Powerpoint tips from someone who knows a lot more than I

Great advice for your next presentation:

You Suck At PowerPoint! from Jesse Desjardins - @jessedee

Blending Learning

This TEDx video features Dr. Joseph Kim discussing his recommendation for improving the relationship between teacher and learner.  While his talk is geared towards undergraduate university teaching, there are several pearls for medical teachers.

In order to improve teaching, he points out that we need to:

1. Structure courses to take advantage of technology:

This topic is getting a lot of airtime lately.  It even made the New England Journal of Medicine.  Blended learning, flipped learning, individual interactive instruction, asynchronous learning.  While the exact methodology employed varies, they all share an important principle: Give the learner the material on their time, at their pace.

Critics will cite difficulty with verifying completion of the material, but I think they're missing something.  Likely, they still depend on synchronous lectures to fill the valuable class time.

By putting the lectures online you take advantage of repetition, giving students the ability to master the material.  You also take advantage of adult learning by the learner the ability to skip forward if the material is too basic.

2. Rethink how we use class time effectively

Now Dr. Kim gets at the crux: we need to stop wasting learners time.  If the session fails to add value to their learning, it is wasteful.  Salman Khan, of Khan Academy fame, discusses how using video allows teachers more time with the learners in another powerful TED Talk.  By moving from the "Sage on the Stage" to the "Guide on the side" the teacher is now in the position to assess the learning and help the students master the material.

It is important to recognize that class time is now used to explore issues in greater depth.  Class time is now longer "lecture time" but is used for small groups, problem solving, or projects.  As Dr. Kim points out: learner build meaning and add a personal context to the material

The biggest threat to this type of teaching is time.  I've had the good fortune to spend the last five years teaching at a residency that utilizes this approach in a low tech fashion: assigned reading.  Each week our learners are assigned 50-100 pages of journal articles about a specific topic, such as head trauma, cardiac ischemia, or pulmonary infections.  The faculty then lead a two hour discussion every week about the topic.  We utilize many methods for leading the discussion: creating mind maps, reasoning through cases, guided discussions, role playing, etc.  It take a phenomenal amount of time to read the material and design the learning experience, but the learner engagement is phenomenal and our boards scores aren't too shabby either.

3. Make the pursuit of scholarly teaching a priority

What Dr. Kim is really getting at is the Scholarship of Teaching and Learning (SOTL), a term popularized by Ernest Boyer in his book Scholarship Reconsidered.  Educationalists view teaching as a continuum:

Teaching: routine instruction; teaching the way we were taught with little insight into how to improve education

Scholarly Teaching: Teachers who "inform" their own teaching; use pedagogy to improve practice; obtain feedback from students, outside/peer evaluators, and self-reflection to improve practice

SOTL: The actual research into what works and doesn't work in education

SOTL provides the evidence for evidence-based education, hence the need to make it a priority.  With SOTL, we can:

Improve learning outcomes
Improve instructional design
Improve teaching and faculty development

SOTL is a big topic, and I'll be writing on this more later.

So, using technology to flip the classroom, empowering students to learn, and actively investigating what works and doesn't work is the way forward?  As Dr. Kim concludes, by focusing on these three issues, "we can make informed decisions that will lead to better educational design and sound education policy."  I can't agree more!

Other References:

O'Brien, M. (2008). Navigating the SoTL Landscape: A Compass, Map and Some Tools for Getting Started. International Journal for the Scholarship of Teaching and Learning. 2(2): 1-20.

Technology is constantly advancing.  New tools arrive on the scene each year, and often we don't know whether to ignore them or incorporate them into our teaching.  The slideshow below is a compilation of 100 tools that can be used help our students understand content. Take a look and let me know what tools you use in the classroom. How do you determine whether they're tools or gimmicks?

Top 100 Tools for Learning 2011 from Jane Hart

An Introduction to Medical Photography

I've always been a bit of a photobug.  I blame my grandmother who gave me my first camera when I was just a young kid.  Back in those days, we had this stuff called film.  The pictures were unpredictable and expensive, so I only took pictures of things I felt were important.  Fast forward 20 years, and the technology is incredible.  Digital photography is everywhere!  Cameras, phones, and maybe even glasses soon.

With the explosion in technology, it's very easy to take pictures of clinically relevant cases.  Images are a great teaching tool, but you need to get the right picture.  A few years ago, I attended the SAEM workshop on medical photography taught by Dr. Jason Thurman.  The course is great and if you have the chance to attend, I highly recommend it.  Here are some pearls I gleaned from their teaching as well as some additional hints to improve your skills.

1. It all starts with consent.  Like any procedure, to take a picture for educational purposes, you need to obtain consent.  This is likely to be institution specific.  Check with you institution to determine if you need an additional form.

2. What equipment do you need? These days, the quality of camera phones has improved dramatically.  That being said, dedicated cameras still have more functionality.  Digital SLRs offer the greatest functionality, but also cost a significant amount.  My advice would be to start small and if you think this is for you, move up to a dSLR.

3. Know the basics

Exposure: The amount of light that hits the sensor.  In photography this is controlled by the aperture and shutter speed.  These controls have a reciprocal relationship.

Shutter Speed: Simple; the amount of time that the shutter is open, expressed as a fraction of a second (1/60, 1/90).  Slow shutter speeds mean blurred motion if the subject is active.

Aperture: The opening in the lens that allows light through, expressed as the f-stop number; like gauge: bigger number = smaller opening.  Aperture is REALLY important because it controls the depth of field, which is basically the amount of the scene that is in focus. The smaller the aperture, the greater the depth of field.  This comes into play when taking close up or macro photos (like the eye above).  The closer to an object you are, the narrower the depth of field becomes.  Since you'll have to use a small aperture (f16 or smaller) your shutter speed will likely be slow, hence, you'll need a flash.

Gray World Assumption: All camera light meters try to make the detected scene 18% gray based on some light physics.  Because of this, scenes that are dark or bright end up messing up the exposure. (Think about the last time you tried to take a picture in bright sunlight or snow).  To compensate for this, watch the sensor and adjust the f-stop + or - one stop.  Fortunately with digital photography, we can view the pictures and make the adjustments on the fly (burned up a lot of good film trying to master this technique)

Lighting: There are 3 types of lighting: axial, texture, and flat.


Axial lighting involves holding the flash parallel to the barrel of the lens.  This reduces harsh shadows that might be created if the flash was placed in the shoe.  The image of the eye above was taken using axial light

Textural lighting adds dimension to an image by placed the light source at a 30-45 degree angle off to the side.

Image of a child with chicken pox taken using texture lighting

Flat Lighting produces the most accurate color.  It's accomplished by placing the flash on the side of the barrel or using a special flash called a ring flash.

Image of erythema migrans taken using a ring flash to produce flat lighting

4. Control the background: remove any distractions! (These, incidentally, can be an identifier)  Things like jewelry, tattoos, clothing all take away from image quality.  Place the body part in question onto a solid clean background (leftover surgical towels work AWESOME for this).  If possible, add a ruler to demonstrate scale.

Get Close, control the background, and use a scale

5. Get the right views: Think like a radiologist.  If photographing the face, get an AP, lateral, and oblique.  Think similarly for the rest of the body.  Don't be afraid to get a standard shot and then zoom in to focus on the pathology.

Now get out there, take a camera, take lots of pictures, share them, and Vive le FOAMe
Google +1

Hack Your Education

Can you learn medicine in just 1 year?  Unlikely, but if it's possible to cover the content of a MIT computer science degree in 1 year, then anything is possible.  In this talk from TEDx Eastside Prep, Scott Young, a self described "speed reading, vegetarian, holistic learning, productivity hacking, recent university graduate," discusses his views on the future of learning and how it will be students, not institutions, who drive the disruptive changes forward.  Watch and enjoy!

Back in the Saddle

"If you fall off your horse, get right back in the saddle."

It's been too long since I last sat down to write.  I've plenty of great material to share.  I've spent the last 5 months studying medical education as part of a master's degree program, so stay tuned.  We'll be talking a LOT about medical education.

In the mean time, I wanted to share this video of Atul Gawande, author of The Checklist Manifesto, as he talks about the need to focus on becoming a medical Pit Crew instead of focusing relentlessly on maintaining our autonomy.

Great stuff to ponder as we think about needed reforms in medicine and medical education.

Advice to New Interns

It's that time of year again.  The time of the year that you see the new interns scrambling through the department, eyes wide as saucers, running scared, and hungry for experience.  As an educator, it's a refreshing time to be at work!

With the start of the interns, many blogs have been providing advice to help them on their way to a successful career.  Some of the better examples are here and here.

But this is emergency medicine, and while the given advice still applies, I wanted to add a little more, just for our learners.  When I began my residency, one of our attendings handed us a copy of "The Ten Commandments of Emergency Medicine."  I still have my original copy and now and then I hand it out to my residents.  As I dusted it off this year, I realized that the article was written in 1991!  Are the commandments still relevant?  Read on. . .

Secure the ABC's

Relevance: High

We pride ourselves on being the masters of resuscitation.  Mastering the patients' ABCs should be the priority the moment you walk in the room.  Simply walking in and observing your patient can give you an amazing amount of information.  Is the patient able to speak full sentences? Are they talking at all?  Do they make sense?  How is their color, work of breathing, pulse, etc?  If you find a problem, fix it first.

The authors of the article expand the ABC's mnemonic a little ABCD2EFG2.  While most of these are familiar to us, the addition FG2 is useful to remember:

Fetal Heart tones: a needed vital sign in pregnant patients
RhoGam: Consider getting the type and Rh in pregnant trauma patients
Guardrails: Confused and elderly people fall out of bed far too often.  If you put them down or find them down, then take the 10 second and put them up!

Consider or give naloxone, glucose, and thiamine

Relevance: Glucose, high; others moderate

Any patient with altered mental status or a new neurologic deficit deserves a fingerstick glucose.  Almost every one of us has forgotten this truism once.  The embarrassment experienced by performing the stroke workup only to get the critical glucose level back from the lab is never forgotten

As for naloxone, consider it, but give it in smaller doses if you give it at all.  Remember "Priumum non Nocere."  After witnessing an addict in iatrogenic withdrawal once, I'm more likely to give 0.2 to 0.4 mg or simply intubate the patient and wait.

Thiamine is safe and potentially helpful.  While we still give it to the patient with alcoholism, the population that seems to need it the most these days are the post-gastric bypass population.

Get a pregnancy test

Relevance: Very High

I remember a story about a seasoned senior EM attending being asked what the biggest development of his career was.  The answer?  The urine pregnancy test.  Any female, age 10-55, deserves this quick test.  You'll lose count of how often your workup will be changed by the results of this test.

Assume the worst

Relevance: Very High

Amal Mattu likes to quip, "When emergency physicians here hoofbeats, we think lions, and tigers, and bears."  We aren't after the zebras.  Whatever can kill the patient we rule out first.  Only then do we move on less severe and more likely conditions.  Check your attitude at the door.  Don't get hung up on the 20/10 pain while the patient sits eating a bag of chips.  Take them at their word, do your best exam, and give them the benefit of the doubt.  You will be humbled time and time again by the seemingly stable patient who tries to die, sometimes successfully, in front of you.

Do not send unstable patients to radiology

Relevance: Moderate

This is one area that has changed in recent years.  It no longer takes as long to get studies done, and sometimes that septic elderly patient will need a CT to find the phlegmon of infection.  I would change the commandment to: Do not send unstable patients to radiology alone; you must go with them.  If conditions exist which can be fixed first then do so: secure the airway, begin fixing volume problems, etc.  If an alternative exists, such as bedside ultrasound, use it to your advantage, but don't fail to make the diagnosis simply to avoid taking the patient out of the department.  Oh yeah, and when you take them, take the right equipment too.

Look for common red flags

Relevance: High

I always get a little but of a laugh when reading this one.  It talks about FOUR vital signs!  With pulse ox and capnography and pain (really?) we have more vitals than we know what to do with!  The point is simple: look at the vitals and explain them.  Your history will gain you more than an entire battery of labs.  Ask about comorbidities.  Ask about risk factors; that patient with an IV drug addiction who has back pain and a low grade fever isn't looking to score narcotics.  Remember the extremes of age.  Pay particular attention to revisits.  These patients are giving you a second or third chance to make the correct diagnosis.  And remember, before anyone goes home, they must be able to eat and walk.

Trust no one, believe nothing (not even yourself)

Relevance: High

Anything that any tells you, in person, or in writing, might be false.  The "frequent flier" may be in the department often, but also might have real disease.  Always start with a open mind, talk to the patient, examine the patient fully, and look at every image and study yourself.  Remember, the cardiologist and radiologist aren't seeing the patient and can miss significant findings.

The same advice applies to your teachers, and to this post.  Be skeptical but not cynical.  Take the time to check the facts, read the literature yourself, and try both old and new techniques.  Did you find an absence of evidence about a treatment?  You may have just found your research project!

Learn from your mistakes

Relevance: High

I've learned far more from my mistakes than my successes.  We all make mistakes.  The important part is to learn from them.  Possibly even more important is learning OF them.  Emergency medicine is particularly prone to an absence of feedback about our mistakes.  Did you have an uncertain diagnosis?  Look into the case and follow up on the patient after discharge.  Learning about our errors is essential to improving our practice.

Since we all make them, try not to judge others by their mistakes.  Learn from their errors, but look deeper as well.  Were there any system issues, communication errors, etc, that may have contributed to the error?  Can any of these be fixed to prevent the error from occurring again?

Do unto others as you would do to your family (and that includes coworkers)

Relevance: High

You'll more often do the right thing when you follow this maxim.  Respecting our patients, colleagues, and coworkers demonstrates the caring attitude expected of a good physician.  And remember this if you decide to be rude: "The toes you step on today might be connected to the backside you need to kiss tomorrow."

When in doubt, always err on the side of the patient

Relevance: High

We see the patients that society and even healthcare tend to forget: the homeless, the addicted, the psychiatric, etc.  We need to be the ultimate patient advocate.  We strive to relieve suffering.  To do what is right for the patient, we need to consider the course of action that would minimize their suffering and keep the patient safe.  This will unfortunately put us at odds with our administrators, and at times, our peers, but if we fail to take care of our patients, then no one else will either and we will have violated our sacred oath.


As you can see, despite being 20 years old, these "commandments" still have a significant amount of relevance today.  For sure, they could be added too, but for the start of your career, paying attention to this short list will help you to save lives become a better emergency physician.