A Practical Checklist?

It seems like checklists are the "in" thing in patient safety right now.  It makes sense; follow this list of things and you won't hurt patients.  The problem is, they only work when you use them.  

While doing some background research on checklists in prehospital settings, I found this gem in the open access Scandinavian Journal of Trauma, Resuscitation, and Emergency Medicine.  The article is the print version of an oral presentation, so it isn't "science" but it is practical.  Prehospital airway management is a hotbed of controversy right now.  The data seem to point to worse outcomes, delays to definitive care, and decay of skills.  With all of these problems, anything to make the procedure safer is a welcome addition.  Enter the "checklist."

This group of prehospital providers created a novel approach to their airway management.  They took a disposable plastic sheet and printed it up with the following graphic:

Notice anything cool?  While it still has a text driven checklist (on left), the visual representations offer a rapid and convenient way to prepare for intubation.

Their checklist approach is broken into  the following areas:

Pre-anesthesia checklist

Monitoring:

Equipment:

Drugs

Staff

It would be easy to replace their text with the more familiar "P's" of intubation:

Preparation

Positioning

Preoxygenation

Pretreatment

Push the Drugs

Placement with Proof

Post-Intubation Management

On the far right you'll also notice a box for induction medications and maintenance medications. 

The thing I really like about this list is the visual representation of the equipment.  Just looking at it, I believe that it would really decrease the time in the "preparation" phase.  Look at what it includes:

Equipment for bag ventilation: oral and nasal airways

Drugs for the procedure (I would like to see these boxes include dosing guides for the common medications)

Equipment for intubation:

2 laryngoscope handles and blades

2 different sized endotracheal tubes

syringe

tube holder

qualitative end tidal CO2 detector with BVM connector

Backup Equipment: 

Bougie

LMA

This is HUGE.  How many of you out there really take the time and get your backup equipment out before you need it?  This demonstrates true foresight.

The only thing that I see missing is the suction.   

When working clinically by myself or with the residents, I'm constantly running through a little mental checklist that includes most items on the above list.  Being able to pull out a little plastic sheet that has the list already prepared would free my mind up to think ahead and address other important issues with the sick patient in front of me.  I can easily see how this has potential to really make both prehospital and emergency intubations safer.

Below is a video demonstration of the checklist in action:

Reference:

A pre-hospital emergency anaesthesia pre-procedure checklist R Mackenzie , J French, S Lewis and A Steel from Scandinavian Update on Trauma, Resuscitation and Emergency Medicine 2009 Stavanger, Norway. 23 – 25 April 2009 Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2009, 17(Suppl 3):O26

Great Video for Those Beginning Academic Careers

I was perusing my stack of journals the other day and came by a "Dynamic Emergency Medicine" Article in Academic Emergency Medicine.  Typically this section contains useful videos about new procedures and has a very heavy ultrasound slant.

What I found instead in this particular journal was a link to a 40 minute video interview of some of the leaders in Emergency Medicine, people at the leading edge of the bell curve.  It's a goldmine of good advice for those with interest in becoming a better academic physician.

Take a look and let me know your thoughts!

Interviews with Leaders in Emergency Medicine from Academic Emergency Medicine on Vimeo.

So You Want More Feedback?

Learners, do you want the truth?  Can you handle the truth?  In order to receive better feedback from your teachers, you need to take an active part in the process.  Here's how:

1. Remember that not all feedback is positive.  You need demonstrate a higher level of maturity and self awareness in order to improve.

2. Create your own learning goals and share them.  If your teacher knows what you want to learn, they can provide more focused feedback.  Don't forget to ask your supervisor for input when creating goals in order to keep you goals realistic.

3.  If you're not getting feedback, ask for it.  Emergency physicians are action oriented and a passive leaner will get left behind.

4.  Clarify.  If your teacher says, "You did a great job today," don't be satisfied with your performance.  Ask them what you did well and what needs improvement.  You won't improve if you don't know where you need improvement.

5. If you get some negative feedback, understand that it is meant not as a personal attack, but an opportunity to improve.  Find out from you teacher what the issue is, why it is an issue, and what you need to do about it.  If there is an interpersonal issue (rare occurrence) with the teacher, ask your advisor to help you work through the issue.

6. Don't forget to discuss your success as well as what needs improvement.  You don't want to lose those skills that you do well.

7.  You are probably your harshest critic.  Don't be too hard on yourself.  Take the credit when you do something well.

8.  Be aware of yourself.  If you are feeling stressed, rushed, or simply tired, don't be afraid to ask to reschedule for a time when you have your mental faculties in line.

Your teachers want you to succeed.  Sometimes we're equally rushed or simply afraid of giving you the advice you need.  Following the above list will help us maximize your potential.

Reference:

Rider EA, 

Longmaid HE. 

Feedback in Clinical Medical Education: Guidelines for Learners on Receiving Feedback. JAMA. 1995; 274(12): 938.

Failing at Feedback?

In the last post, we discussed a some background and general tips on feedback, focusing on the  seminal article by Jack Ende, MD.  Unfortunately, despite all of the hype and hoopla surrounding feedback skills, learners still complain about not receiving enough feedback.

Problems with feedback identified in some studies include:

Too teacher-centered
Too much positive skew
Low cognitive level (fails to engage learner)

So why are we failing at feedback?  Perhaps the problem lies with the learner and not the teacher.  In a 2009 article titled "Why Medical Educators May Be Failing at Feedback" Bing-You and Trowbridge offer an alternate view on our failure and suggestions for improvement.  In their article, they highlight 3 key problems with the learners:

1. Poor ability for self reflection


2.  Overpowering influence of affective reactions to feedback


3.  Lack of adequately developed metacognitive capacities

Lets take a look at each of these.

Physicians are notoriously bad when it comes to self-reflection.  We tend to overestimate our abilities.  Just look at the difference between pilots and surgeons on the perception of the effects of sleep deprivation.  Even worse, the most deficient performers may be have the least insight into their incompetence.

So what happens when these learners are faced with negative feedback?  Pure emotion.  The feedback becomes a personal attack.  The feedback may trigger emotions such as guilt or anger.  The learners unconsciously fall back on ego defenses (denial, distorting information) that prevent a fair assessment of the feedback.  Knowing this, it makes sense that learners who have negative reactions to feedback find it less useful.

Learners also need strong metacognitive skills to appropriately process feedback.  Metacognition is a the process of "thinking about thinking."  Reflection is a valuable metacognitive skill that students can use to critically evaluate the feedback and apply the needed changes.  A lack of this skill probably accounts for some of the overconfidence displayed by learners.

So how do we overcome these barriers and get through to the learners?

We need to recognize the affective component of feedback.  Knowing that negative feedback will likely invoke some degree of ego-defense, we can use guided reflection to help our students process the information at a metacognitive level.  Using follow-up activities to reinforce the positive changes may also help overcome the negative emotions.

There is a growing body of literature about how to teach metacognition.  In emergency medicine, we constantly practice procedures.  Why not teach metacognition early?  Practice with the metacognitive skills students will increase their self awareness and, hopefully, their self-assessment skills.

We need to take another look at feedback.  Efforts to improve feedback need to take these learner factors into account.  We owe it to our learners and our patients.

Reference:

Bing-You RG, Trowbridge RL.  Why medical educators may be failing at feedback.  JAMA. 2009 Sep 23;302(12):1330-1. PMID: 19773569 [PubMed - indexed for MEDLINE]

What is the Deal with Feedback?

"Anyone willing to be corrected is on the pathway to life.  Anyone refusing has lost his chance."

-Proverbs 10:17

"We are training a group of physicians who have never been observed"

-Ludwig Eichna, MD

Today marks the first of a series of posts on feedback.  I had initially planned on a single post but as I dug deep into the literature, I realized that there is far too much good stuff for a single post.  

Feedback is such a hot topic in the medical education literature.  We pay a lot of attention to it, yet students still rate our feedback skills as mediocre at best.  They want feedback, and from what I've seen clinically, they NEED feedback.  Unfortunately, as in many educational endeavors, we haven't been trained in appropriate techniques.  Even with training, learners will often miss the fact that they've even received feedback.

Feedback is an essential component to improvement.  Without insight into our failures and successes we fall into a routine and make the same errors over and over.

So what is feedback and why does it matter?  

August 12, 1983: A Call to Arms.  It was on this day in JAMA that Jack Ende, MD, published what is possibly the most referenced article on feedback.  His work is still relevant today.

He defines feedback as "An informed, nonevaluative, and objective appraisal of performance that is aimed at improving clinical skills rather than estimating the students personal worth."

The above definition highlights some keys to good feedback:

Informed and objective: Feedback is based upon first person observations of skills, behaviors, and attitudes.  Without this first person account, a student will tend to discount the value of the feedback.  

Nonevaluative: Feedback is much different from evaluation.  Evaluation is a summative judgment that occurs at the completion of a period of time.  Feedback is formative; it allows the learner to identify areas in need of improvement in real time without fear of a negative evaluation.

Aimed at improving clinical skills: The skills we need to master to become a competent physician are so vast that it is almost overwhelming.  Feedback helps to accelerate the process by offering tips and pearls for improvement.

Dr. Ende also includes his guidelines for giving feedback within the article.

Feedback Should:

1. Be undertaken with the teacher and the learner working as allies, with common goals

Start each shift by finding out what skills your learner wants to focus on.  This gives the learner an active role and allows you to create a metric for feedback later in the shift.  

2. Be well timed and expected

Feedback should be expected by the learner, or better, solicited by the learner.  An understanding on the teacher part is needed to avoid times when the learner is not overly stressed.

3. Based on first hand data

The best person to provide feedback is the person who observed the trainees performance.  This is often the same person experienced enough to make relevant observations of performance.

4. Regulated in quantity and limited to behaviors that are remediable

Keeping feedback short and limited to only 1-3 behaviors or skills needing improvement allows for the learner to make the needed corrections without overwhelming them with information.

5. Phrased in descriptive, nonevaluative language

Care should be taken to word the feedback effectively in a nonjudgemental fashion.  "Your differential did not include _____" is much better than "Your differential is limited and needs a lot of work."

6. Deal with specific performances, not generalizations

How often do you hear "Good job today" as the only feedback a student gets?  While good for the individual ego, this kind of feedback is useless when if comes to effecting improvement.  Focus on "actions" in order to provide more effective feedback.  Statements that allow for psychological distance are helpful as well.  For example,"The choice of sux for a paralytic in this dialysis patient didn't account for the possibility that he may have hyperkalemia" is better than "You completely failed to consider the contraindications to sux when performing RSI on this patient." 

7. Offer subjective data, labeled as such

When offering subjective data, make sure to use "I" statements, especially when offering personal opinions or reactions.  Consider the following: "While watching you perform the history, I felt that you were uncomfortable addressing the sexual history" vs "You looked uncomfortable addressing the sexual history."  The latter statement could give the learner the fear that their discomfort was on show for all to see.

8. Deal with decisions and action, rather than assumed intentions or interpretations

By focusing on the decisions or actions, and not the learner per se, the learner and teach can review the effects of the decision without assigning blame and inducing psychological protection mechanisms that would prevent to learner from accepting the feedback.

Feedback is an essential part of learner improvement.  While Dr. Eichna identified the problem with the lack of observation more than 30 years ago, he missed the fact that even when observed, faculty fail to offer insights for improvement.  This is where the value of good feedback skills becomes mandatory.  Without it, mistakes continue uncorrected, sound practice is not reinforced, and the students rarely become clinically competent.  Feedback is hard, but not as hard as some believe.  With practice, these skills will become second nature and you will make a difference in the care of thousands of patients.

Reference:

Ende J. Feedback in clinical medical education. JAMA. 1983 Aug 12;250(6):777-81. PMID: 6876333 [PubMed - indexed for MEDLINE]

Becoming a Better Mentor

Mentor and Telmachus, son of Odysseus

Mentoring has been identified as a critical factor in achieving success in many fields.  Unfortunately, like many skills related to the education of healthcare professionals, mentors rarely receive any training in how to become a better mentor.

This is unfortunate.  Faculty who have had an effective mentor report the following:

-Increased confidence

-Increased research productivity

-Higher career satisfaction

-Meaningful involvement in academic activities

-Development of close collaborative relationships

With all of the above benefits, it's surprising that their isn't more attention paid to developing more effective mentors.  As with many of the skills, we're often left to figure it out ourselves.  

So what skills are needed to be a better mentor?

While not an exhaustive list, some traits identified with being an effective mentor include:

1. Being knowledgeable and respected in their field

As I identify mentors for myself, this is a key trait that I look for.  But what about the typical residency mentoring structure?  Residents are often assigned to a random faculty member based on volume and availability.  One change we made to our program was to allow residents to self-select after the first 6 months.  Residents can also change mentors as they see the need.  As a mentor, I know that I constantly need to continue to improve my expertise within my chosen niche.

2. Being responsive and available to their mentees

This can be a difficult task with the demands of clinical emergency medicine.  We're often at work while the rest of the world goes to dinner, watches TV, and heads to bed.  Setting aside dedicated time to meet with the mentee goes a long way.  I try to make myself available on the residents education day.  They're already going to be around, so why not take the time to sit down with them and see how they're doing.

3. Interest in the mentoring relationship

This trait is somewhat of a no-brainer.  Why would you participate if you aren't interested? Take a deeper look.  Many times we enter the mentoring relationship with full intentions to make the relationship work.  While our initial interest may have been high, sometimes life happens and we let the relationship stagnate.  We need to constantly monitor the effectiveness of our mentoring relationships and know when to direct our mentees on to a more effective mentor if we can no longer meet our end of the bargain.

4. Being knowledgeable about the mentees capabilities and potential

This can only be acheived with time dedicated to learning about the mentee.  Fortunately, working with residents offers ample time to learn about them and observe their capabilities first hand.  When initiating a mentoring relationship, it is helpful to dedicate at least 30 minutes of time to a relaxed interview with the mentee to delve deeper into their interests, goals, and to learn about what they desire from the relationship.

5. Motivating mentees to appropriately challenge themselves

I constantly struggle with this skill.  Unlike teaching, where the challenge comes from the subject matter, challenging a mentee is more difficult.  How do you challenge your mentee?  I try to offer my mentees involvement in projects that come along.  Follow this up with your expectations, and you have issued the challenge that they need for professional growth.  Don't forget to offer support in additional to challenge.  It take just the right amount of each to grow.

6.  Acting as an advocate for their mentees

Failing to act on this trait came close to ending my academic career.  Early in my first year out of residency, I was mentoring a new intern who was having academic and professional difficulty.  In the ensuing months, I had a seat at the table for many remediation sessions.  Unfortunately, the whole situation became quite hostile.  What I should have done better was to take my concerns up the chain of command.  If I had been a better advocate for my mentee the situation would likely not have progressed as far as it did.  Like many things in life: Live and Learn.  As mentors, we owe it to our mentees to be their advocates.  If they need resources to get research done, we can help them get it.  If they're having difficultly, we can level the playing field to make sure that each party has equal representation at the table.

Mentoring is a difficult skill to master.  With all of the demands of being a clinician and faculty member, it isn't surprising that our skills are mediocre at best when it comes to being a mentor.  The above simple traits can help to guide you in the right direction as you continue to improve as a mentor to your students and residents.  

If you're already an expert, what traits do you feel are needed to be effective?

Reference:

Ramani S, Gruppen L, Kachur EK. Twelve tips for developing effective mentors. Med Teach. 2006 Aug;28(5):404-8. PMID: 16973451 

Toxic People

Do you ever have to work with people that just drain the life out of you?  I'm not referring to patients, but to those colleagues and consultants that you have to deal with on a daily basis.  I recently had the opportunity to sit in on a lecture given by Marsha Petrie Sue, author of Toxic People and The Reactor Factor.  I think we can all benefit from an understanding of her approach to reading people and managing conflict.

So who are the players?

Steamrollers: These are the bullies.  They come off as overbearing and try to make you feel small

Zipper Lips: "Verbal Anorexic."  They think of their knowledge as power and don't share it

Back Stabbers: People that are in it for themselves, always looking for an advantage

Know-It-All: These guys LOVE the limelight and have a hard time letting other contribute

Needie-Weenie: People with this type of personality are fearful of change and have a need to be liked

Wine and Cheeser: Nothing is ever right to these people.  They do make good Devil's Advocates though. . .

And how do you deal with them?

First, reflect on whether you react or respond.  You need to take the time to mentally step back and respond.  Reacting just gets in the way of progress.

Since Steamrollers try to be overbearing, first, use their name.  A persons own name is the most recognizable word in their vocabulary.  This technique stops them in the tracks and opens their ears.

Example: "Rob, as I was saying, to fix this we could _______."

To deal with a Zipperlip, you need to change the rules they like to play by.  Call them on their habit.  Give them deadlines but be willing to wait, and wait, and wait, if they decide not to respond.

Example: "I expected you to respond by  now, we can schedule a time to meet this afternoon instead if it is better for your schedule."  This puts the ball into their court.  Resisting involvement now takes time away from them until they participate.

Back Stabbers are best dealt with in public.  Try to call them out on their behavior.

Example: "That did sound like you were serious.  Is this something we need to address?  Does everyone else feel this way"

Know-It-Alls: In this case, busy hands are happy hands.  Give them a task and they're in seventh heaven.

Example: "Rob, you're the expert in this case.  Why don't you help me understand  where you're coming from.  Also, can you help me keep track of all of the other ideas offered today?"

Needie-Weenies: In order to get buy in, you need to allow this type of personality to lead some of the change.

Example: "I'm glad that you basically agree with the curriculum updates.  What part could be most improved?"

Wine and Cheesers: These guys just love to complain.  To deal with them, call their issue and offer to help.

Example: "Are you looking for specific solutions to the call schedule mishap, or do you just want me to look into the problem with you?"

These are just a few of the many methods for dealing with the various types of personalities.  A better understanding of the players helps to make teams more effective and improves the workplace culture.

Now that you know these quick tricks, what is your type?  I personally think that I'm a know-it-all and when I don't feel appreciated, I can become a zipperlip.  You?

Also, what techniques have you found helpful in dealing with the various types?