Teaching Residents Soft Skills

Professionalism.  Communication.  Empathy.  Skills needed for all physicians.  Unfortunately, with the hustle and bustle of everyday work and the "do more in less time" mentality that pervades our practice, relationship skills are often overlooked or frankly ignored.   If one was to look at the satisfaction with practice in emergency medicine, they would find a significant amount of burnout and unhappiness with practice.  Keeping this in mind, how do you work with residents to teach them the soft skills which lead to the rewarding practice of medicine and a more satisfying relationship with patients?


Wright et al set out to identify a list of practices that lead to a more fulfilling practice life.  The list that they have created captures behaviors and attitudes that may help achieve this goal on a personal level.  Even more helpful to the educator, the list creates a wonderful set of tasks that you use to help a trainee assess themselves and continue on the journey to personal and professional growth.


To use the list, I've begun to create a set of cards, each containing one precept.  I like to start a shift by asking the resident what they want to learn on that particular shift.  I often find that their list is somewhat generic, such as "I want to work on my procedures."  Instead, by pulling out these cards resident can pick any card and suddenly we have a simple task to practice.  I can then observe their behavior and offer simple feedback on their success with the task.  


The list can be customized, expanded, and is designed to change as medicine changes.  Look it over and try it out.  I think that you'll find it helps both the learner and the teacher.  As Robert Heinlein pointed out, "When one teaches, two learn."


The List:


Promotion of relationships with patients
1. Greet patients by their names, tell them you name and your role in their care
2. Smile
3. Sit down when talking to patients
4. Listen
5. Be wholly present when interacting with patients and avoid unnecessary interuptions
6. Learn who your patients are and consider sharing something about yourself with them

7. Show the utmost respect for all patients

8. Be humanistic, compassionate and caring

9. Even if it is a struggle to think positively of a patient, always speak of them in a positive way; this will influence your thinking positively

10. If you are feeling negative emotions towards a patient, try to understand why you are feeling this way

Principles of the effective clinician

11. The history and physical examination are not like a biopsy fixed in formalin, but are dynamic entities that should be revisited frequently

12. A patient’s history should not be “aspirated”; it should instead be “built” purposefully with effective communication skills

13. Be curious – seek to find out exactly how and why events occurred and do not accept diagnoses and conclusions made by others

14. Recognize the patient as teacher

15. Elaborate a differential diagnosis that is as broad as the history and physical examination dictate

16. After forming a diagnostic hypothesis, focus on any symptoms or signs that are either atypical or incompatible with the diagnosis; these must be explained and not ignored

17. Always consider and exclude catastrophic treatable diseases

18. Continually strive to improve your diagnostic skills by mentally committing to a specific answer or conclusion before definitive testing

19. Watching patients walk is a critical component of the physical examination, particularly if their level of function is compromised

20. Look at the sacrum and heels of any patient who is bed-bound

21. Think about and plan for how to best deliver the information before telling important news to patients about their health

22. Explain medical concepts in simple language; avoid medical jargon and make sure that the patient understands

23. Teach patients what they need to know to make an informed decision

24. Strive to become a healer

25. Solicit help when you are stumped or at a loss in caring for a patient

26. Review your patient’s drug list and require explicit justification for every medication

27. Remember that the ill patient is not at his best

28. Do not discuss patients in public places (eg, elevators)

29. Appreciate the contributions of all members of the health care team

30. Try to be as organized as possible – be prepared and be thorough yet efficient

31. Focused reading to answer specific clinical questions is more nourishing leafing through a current issue of a medical journal

32. Know that much practice, reading, and years of hard work are essential parts of becoming an excellent physician

33. When you have made a mistake in the care of a patient, follow these steps: (a) admit it, (b) inform the patient, (c) if possible, initiate reparation, (d) institute a mechanism whereby you will not repeat the error, (e) attempt to establish a mechanism whereby others in the system cannot make the error, (f) forgive yourself

Growth and improvement

34. Strive to achieve personal awareness and an understanding of your beliefs, values, and attitudes

35. Recognize and acknowledge powerful experiences

36. Seek out and embrace helping relationships

37. Make time for reflection

38. Observe other physicians carefully and learn from role models

39. Realize that people are watching you closely – strive to be a role model for others

40. Be creative and innovative

41. Try to look into an accurate mirror

Values to guide one’s career in medicine

42. Avoid being cynical

43. Understand that medicine is a public trust

44. Be humble

45. Be ethical in all of your work as it relates to the profession of medicine

46. Aspire to become a great teacher

47. Stand up for what you believe in

48. Aim for a comfortable balance between your personal and professional lives

49. Try your best

50. Continually search for meaning in your work in medicine

51. Celebrating successes may help to avoid burnout

52. Be thankful and happy that you are in medicine

Reference:

Wright SM, Hellmann DB, Ziegelstein RC. 52 precepts that medical trainees and physicians should consider regularly. Am J Med. 2005 Apr;118(4):435-8. PMID: 15808145

Deviant Skill: Mindful Practice Part 2

-

In the last post, we covered the types of knowledge relevant to clinical practice. Now, we're going to delve into exactly what mindful practice entails.

Mindfulness is an extension of reflection. Mindful practice involves being mentally aware of action, thoughts, sensations, images, and emotions.

A quote from the cited article that explains the theory of the practice so well:

"mindfulness leads the mind back from theories, attitudes, and abstractions. . .to the situation of experience itself, which prevents us from falling prey to our own prejudices, opinions, projections, expectations and enables us to free ourselves from the straightjacket of unconsciousness."

Wow, deep stuff! I love the mental image of the straightjacket of the unconsciousness. Mindful practice may derive from a philosophical basis but in practice is just active reflection on mental processes.

The goal then is to become aware of your mental processes. To do this you must:


-Listen more attentively


-Become more flexible


-Recognize bias and judgement


-Act with principles and compassion


-Have curiosity about the unknown


-Be humble about the imperfect understanding of another's suffering

Consider the following: a resident is having difficulty with an intubation that you are supervising. What options does he have? He has to weigh the humiliation of admitted incompetence, the loss of self esteem related to said admission, and the pride of knowing when to ask for help. If he isn't a student of mindful practice then he will learn little and will probably blame himself or the patient for his failure. If instead, he is mindful, he will reflect on the factors that influenced his failure, such as technique, patient factors, choice of position, choice of tools, etc, and will be mentally and technically ready for the next intubation.

Mindlessness, on the other hand, is responsible for many of the negative deviations in clinical practice. This behavior seems to pervade the more emotionally involved or high pressure situations. In emergency medicine, this may be due to attempts at efficient flow, feeling of being overwhelmed, or a desire to avoid admitting incompetence.

There are a variety of ways to become mindful.


-Keep a journal of reflection


-Practice meditation


-Review videotapes of sessions of yourself with patients


-Create personal learning contracts when deficiencies are discovered


-Evaluations, both self and peer created


-Critical incident reports after an error

Ultimately, becoming mindful takes time and practice which is why it is probably viewed as an expert skill. As educators, we can begin to teach these skills. We can ask our students questions to make the unconscious conscious. How do feel about this patient? What are you uncertain about in this case? How will address your feelings of revulsion about this particular case?

Barriers to mindfulness are many. In emergency medicine, we are victims of mental and physical fatigue, pressure to do more with less, patient anger and unreasonable expectations, and more. All of these can lead to close mindedness and resentment of practice.

As you can see, becoming a mindful practitioner is within reach of all of us. Despite the many challenges, simple awareness and practice of this skill will lead you toward better patient care and becoming the ultimate "positive deviant."

As mindful practice is easier with guidance, has anyone out there practiced this in any form? I would love to hear insights from active practitioners who could provide tips and tricks to accelerate learning these skills. Leave a comment!

Reference:
Epstein RM. Mindful Practice. JAMA. 1999 Sep 1; 282(9): 833-9. PMID: 1047868

Deviant Skills: Mindful Practice

Want to take your expertise to the next level?  Do you really want to become a deviant?  To do so, then you must become a student of "Mindful Practice."  In this post, the first of two parts, I hope to explain about types of knowledge present in medical practice.  In part 2, I will explain the nature of mindful practice and mindless practice.  

Mindful practice is a term that is applied to a practice used by elite clinicians.  At it's most basic, it is critical self reflection.  Unlike normal reflection, used at the end of a process, mindful practice is experienced in real time.

It is the ability of a physician to listen attentively to a patient while recognizing personal biases in play; it is the ability to recognize and correct for mistake, refine technical skills, make evidence based decisions, and act within a personal value system.  It allows the practitioner to act with the highly desired skills of compassion, competence, and insight.

In practice, there are 2 types of knowledge that we use: explicit and tacit.  Explicit knowledge we all know and love.  It is the conscious application of rules or objective data to a patients condition.  It also tends to be easily quantified and studied.  Tacit knowledge, on the other hand, tends to be unconscious and not easily studied.  It is gestalt at its finest.  Think about riding a bike.  As you ride, you make adjustments for speed, position, and direction almost without thinking.  In a similar fashion in emergency medicine, a expert can walk in the room and determine that a patient is septic before having objective data before them to confirm their suspicions.  

This ability is the result of preattentive processing by the brain.  Essentially, the unconscious mind of the expert is evaluating perceptions and features and relegating some information to the background, all before these thoughts are made conscious.  There are many tasks in medicine that fall within this behavior: realizing that a patient has provided enough history to make a diagnosis, proper depth of insertion of a laryngoscope, or manipulating a hip to reduce a dislocation.

Unfortunately, this tacit information is very difficult to teach and is learned instead through practice and observation.  While many of us practice some form of evidence based medicine, the tacit knowledge of an expert takes the evidence and adds to it the messy details:

-Cost

-Context

-Convenience

-Patient Values

-Personal emotion

-Bias

-Prejudice

-Risk aversion

-Tolerance for uncertainty

-Personal knowledge of the patient

The awareness of this process remains relative unconscious to the expert and continues to demonstrate how judgement is both a science and an art.

In addition to tacit and explicit knowledge, there are also some domains of knowledge that we all have:

Propositional: fact, theories, concepts, and principles

Since this knowledge often comes from books and instructors, we need to be self aware of what we know and do not know.  We also need to appreciate the transient nature of this knowledge as it is constantly changing

Personal: knowledge gained through experience; intuition, personal interpretation

This knowledge is often neglected during training due to confusion between personal knowledge and anecdote.  Consider uncritical application: What if you missed a pulmonary embolism and subsequently ordered a d-dimer on every patient with pain or shortness of breath?  This is application of an decontextualized anecdote.  We see this all the time in medicine.  How many of you have been taught: "Any patient with an elevated WBC count and belly pain gets imaging."  Compare instead the physician who increased their tacit knowledge by self reflection that made them aware of the processes and thought that led to the misdiagnosis and allowed them to recognize the error in the future.

Process Knowledge: knowing how to accomplish a task, gathering information, procedures, etc

This includes the knowledge of metacognition, or thinking about thinking.  Process knowledge allows us to modify actions, whether diagnostic or procedural.  Reflection on processes also all us to gain insight into our blind spots.  It uncovers "unconscious incompetence."

Know How: knowing how to get things done

Remember your first month on the real job?  You probably we a fairly inefficient physician.  Know how is knowing not only what test to order, but that communication with all involved parties, i.e. nursing or radiology may get the test completed sooner.

So now that we know what knowledge is, how do we become mindful to using it to become a positive deviant?  In the next post, I will cover the characteristics of a mindful practitioner and cover the dreaded opponent: mindless practice.  Stay tuned!

Reference:
Epstein RM. Mindful Practice. JAMA. 1999 Sep 1; 282(9): 833-9. PMID: 1047868

Patient Safety: Whose Job Is It Anyhow?

Today I went somewhere that I've never been before.  Despite working my job in the emergency department for the last 2 and a half years, I had never been to the medical staff dining room.  As I perused the bulletin board filled with newspaper clippings of local physicians in the news, I came upon a letter to the editor written by a physician somewhere in the midwest.

 The headline  made reference to airlines and checklists and caught my eye right away.  Unfortunately, the writer used his podium to rail against the current patient safety movement.  He made fun of checklists, insisted that an "airline" style of patient safety is too expensive and manpower intensive, and, in general, failed to acknowledge medical errors are a huge issue!

Reading though to the end, I was disappointed that the authors' narrow view misses the fact that if we are to improve patient safety, we all must focus on change.  The airline industry is often held as an example because of the remarkable record of safety.  It wasn't always this way.  In the late 1970's, a spate of incidents caused the entire industry to take a critical look at their processes and design new ways to deal with the errors.  Checklists, team training, simulation, process redesign, and multiple other safety innovations were the result of their efforts.  They took the time to test their ideas and redesign them.  In short, they changed, and they're still doing it!

Medicine can learn a lot from their efforts.  The message isn't that 2 doctors (pilots) per patient (plane) with 3 nurses (hostesses and hosts) and a host of support staff armed with checklists will make care safer.  The message is that we need to study our processes, learn about the latent conditions that predispose us to err and make changes to eliminate them.  We can create tools to improve care.  These may be checklists but they're not the only tool to use.  We can study staffing and it's effects on waiting, technology, teamwork, and more.  This list goes on and on.  Perhaps the best thing we can learn from the airline industry isn't about the tools they use, but the methods they used to create the environment in which all players want to be a positive deviant.  After all, being ahead of the curve when it comes to refining the process of providing safe care is at the heart of our oath towards humanity: "Primum non nocere, or first, do no harm."

Formula One and Patient Handoffs

Gentlemen, start your engines! Who can resist the high octane, high speed formula one races? Okay, maybe a lot of people could care less about these high stakes races but if you look closely at a successful race team, some patterns of excellence begin to appear that have crossover lessons applicable to medicine. This was recognized by some British physicians who recently published a their experience in using the lessons learned to improve patient handoffs.

Handoffs have become a real hot topic in medicine. With the increase in resident work hours restrictions, handoffs have been identified as one of the more hazardous times in patient care.

This study was an interesting prospective intervention looking at performance change before and after the introduction of a standard handoff protocol. The specific protocol was designed to look at the transfer of a child after surgery for congenital heart disease to the ICU. Before the researchers began their protocol design, they spent a day with the Ferrari F1 racing team at the team headquarters in Maranello, Italy. (How can I sign up for this?)

Why Formula One? The pitstop in Formula One racing is a great example of how a multiprofessional team functions together under high stakes conditions to perform a complex task with minimal error. Think about it: stop car, jack it up, change 4 tires, fully fuel it, clean the drivers visor, drop the jacks, and back to the races, all in about. . .7 SECONDS! Needless to say, the lessons to be gleaned were many and became the basis for the new protocol.

To be truthful, the actual results of this study are not nearly as interesting as the lessons that they learned. Their protocol did result in a decrease in errors to be sure: technical errors went from 5.42 to 3.15, information omissions dropped from 2.09 to 1.07, multiple errors dropped from 39% to 11.5% and so on, but I digress.

So what did they learn that is useful to us?

Leadership: In F1 racing, there is a "lollipop" man who coordinates the entire procedure. How many of you walk into a trauma resuscitation and know who will lead the team, what resident is doing what, which nurse is on monitor duty, drug administration duty, or documentation duty? In this particular study, these roles became defined.

Task Sequence: In racing as well as aviation, the order of events is known. In handovers we are terribly inconsistent with our information. We often have no set sequence to follow leading to omission of critical information. This study broke a critically ill patients transfer into 3 phases: equipment and technology handover, information handover, discussion and plan. This allowed the team to focus on specific transfer issues and markedly decreased technical handoff errors.

Task Allocation: In racing, each team member does only 1 or 2 tasks. Need I make a reference to medicine? In the study protocol, when a transfer took place, people were assigned a specific task who were identified to receive the critical information about their task, ie ventilator, pumps, drains, monitor, etc.

Predicting and Planning: In racing, there is a method used called Failure Modes and Effects Analysis which allows breakdown of tasks and risks to predict problems. Use of a similar tool allowed these researchers to identify and refine safety checks and develop tools such as a ventilator transfer sheet to streamline the transfer of care.

Discipline and Composure: In racing, there is little to no verbal communication; the whole stop only takes 7 seconds. In medicine, handovers can be chaotic, with multiple people trying to give information to others at the same time. The nurses rarely know what the docs say to each other and vice versa. Having the discipline to allow one practitioner to talk uninterrupted can minimize the loss of information during a handoff.

Checklists: Well established in racing and aviation. I'll be posting more on this later, lots more. . .

Involvement: More of an aviation trait, but all team members are trained to speak up with concerns. In medicine, we have a long way to go to improve this area. Simply encouraging the behavior as part of the protocol was how this particular study addressed the issue.

Briefing: Again, well established in racing and aviation. In the emergency department, I rarely see this employed. Multidisciplinary handoffs are far from the norm and are potentially a rich area for improvement.

Situational Awareness: The previously mentioned lollipop man has this responsibilty in racing. Being at the front of the car, the driver doesn't go until he or she gives the okay. Identifying one person to stand back and make safety checks when handoffs occur or other chaotic processes such as codes can improve the overall situational awareness.

Training: Racing and aviation are fanatical about training and repetition. Despite being experts, the pit crew practices time and time and time again to improve their skills. Pilots routinely make trips to the simulator to practice the usual and unusual situations they may face. In the study, they found that staff turnover limited the ability to train. This situation is so common in emergency medicine as well. Instead of long and grueling training, this study focused on a simple process that could be learned in 30 minutes and made helpful training sheets available at EVERY bedside as a memory prompt.

Review Meetings: In racing and aviation, review of past actions is a way of life. Creating an open forum to frequently review problems and suggest solutions will promote lasting change in medicine. Everyone from residents, nurses, docs, and ancillary staff should be encouraged to attend and provide input.

Handoffs are a way of life in emergency medicine. It's pretty easy to look at this study and see parallels that would make our practice safer for patients. Simply focusing on improving the culture in one or two of the themes above will yield exciting dividends in the long run. Are you in?

Reference:

Catchpole KR et al. Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality. Paediatr Anaesth. 2007 May; 17(5): 470-8. PMID: 17474955

For My Mentor: My Favorite Apps

If one wanted an example of a positive deviant, i.e. a person on the leading edge of the bell curve, in emergency medicine education, Michelle Lin, MD would top the list of potential candidates. I am very fortunate to look to her as a friend and virtual mentor as I develop as an academic clinician. She has her own amazing blog: Academic Life in Emergency Medicine, which you need to check out now if you haven't already. Recently, she put out a request for clinicians to report on their favorite apps for a presentation she is working on. I figured this would be the least I could do to help out.

In no particular order:

DropBox: This is a great "cloud" file hosting app and program. Download both to take full advantage of the program. The program works just like a usual folder on you desktop but once a file has been placed inside, it syncs with the cloud and your files magically appear on any computer or device that has dropbox installed. Also, you can share your files. I recently uploaded an entire folder of "Resident as Teacher" articles to share with another EM guru. This prevented me from having to attach lots of files to an email and send them to him.

Evernote: Michelle has talked about this app at length but I figured I would share my .00002 cents as well. Evernote is my go-to note program. Like Dropbox, use the desktop program in addition to the app. It allows you to add PDF files, pictures, and free text and then put them into notebooks, tag them with memory clues, and free text search them. Here's the real sweet part though: the company has made add ons for your internet browser that allows you to "clip" an entire webpage of portions of text from online and saves it to the program automatically.

Medical Mnemonics: This program is a lot of fun. I often have a hard time remember mnemonics which makes them more difficult to use. Not any more. This app lists them all and also allows you to use your own. You can also search by condition: Ranson Criteria anyone? GA LAW comes right up. For more "mnemonically" oriented learners, I can share this with them to their hearts content.

MediMath: The app has calculators galore. It's almost as good as mdcalc minus the clinical risk stratification tools that are located on that site. Its interface is quick and easy to use.

Persiflagers Annotated Compendium of Infectious Diseases: One of my two antimicrobial guides. This app is written by an infectious disease specialist with a wonderful sense of sarcastic humor that he writes into his advice on treatment in the form of Rants. For example: Necrotizing Fasciitis and hyperbaric therapy, "I said it was great for the bends, but primarily served to make hyperbaric doctors richer. Why do you ask? Turns out he was the medical director for a hyperbaric chamber. Oops. Open mouth, insert foot." Beyond the therapy, his recommendations are up to date and cover the spectrum of possible causes.

Radiology 2.0: One Night in the ED: This is a case based app that reviews pathology on abdominal and pelvic CT scans. The images display beautifully on the iphone and even better on the ipad. If you have a learner who wants more, sit them down with this for a few minutes.

Perfect OB Wheel: The best OB Wheel I've found. It lets you enter the due date, LMP, or even the current weeks and gives you the remainder of the missing information. It also gives you an estimate of the fetal size. Pretty cool.

PediSafe: This one is an ipad only app but is really pretty spectacular. It takes the Broslow Tape colors and gives you all the information up to 99 kg! That would be a VERY big kid. Apps like this one really have helped make practicing medicine a little safer.

Neuromind: Written by a neurosurgeon, this app contains all the neurological scores you need. Also included are some nice anatomical diagrams to demonstrate relevant anatomy, dermatones, etc.

GoodReader: This is another ipad only app but is my favorite reader. Since our curriculum is so heavy on literature, I read a LOT. This program helps me to save paper and my notes since I can highlight, markup, and add notes to the PDF files.

Eye Handbook: A great reference to all things ophtho. I like the toolkit is contains as well as atlas to help demonstrate the exam findings that I discuss with my residents.

Epocrates: I think everyone knows this app and either uses it or chooses not to. I'm in the former group. I like the fact that I can do an interaction checker through it as well.

Stroke Track: Written by an EM physician and it shows. The app gives you all of the contraindications to tPA use and puts a real time NIHSS calculator in your hand. It even gives you hints on how to perform the exam!

SlowMo: I learned about this app from Scott Weingart, MD, of EMCrit fame. A few podcasts back he talked about vestibular stroke and physical exam findings. One of the problems with the exam is actually seeing what the eyes are doing. This app allows you to slow down a video taken on your iphone/ipod touch and see exactly whether the reflex is expected or pathological.

EMRA Antibiotic Guide: My second go to antibiotic reference. Simple, well thought out, and designed by the future leaders of our professional. It's updated annually.

Emergency Medicine Ultrasound: A nice little gem of an app. I recently came by this one and have found it useful to teach residents about ultrasound. It includes video in addition to still pictures and text.

Clinical Oversight: Conceptualizing the Relationship Between Supervision and Safety

Have you ever stopped and wondered what good clinical supervision means? Supervision is one of those concepts in academics that we are expected to do with little, if any, guidance. Many factors within medicine have led to an increase in the expected levels of supervision recently. Work hours restrictions, Medicare rules, and a call to arms about patient safety have prompted calls for more and better supervision. The problem is, "What is appropriate clinical supervision?" This article took a qualitative observational research approach to looking at this exact problem with a goal of defining a conceptual model of clinical supervision.

Methods:

This study uses a qualitative approach referred to as grounded theory methodology. Participants were faculty and teaching teams from the emergency department and general medical floor. To minimize the Hawthorne effect, incomplete disclosure was employed, i.e. the participants knew they were being observed, but they didn't know what was being observed. Observational data were collected and refined over a single calendar year.

Results:

Their analysis revealed that supervisory activities related to patient care are distinct from other types of supervision, such as formal teaching. These activities seem to fall along a continuum from less to more involved.

Routine Oversight: These are activities planned in advance and expected by all involved in the clinical setting. In a sense, routine oversight is simply monitoring the trainees activities. In emergency medicine, this type of oversight is used when hearing case presentations from students or residents followed by probing, refinement, and confirmation of the management plan.

From my perspective, this is the bread and butter supervision that we all do from shift to shift.

Responsive Oversight: In this type of oversight, the direct involvement of the supervisor increases either as a result of a direct request from the trainee or in response to a concerning clinical situation. This can involve repeating history and exam findings, observing trainees in action, or coaching learners at the bedside (i.e. supervising procedures).

Triggers that increase supervisor vigilance often result in responsive oversight. These include:

• Clinical Cues: unexpected changes in patient conditions, unstable patients
• Information from a secondary source: family or nursing concerns brought to the supervisor
• Language Discrepancies: Clinical presentation not matching clinical data (labs, radiology, etc)

I find that this level of supervision varies from learner to learner depending on my trust in the trainees abilities and confidence.

Direct Patient Care: This is the highest level of supervision and often is initiated when the supervisor realizes that the clinical situation has exceeded the learners ability to manage the care of the patient. This may happen quickly, as one would expect when working with medical students, or may happen only in extraordinary situations with senior trainees.

Personally, when working with senior trainees, I find that this becomes more of "Team Management" with the senior assuming control of some tasks while I handle other tasks to manage a critical ill patient.

Backstage Oversight: The final type of oversight occurs with little trainee knowledge. Backstage oversight includes seeing patients independently of the trainees (we do this a LOT in emergency medicine) or reviewing pertinent patient data such as labs or radiology in the absence of learners.

Final thoughts: As a junior faculty member, finding the right balance of supervision to learner autonomy has been a challenge. This article confirms what we probably all do in our day to day clinical practice. It demonstrates that supervision is a fluid process involving an ebb and flow of involvement that is linked to learner and patient factors. Increased awareness of factors that should prompt us to upgrade our level of supervision will benefit our learners and potentially make patient care a little bit safer.

Reference:

Kennedy TJT, Lingard L, Baker, GR, Kitchen L, Regehr G. Clinical Oversight: Conceptualizing the Relationship Between Supervision and Safety. J Gen Intern Med. 2007 Aug;22(8):1080-5. PMID: 17557190

Finding a Niche

What is a niche and how do you find it?

In academic emergency medicine, faculty often have areas of "interest." The topics covered are as broad as the practice of emergency medicine. I have to admit that nailing my interest down to one of two topics has been near impossible until recently. I've always been a jack of all trades, master of none.

If you've ever attended the CORD or SAEM scientific assembly then you would have had the opportunity to sit down and listen to one of the Jedi Masters of emergency medicine education, Amal Mattu, and hear him speak on the topic of "Finding Your Niche." His advice has proven to be helpful and I would like to share some of it with you now.

Why should you develop a niche? This is all about adding value: to yourself, your department, and your program. Having an area of expertise will often lead to opportunities for research, teaching, or speaking. Down the road, this will help with promotion, but for the present, you have the opportunity help your department grow.

How do you choose a niche? Sometimes, it chooses you. Start by talking to your chair or program director. This is how I fell into my growing niche: patient safety. They often have an idea of what the department or program needs and can make suggestions. They also know your strengths and may suggest a niche that you didn't even think about. Initially, this should be a broad area that will likely become narrow once your expertise in the area increases. A word of caution though, be careful when picking a niche that is saturated with experts. While you can still develop a niche in these areas, gaining renown and standing out from the crowd will take longer.

How to you develop your niche? This is where the rubber meets the road. First, maintain your expertise in general emergency medicine. After this, its time to create a plan for gaining expertise. Find a mentor to help guide you through the process. Look up and read everything you can in the EM literature and beyond related to your niche. Attend national meetings and make sure to review the abstracts and presentations from others within you chosen topic of expertise. Consider a fellowship or, create you own! Work on learning to write, research, and present so that you can gain recognition for your expertise. Finally, seek out opportunities to teach your niche at the local, regional, and national level.

Finding and building a niche is not easy. It has taken me 3 years to narrow my broad interests sufficiently enough to begin moving forward. At first, my interests included cardiac emergencies, ultrasound, teaching, wilderness medicine, and a few others. Time and study has narrowed it to teaching and patient safety, two topics that actually groove together nicely.

To my readers: What is your niche and what advice can you give to others to help them find their niche?

Better

Have you ever wanted to be better? Better at your job? Better at sports? I think that we can all relate to the desire to be better. In emergency medicine, learning to be better is the name of the game. Better at diagnosis, better at management, better at flow. The list goes on. This desire to become better is the inspiration behind this blog. Through future posts I hope to explore topics related to this noble goal. Specifically, I plan to address topics that are near and dear to me: developing as a faculty member in emergency medicine, patient safety, and leadership.

I would be remiss if I failed to mention a book which opened my eyes to the possibilities ahead. "Better" by Atul Gawande is a must read for physicians determined to become "positive deviants." The book itself is a quick read contained Dr. Gawande's wonderful prose, but the real gem is in his afterward where he explains his personal thoughts on some simple steps to take to become better. These are:

1. Ask the unscripted question. How important is this in emergency medicine. The pressure to constantly see more patients, "move the meat," etc leads us into a habit of paring our conversations to the minimum. Taking a few seconds to ask a simple question, completely unrelated to the visit at hand can really change the tone of the encounter. Family, hobbies, previous experiences all can provide topics to ask about. I've had the pleasure of working with a resident who was very good at this habit. Patients seemed universally pleased with his care, just because he made himself more human and demonstrated to the patients that he cared. As the old quote states: "They don't care how much you know until they know how much you care."

2. Don't complain. Whoa. Easier said than done. He makes the point quite clearly though that complaining has the ability to change our mood and the moods of those around us. It seems that we never lack topics to complain about from consultants who are rude and demanding to patients who behave likewise. It sometimes is too easy to complain. This will be a skill that takes some practice for sure. . .

3. Count Something. Such a simple suggestion! One can not know how to become better if we don't have a starting point. There are so many things we can count in emergency medicine (some are counted for us). Pick something small but interesting and start to run a tally. Soon enough, you'll likely uncover patterns or trends. These will in turn lead you to solutions on how to improve, how to become better.

4. Write something. It doesn't have to be much. Like so many other people, you can write a few lines for a blog or publish an article in the local emergency medicine newsletter. Writing helps to focus our energy and forces us to step back and think about what we want to say. There is no better tool for guiding reflection than picking up a pen or keyboard and beginning to write.

5. Change. It sounds so simple, yet feels impossible at times. To be a positive deviant though, you must change. You don't need to be the first, but you don't want to be average either. To become better, you must recognize shortcomings and simply change.

These are only some of many ideas of what it takes to become better. Check back in the future and join me on this exploration into becoming better in emergency medicine!