems on your own.  On the other hand, you won’t be productive if you spend too much time stymied by a road block.  The balance between reaching out and struggling through is dependent on the particular mentor-mentee relationship; don’t be afraid to ask for feedback in your mentorship meeting about this.
  3. Show gratitude for, and be respectful of your mentors time.2 Your mentor is a busy person.  If you’re hoping to submit an abstract or you need your mentor to write you a recommendation letter, make sure to allow a reasonable amount of time.  One week is the minimum to review an abstract; several weeks are necessary for a letter of recommendation.  If you’re not sure, check-in with your mentor about what a reasonable amount of time might be for the task.
  4. Be enthusiastic and accountable.3 Having a positive attitude and being accountable goes a long way.  Set specific, measurable goals with deadlines, and then meet the deadlines you set!  If you didn’t meet the deadline, be clear about why not.
  5. Have regular meetings and take notes during these meetings. Meeting regularly is a key component of mentorship.3  Take notes during your meetings.  Some experts recommend keeping a “mentoring journal” where you keep all of your notes in one place.3,5
  6. Be open to feedback and remember feedback is bidirectional.2,3 Be open to feedback and try to see it as opportunities for growth and development.  If your mentor edits your writing and there’s more red than black, don’t take the editing personally.   Also, remember that you can give your mentor feedback; UCSF has a template for feedback that is helpful.5
  7. Mutually agree on format of communication.3,5 Your mentor might mostly communicate through email and may not use text messages for professional interactions.  Have a conversation early in your relationship to understand your mentors preferred method of communication.

 

 

 

Straus SE, Chatur F, Taylor M. Issues in the mentor–mentee relationship in academic medicine: A qualitative study. Academic medicine. 2009;84(1):135-139.

Straus SE, Johnson MO, Marquez C, Feldman MD. Characteristics of successful and failed mentoring relationships: a qualitative study across two academic health centers. Academic medicine: journal of the Association of American Medical Colleges. 2013;88(1):82.

Moores LK, Holley AB, Collen JF. Working With a Mentor: Effective Strategies During Fellowship and Early Career. Chest. 2018;153(4):799-804.

Wadhwa V, Nagy P, Chhabra A, Lee CS. How effective are your mentoring relationships? Mentoring quiz for residents. Current problems in diagnostic radiology. 2017;46(1):3-5.

Faculty Mentoring Toolkit. https://academicaffairs.ucsf.edu/ccfl/media/UCSF_Faculty_Mentoring_Program_Toolkit.pdf. Accessed September 26, 2019.

 

Want CME Credit for reading this tip?? Go Here: https://mainehealth.cloud-cme.com/MITEmonthlytipoctober

 

Electronic Communication with Patients

Posted & filed under .

Electronic Communication with Patients

Annabelle Rae C. Norwood, MD

Electronic communication has now become a routine part of clinical practice. A lot of non-urgent communication with patients and their providers now occur through on-line channels such as secure messaging and e-mails.  In particular, MaineHealth is highly encouraging patients to sign-up for and utilize MyChart, wherein patients can directly send messages to their providers. As such, there may be a need for medical educators and health care institutions to provide more guidance and education about this topic. (1) It has been shown that electronic communication with patients, can actually improve patient care and outcomes such as improved medication adherence (2). However, everyone communicating with patients through these online portals should be cognizant of privacy, confidentiality concerns, and HIPAA rules. Therefore, communication with patients should only occur in secure networks and not through personal e-mails, and definitely not social media. Institutions themselves, however, should also reinforce with patients that online communication should be only about non-urgent matters such as refill requests, that messages should be brief and descriptive and that these messages are going to be a part of the medical record (3).

There are also certain business e-mail etiquette (4) that may be applied to answering patient communication.

  1. Use a professional salutation. “Hi”, “Hello” or a more formal “Dear (name)” are all appropriate salutations. “Hey”, “Hiya” or “Yo” are not.
  2. Try to answer messages in a timely manner. Two business days is usually standard. It may also to just help the patient acknowledge that you have received the message, even if you don’t have an answer right away.
  3. Don’t send angry messages. In that rare instance where a patient were to send offensive or threatening e-mail, in one study analyzing secure messages in two Veterans Administration health care centers, offensive or threatening messages only comprised 0.2% of all messages sent. (5) Formulate an appropriate response when you’re calmer is better.   It would also be good to bring up this situation to your supervisor or team on how best to address this patient’s concern.
  4. Avoid using abbreviations like LOL, writing in all CAPS, using emoticons and using a string of exclamation points!!!!! These are not professional.
  5. Proofread your messages before sending them.

References

  1. A critical appraisal of guidelines for electronic communication between patients and clinicians: the need to modernize current recommendations. Joy L Lee, Marianne S Matthias, Nir Menachemi, Richard M Frankel, Michael Weiner. 4, 2018, Journal of the American Medical Informatics Association, Vol. 25, pp. 413-418.
  2. Creatine a synergy effect: A cluster randomized controlled trial testing the effect of a tailored multimedia intervention on patient outcomes. Annemiek J Linn, Lisetvan Dijk, Julia C M van Weert, Beniam G Gebeyehu, Ad A van Bedegraven, Edith G Smit. 8, s.l. : Patient Education and Counseling, 2018, Patient Education and Counseling , Vol. 101, pp. 1419-1426.
  3. Expanding the gidelines for electronic communication with patients: Application to a specific tool. Stephanie L Prady, Dierdre Norris, John E Lester, Daniel B Hoch. 4, 2001, Journal of the American Medical Informatics Association, Vol. 8, pp. 344-348.
  4. Whitmore, Jacqueline. The Do’s and Don’ts of Email Etiquette. [Online] 2016. [Cited: May 28, 2019.] https://www.entrepreneur.com/article/272780.
  5. An analysis of patient-provider secure messaging at two Veterans Health Administration medical centers: message content and resolution through secure messaging. Stephanie L Shimada, Beth Ann Petrakis, James A Rothendler, Maryan Zirkle, Shibei Zhao, Hua Feng, Gammae M Fix, Mustafa Ozkaynak, Tracy Martin, Sharon A Johnson, Bengisu Tulu, Howard S Gordon, Steven R Simon, Susan S Woods. 5, 2017, Journal of the American Medical Informatics Association, Vol. 24, pp. 942-949.

Mastering Millennial Mentoring

Posted & filed under .

MITE Monthly Tip: April 2019-Angela M.  Leclerc, PA-C

Mastering Millennial Mentoring

Generation gaps between teacher and learner are encountered every 10-20 years. Generations are shaped by unique historical circumstances.  Currently, millennials make up approximately 25 % of our workforce and this will increase to 40% and 75% of the workforce in 2020 and 2025 (1).  Adapting to changes in expectations and work habits is imperative to educating learners, preparing future master educators and fostering productive mentoring relationships.

Millennials are frequently labeled to be distracted, impatient, entitled and too engaged in social media and not infrequently found to be on personal device during moments of teaching.  These labels are often misguided.  This generational cohort has been dubbed the “digital natives” with most of their lives accompanied by rapid expansion in technologies, having information and instant communication at their fingertips within seconds.   The millennials have been characterized to appreciate honesty, instant feedback and collaboration. (2)

Here are some tips when mentoring millennials:

Tip What they desire How you deliver
Micromentoring accessibility, frequent short meetings, fast responses Hold brief meetings on narrow topics to discuss progress.  Meetings would be about a single topic with a focused question or set of questions to be addressed.
Reverse mentoring flat leadership structure Find strengths of the mentee, perhaps social media as a means of disseminating research, journal club and networking, harness and promote their unique leadership abilities
Mentorship teams collaboration A team of mentors, interdisciplinary, providing cognitive diversity and the ability to capitalize on the individuals strengths

Adapted from Chopra V1,2, Arora VM3, Saint S1,2. Will You Be My Mentor?-Four Archetypes to Help Mentees Succeed in Academic Medicine. JAMA Intern Med. 2018 Feb 1;178(2):175-176

Finally, the millennial generation has been shaped by the #metoo era.   I agree with the author in JAMA, Mentoring in the Era of #MeToo, with her fears of gender-based neglect.  I most certainly harbor a great amount of empathy for those women who have suffered from sexual harassment and sometimes worse.  However, many of my mentors have been male and have professionally influenced my practice and career path and are close colleagues of mine, likely for life.

The author refers to key behaviors exhibited by her male mentors:

  • Always demonstrate exemplary professional behavior during and outside of the work day (never compromised by alcohol consumption or flirtatious interactions)
  • Behave comfortably, but as if others are watching, demonstrating integrity
  • Refrain from physical touch except in larger social settings where you may give a hug in greeting.
  • Never mention anything about appearance or appearance of others and avoid generalizing comments about gender
  • Text with important or urgent things, and sometimes just very funny things, but never anything that wouldn’t share with either spouses.
  • Most importantly, they have chosen to speak up to support women while other men have chosen to sit quietly or, worse, offend (4)

 

References

  1. Waljee JF1, Chopra V2, Saint S3. Mentoring Millennials. 2018 Apr 17;319(15):1547-1548
  2. Williams VN1, Medina J2, Medina A3, Clifton S4. Bridging the Millennial generation Expectation Gap: Perspectives and Strategies for Physician and Interprofessional Faculty. Am J Med Sci. 2017 Feb;353(2):109-115
  3. Chopra V1,2, Arora VM3, Saint S1,2. Will You Be My Mentor?-Four Archetypes to Help Mentees Succeed in Academic Medicine. JAMA Intern Med. 2018 Feb 1;178(2):175-176
  4. Byerley JS. Mentoring in the Era of #MeToo. JAMA. 2018;319(12):1199-1200

Encouraging Reflection to Deepen Learning and Combat Burnout

Posted & filed under .

Encouraging Reflection to Deepen Learning and Combat Burnout-Rebecca Hutchinson, MD

Kolb describes 4 stages of experiential learning, the type of adult learning that forms the cornerstone of medical education.1,2

Although all of these steps are important, reflection is believed to be particularly important to create deep or lasting learning.3  Reflection is a metacognitive process, or thinking about thinking; this process allows the learner to make connections between new information and prior experiences and knowledge.4  Effective reflection results in connections that increase accessibility of the learning, allowing application to relevant subsequent scenarios.  Reflection can be written or oral, there is no evidence to suggest superiority of one method over the other; this MITE tip will discuss methods of facilitating both.5

There are many ways that we can incorporate reflection into our education of medical trainees of all levels.  Prior to encounters, we can encourage reflection by explicitly discussing our objectives for the visit using questions such as: “What physical exam maneuvers might be most helpful to determine our management for the day?”  or “What questions should we ask the patient in order to further refine our differential diagnosis?”  This type of reflection will help the learner know what to focus on during the encounter, increasing the yield of the learning experience.  This type of ‘pre-visit’ exercise can help all members of the treatment team maximize their learning from a shared patient encounter even if they are not participating in an active way.  We can also encourage reflection after encounters.  Some examples of questions that could be used to reflect are:  “how did the physical exam compare to what we expected to find in this patient with advanced heart failure?” or “what emotion do you think the patient was having when you explained the plan for the day?”1

In addition to facilitating deep and lasting learning, reflection has also been shown to be an effective way to improve resiliency and well-being of the clinician as well as increase empathy for patients.6,7  It is particularly important to help learners take the time to reflect after challenging emotional experiences.  We can do this by having formal or informal debriefing sessions where all members of the care team have the opportunity to share how they are feeling or how the experience is impacting them personally.  We can also encourage reflection through writing, such as through the use of journaling.  Additionally, you could consider having medical students and/or residents do a writing exercise at the end of a month long rotation to encourage reflection.5  Some examples of prompts are: writing gratitude letters to patients, writing about a patient who surprised them and explaining why, reflecting on a time when they felt they communicated something difficult in a way that was effective (or not!).  One fun exercise to consider doing as a group to aid in reflection and team bonding is having everyone write a six-word story.  A famous example of this is “For sale: baby shoes, never worn,” attributed to Hemingway.  These writing exercises help our learners, but they can also help us.

References:

  1. Maudsley G, Strivens J: Promoting professional knowledge, experiential learning and critical thinking for medical students. Medical education 34:535-544, 2000
  2. Kolb DA, Boyatzis RE, Mainemelis C: Experiential learning theory: Previous research and new directions. Perspectives on thinking, learning, and cognitive styles 1:227-247, 2001
  3. Mann K, Gordon J, MacLeod A: Reflection and reflective practice in health professions education: a systematic review. Advances in health sciences education 14:595, 2009
  4. Sandars J: The use of reflection in medical education: AMEE Guide No. 44. Medical teacher 31:685-695, 2009
  5. Aronson L: Twelve tips for teaching reflection at all levels of medical education. Medical teacher 33:200-205, 2011
  6. Chen I, Forbes C: Reflective writing and its impact on empathy in medical education: systematic review. Journal of educational evaluation for health professions 11, 2014
  7. Zwack J, Schweitzer J: If every fifth physician is affected by burnout, what about the other four? Resilience strategies of experienced physicians. Academic Medicine 88:382-389, 2013

A Compassionate Script

Posted & filed under .

A Compassionate Script-Kathryn Brouillette, MD

With stressors abounding of record-level hospital census, the opioid epidemic, flu season, the holiday rush and the day-to-day grind of showing up for work while also managing household IADLs, I hope to offer a little salve for burnout.

It is simply compassion, the root meaning of which is to suffer or feel (-passion) with (com-) another person, in this case, our patients and their families. A quick reminder as to what compassion is not[i]:

  • Pity or sympathy
  • Kindness
  • Benevolence
  • Social justice

Compassion is much more specific, regarding a particular person’s feelings about the present situation.   It requires[ii]:

  • Imagination, as we put ourselves in another’s circumstance.
  • Intimacy, as we learn of the hardships of another.
  • Honesty
  • Time

Providers may suffer atrophy in these qualities as their medical education and careers progress.  These are, however, precisely the items touted to be antidotes to burnout[iii], litigation[iv], and medical error[v].  How do we get them back into our lives, our patients’ lives, manage the patient’s care safely, and still make it home on time for dinner?

One possible answer of many: fake it till you make it.  Use a script, perhaps this one:

  • Sit down when you speak with a patient. Lean towards your patient.
  • Ask your patients to tell you about themselves in an open-ended way: “Tell me about your family. Where are you from?  How do you like to spend your free time?”
  • Let them speak, without interruption, for at least 2 minutes.
  • Find something you share in common with them, e.g. “I grew up in a small town as well…”
  • Offer information about yourself, perhaps even revealing some of your own vulnerability. e.g. “I really miss my family around the holidays, too, especially since my parents died.” Gentle humor can sometimes be appreciated
  • After gathering the necessary history/information and performing your exam. Use supportive statements as the history is recounted, e.g. “Oh my, that sounds very scary.” Summarize your thoughts on their case using plain language. If you have uncertainty about the diagnosis, tell them and explain why.
  • As you are leaving, provide supportive statements, e.g. “I am with you”; “I hear you”; “Let’s get you feeling better”; “You’re not alone”; or “I’ll be thinking about your care tonight.”

These added minutes do take time, but the payouts include:

  • A closer rapport with your patient, who will be more likely to divulge important information regarding symptoms.
  • An enriching human interaction for both provider and patient
  • A patient who feels both validated and cared for is more likely to comply with medical therapies.
  • Better medical outcomes for patients and providers.

Whether it is second nature to you, or something that takes practice, compassionate interactions, just like apathy, can be infectious.  Try to share them as much as you can.

 

 

 

[i] Pence, Gregory E.  Can Compassion Be Taught?  Journal of Medical Ethics. 1983, 9, 189-191.

[ii] Pence, Gregory E.  Can Compassion Be Taught?  Journal of Medical Ethics. 1983, 9, 189-191.

[iii] Vallerand et al.  On the Role of Passion for Work in Burnout: A Process Model.  Journal of Personality. 2010, 78(1), 289-312.

[iv] Levinson, Wendy.  Doctor-Patient Communication and Medical Malpractice implications for Pediatricians. Pediatric Annals.  1997, 26(3), 186-193.: I

[v] Shanafelt et al. Burnout and Medical Errors Among American Surgeons.  Annals of Surgery.  2010. 251(6), 995-1000.

Can you really make your brain BIGGER: Using cognitive science to increase your study efficiency and retention

Posted & filed under .

Can you really make your brain BIGGER: Using cognitive science to increase your study efficiency and retention by Jason F. Hine, MD-Emergency Medicine SMHC

How are we as clinicians going to keep up with the ever-expanding fund of medical knowledge?

The rapid expanse of medical knowledge is a well-recognized reality creating a daunting circumstance for us as clinicians- trying to keep up with what we need to know.1 There are several strategies to help the practicing physician keep up. These include:

  1. “Peripheral brains” such as smartphone apps and pocket cards
  2. Secondary journals- which were discussed in our November Monthly Tips
  3. Efficient study techniques

Wouldn’t it be great if you could improve the efficiency with which you study and learn?

Enter cognitive science. While this is a vast field of research covering a range of topics, one area of study has been in the production and retention of memories.  A summation of this field’s findings can be found in the book Make It Stick: the Science of Successful Learning.2 Cognitive scientists Henry Roediger and Mark McDaniel teamed up with story teller Peter Brown to outline how we can improve our efficiency in learning and memory retention. In its simplified form, this involves four processes:

  • Retrieval Practice (R) – As a medical student you cannot spend 3 grueling hours on acid-base analysis, put the book down and expect to nail an ABG interpretation 4 months later. To solidify a memory into our long-term bank we must practice using it. Quite simply, this is the act of pulling information (a memory) from our memory back. This is retrieval practice.
  • Spacing (S) – The idea of spacing is linked to retrieval practice but gives greater detail about when we should be retrieving memories. It is fine to practice retrieving a memory 30 minutes after it is created (ie shortly after you read a new article), but it is more powerful and efficient in creating memory retention when some time has passed. Allowing for a bit of forgetting to occur and making the retrieval effortful leads to greater retention.
  • Interleaving (I) – Interestingly, cognitive science has found that when we mix our study of different subject matter we often gain a greater understanding of each. This is thought to be related to pattern recognition across topics, rule generation, and the linking of memories in our brains. By mixing our review of several articles, therefore, we can improve our retention of the take-home from each.
  • Generation (G) – The concept of generation is akin to an active rather than passive learner. It explains that in creating from our memory we again reinforce the content and improve retention. Activities such as recollective summaries or content application are much more retention-producing than passive actions such as rereading.

So, after reading an article use these steps to “Make it Stick”:

  1. Take a moment to write out the key points of the paper and how they may affect your practice (R, G).
  2. Create an alert 1 week later (via smartphone, calendar, post it notes, whichever structure works for you) to remind yourself to do a recollection exercise where you spend two minutes writing all you can remember on the article, then review and correct (R, S, G).
  3. Create a notecard with the article title on one side and short summation on the other (S, G).
  4. Whenever you sit to read a new article, review the notecard and simply speak aloud the major summative points (R, S, I, G). Once the article and its content become second nature, the notecard can be filed or discarded.

While more effortful than our inherent learning strategies, this method of study based on cognitive science is more time efficient. For most of us, our typical pattern involves reading an article, putting it down, forgetting it, and rereading it months to years later when we realize the content is lost. In the proposed study construct, after the first active reading session the subsequent retrieval activities are quite short, collectively require less time, and are higher yield for actually remembering the topic.

To learn more on the topic of memory retention, please read Make it Stick or use these links to my podcast website for my summary and interview with the author.

References:

  1. Densen P. Challenges and opportunities facing medical education. Trans Am Clin Climatol Assoc. 2011;122:48-58.
  2. Brown P, Roediger H, McDaniel M. Make It Stick : the Science of Successful Learning. Cambridge, Massachusetts :The Belknap Press of Harvard University Press, 2014.

November Faculty Development: Staying on Top of the Literature

Posted & filed under .

Staying on Top of the Literature by Christopher Turner, MD Pediatric Surgery

When I was preparing for my pediatric surgery boards, I asked an emeritus professor for advice. He recommended what he had done for his boards: read every article ever published in the Journal of Pediatric Surgery. While this may have been feasible in 1979 with thirteen volumes, it was not feasible now with fifty-three. Not only have journals continued to churn out articles, they are doing it more quickly. The number of citations added to MEDLINE per year has almost tripled over the last twenty years from 322,825 in 1996 to 869,666 in 2016. Our ability to produce medical data as a community has exceeded our ability to consume it as individuals. I would like to offer you some strategies and resources to compete.

  1.      Primary Journal. Identify the primary journal for your specialty. Commit yourself to reviewing every issue.
    1. Make it a habit. Try to reserve time on your outlook calendar so it does not get skipped. Do it with a peer so you can hold each other accountable. Pair it with a treat (like a molasses cookie at Tandem!).
    2. If you like print, subscribe. If you like digital and free, consider Browzine (com). This is a service supported by our library that allows easy reading of most major journals on your tablet or phone. It also allows you to track individual journals and save articles.

2.     Secondary Journals. There are many services that curate the literature. Here are a few.

  1. Read (com/read-by-qxmd) or Case (https://www.casemedicalresearch.com) or Prime (www.unboundmedicine.com/products/prime). These apps send you the most popular articles in selected specialties. I have received a weekly email from Read since fellowship. It often shows me interesting articles that I would not have otherwise. Case allows you to listen to audio transcriptions of abstracts which might be useful for your commute.
  2. Journal Watch by the New England Journal of Medicine (org). A good option for medical specialties. It reviews 250 major journals and posts updates by email. The twelve specialties are cardiology, emergency medicine, gastroenterology, general medicine, HIV/AIDS, hospital medicine, infectious diseases, neurology, oncology, pediatrics, psychiatry, and women’s health.
  3. Patient Oriented Evidence that Matters (com). This sends email alerts with updates. I have not used it but it looks promising.
  4. Uptodate and Dynamed. Both of these review services also offer subscriptions to receive email alerts for “practice changing” updates. I have not used them either
  5. TDNet (com). This will send you the table of contents for the journals that you select. I find it clutters my inbox.
  1.      Deep Dive. Through myNCBI, it is possible to receive a regular email with all new publications from PubMed that match a particular search term. This can be overwhelming. It works well for very narrow topics and when you don’t want to miss a thing. Consider it for your research projects. Ask library staff to help you set it up.

I am sure many of you have your own habits and suggestions. Please send them to me if you are interested at cturner1@mmc.edu. I will try to post them here as comments.

I would like to thank Dina McKelvy and the library staff for their help compiling these resources and for their frequent kind assistance.