Tweet Pearls of the Week 1/4 to 1/11

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Mentorship: Who benefits?

Mentorship is one of the professional relationships that fascinates me the most. We've all had those people in our lives that help us advance our careers, gain more insight to our practice, guide us to a more work/life balance. Some might call these people mentors, while other call them coaches or guides. Even after completion of training or schooling, people make use of these coaches/mentors as is the case in sports or medicine. For example Atul Gawande writes how a mentor helped him improve his practice as a surgeon years after completing his training.

This relationship is very complex, but at the same time vital for a successful career. In its complexities we must find what makes it functional and nonfunctional in order to benefit from this interaction. When this relationship is successful there are four winners:

• The mentee
• The mentor
• The institution to which they belong
• Patients 

Mentees and mentors end up with better career satisfaction, career advancement, and better pay, but the relationship has to “click” in order for it to work. The institutions can benefit from improved morale, enhanced productivity, external recognition, and more. When these relationships become dysfunction, and it’s not remedied, it can be harmful to the parties involved. The study below published this past November in Academic Medicine, explores the characteristics that make these relationships a success or or a failure.

 

Fifty-four faculty members from different career streams were interviewed via telephone. Although this qualitative study has its limitations, it contains salient points that are worth considering in this complex relationship.

Characteristics of an effective MENTOR

Altruistic Honest Trustworthy Active listener Previous mentorship experience Enriched network Accessibility Understands the potential and limitations of the mentee Helps promote the mentee’s career

Characteristics  of an  effective MENTEE

Open to feedback Active listener Respectful to mentor’s input and time Responsible Pays attention to timeline Takes responsibility for “driving the relationship” Prepared for meetings

Actions  of  effective mentors

Act as guides rather than supervisors Offers: advice, advocacy, network, goal setting, opportunities, how to navigate the system Provides emotional support focusing on work/life balance Warn mentee of potential pitfalls Protects mentee from harsh interactions Helps mentee have a clear vision of the career path and how interrelates with their personal and social life

Characteristics of a successful  mentor-mentee relationship

Reciprocity Mutual respect Clear expectations Personal connection Shared values

Characteristics and consequences of a failed mentorship

Poor communication Lack of open communication Lack of commitment Lack of time or waning interest over time Personality differences Different personalities have different ways of approaching the world Perceived (or real) competition How much credit does the mentee get as opposed to the mentor? When working together, it is important for the mentor to step back and let the mentee have the spotlight. Conflicts of interest The mentor should not be in a position of authority over the mentee Mentor’s lack of experience Lack of knowledge to provide advice

Tactics for a successful mentoring relationship

Start in the mentor’s office (a safe environment) Establish a communication network (“reiterate and review”) May use a checklist to address: career, education, administration, and personal issues Schedule regular appointments

When the mentor-mentee relationship did not work, participants still felt that these were good life lessons. Interestingly, people in more junior positions found it more difficult to approach more senior members about the failed relationship because of the potential for bad career repercussions. Two useful podcast from the Get-It-Done Guy:

• How to pick a mentor 
• How to leave a mentorship relationship

Since this is a vital process which takes part under institutions, it is being looked at more closely these days. This is a great study and gives a lot of insight into quite an interesting relationship. Although I had participated in mentorships, I was not aware or mindful of all of the characteristics mentioned here. One should be cognizant on how to continually improve the relationship. Rather than waiting until the relationship ends poorly, it is important to have a mechanism to leave the relationship under amicable terms. I hope this post motivates you to become a mentor or gives you some important points to consider when searching for that mentor or coach.

Additional reading on blog about mentorship

1. Blog post: CJEM 2010 review article (Pubmed) on Mentorship in EM
2. Blog post: Acad Emerg Med 2004 article (Pubmed) on Mentorship for Clinician-Educators

References

1. Straus S, et al. Characteristics of Successful and Failed Mentoring Relationships: A Qualitative Study Across Two Academic Health Centers. Acad Med. 2013 Jan;88(1):82-89.
2. Atul Gawande. Personal Best The New Yorker, October 3, 2011.
3. Coates W. Being a Mentor; what’s in it for me? Acad Emerg Med. 2012 Jan;19(1):92-7.
4. Get-It-Done Guy: Choosing a mentor Episode 245: November 26, 2012, Moving on from your mentor Episode 208: February 6, 2012
5. Tobin MJ. Mentoring: seven roles and some specifics Am J Respir Crit Care Med. 2004 Jul 15;170(2):114-7.

Image 1 source: http://ltownteacher.blogspot.com/2011/05/message-to-mentors.html
Image 2 source: http://madisonmusicfoundry.com/education/lessons/

Tweet Pearls of the Week 12/28 to 1/4

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Tweet Pearls of the Week 12/7 to 12/14

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Hypotensive a fib, and does calcium before diltiazem work? #FOAMed... tmblr.co/ZgnhMvZBFesd
— EM Res (@BobStuntz) December 12, 2012

@bobstuntz @pharmertoxguy @amalmattu Ca++ sounds reasonable - have also used @emcrit 's push-dose phenylephrine in unstable afib, as well.
— Ryan Radecki (@emlitofnote) December 12, 2012

Love it when I diagnose an achilles tendon rupture by #ultrasound and the ortho doc requests I review the images with him to learn...
— Laleh Gharahbaghian (@SonoSpot) December 11, 2012

CT demonstrating the internal anatomy of a zucchini and the abdomen in a patient with rectal perforation! #Radiology twitter.com/RadiologySigns…
— Radiology Signs (@RadiologySigns) December 9, 2012

Tweet Pearls of the Week 11/30 to 12/7

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Tweet Pearls of the Week 11/23 to 11/30

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Andragogy: How adults learn best

 

Andragogy refers to learning strategies which help adults to learn more effectively. It is a term that was first used by Alexander Kapp in 1833 and later expanded by Malcolm Knowles to fit the needs of adult education. The concept is contrasted with pedagogy in which the child is lead through the learning process by the teacher. In andragogy most of the learning is self-directed and the teacher is a facilitator in the learning process. 

Pedagogy is more content-oriented. 
Andragogy is more process-oriented.

This is essential in medical education due to the fact that by the time we reach medical school we are less receptive to teacher-centered education and are already in a phase where learning is more independent. Although I had already come across this concept a while ago, this concept was covered in an educator's conference put together by Rob Rogers, MD (@EM_Educator). I followed this conference via twitter and Livestream in mid-November and it was great. (Link to blog and tweets from the conference.)

Knowles identified six characteristics that motivate adult learners (1)

Need to Know	Adults need to know the reason for learning something
Foundation	Experience (including error) provides the basis for learning activities
Self-Concept	Adults need to be responsible for their decisions on education; involvement in the planning and evaluation of their instruction
Readiness	Adults are most interested in learning subjects having immediate relevance to their work and/or personal lives
Orientation	Adult learning is problem-centered rather than content-oriented
Motivation	Adults respond better to internal versus external motivators

I think this concept should help us to become more effective educators because it provides a better look into the mind of the adult learner. It really shows that we are not satisfied when we are given a simple answer such as “because I said so” - an answer that might work with children.

Here are a few examples where you can find andragogy in medical school and residency:

• Problem Based Learning (PBL): A group of trainees gather together to solve clinical problems. 
• Clinical Problem Solving: This makes learning more relevant to real life experiences.
• Trainees have different backgrounds and they bring these experiences with them to a learning group and facilitate learning.
• When the trainee looks up information without being prompted by the trainer it shows the learner is self-reliant. 

A comparison of the assumptions of pedagogy and andragogy following Knowles (Jarvis 1985: 51) (Adapted from table)

	Pedagogy	Andragogy
Learner	Dependent. Teacher directs what, when, how a subject is learned and tests that it has been learned.	Moves towards independence. Self-directing.Teacher encourages and nurtures this movement.
Learner’s experience	Of little worth. Hence teaching methods are didactic.	A rich resource for learning. Hence teaching methods include discussion, problem-solving etc.
Readiness to learn	People learn what society expects them to. So that the curriculum is standardized.	People learn what they need to know, so that learning programmes organised around life application.
Orientation to learning	Acquisition of subject matter. Curriculum organized by subjects.	Learning experiences should be based around experiences,since people are performance centred in their learning.

Of course this concept is not without its criticisms and even Knowles recognized that this concept can also apply to children. It is clear that when we reach adulthood we should move to a more learner-oriented system and move away from teacher-oriented system. In the end during our training the learning process is a team project where the exchange of information can be interchanged between the trainer and the trainee. After training it is still our responsibility to become independent effective learners and stay up to date with the medical literature. If these concepts are applied effectively during our training the process will help us to become more effective long life learners. 

I would love to read your comments on this topic. Are you a content-oriented, a process-oriented, or both type of learner? 

References 

1. Wikipedia; Andragogy; Last update: Sept 17, 2012
2. Smith, M. K. (1996; 1999) 'Andragogy', the encyclopaedia of informal education, Last update: May 29, 2012.
3. Instructional design; Andragogy (Knowles)
4. Dr. Shawn Bullock; Introduction to Andragogy, YouTube Video, Posted Sept 17, 2012

Image 1 source: http://collections.infocollections.org/ukedu/uk/d/Jh0414e/5.1.html
Image 2 source: http://i.ytimg.com/vi/6JbN16oL3Ho/0.jpg

Tweet Pearls of the Week 11/16 to 11/23

 

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Tweet Pearls of the Week 11/9 to 11/16

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Seth Godin's TED talk on "Stop Stealing Dreams"

Seth Godin, a marketing guru, discusses his opinion about “what school is for” in this above video. Although this talk or Seth Godin are not directly related to medical education, this is still related to education and can still be applied to today’s medical education curriculum in many aspects.

Mr. Godin goes on to explain that school was modeled in the industrial age and has changed little ever since. The video covers such concepts as:

• Standardized exams in the industrial age were used as a tool to sort students. The person who created the standardized exams later on came to believe that the standardized exams were too crude, but due to his new conclusions he was excluded from his field. 
• Teachers in the industrial age believed that school was about teaching obedience and respect. 
• The industrial revolution created products en mass, but also needed people who were educated on consuming these products in order to survive. Therefore, schools were also created to educate people (or make replicas of people) about these products.

Mr. Godin states that people are more inclined to do more if it’s art, but do less if it’s work. He also says that now we are more intrigued in interesting stuff, but schools are dissuading us from being creative. With the help of technology: 

• We are finding out new ways of learning so that we don't depend so much on the person standing in front of a classroom giving a lecture. 
• We can read about what interests us
• We can view lectures from experts
• We can learn anything with the help of the internet. 

He then goes on to enumerate 8 things to answer what school is for, or better yet, how he thinks school SHOULD function:

1. Homework during the day, lectures at night.
This sounds like the concept of “flipping the classroom” (similar to Khan's Academy) where students watch lectures at night and come to school to work out problems during the day with their teachers.  

2. Open book, open note all the time.
“There is zero value memorizing anything ever again. Anything that is worth memorizing is worth looking up.” I’m not sure if I agree with this 100%, but it sounds similar to another quote by Albert Einstein about memorizing “Never memorize something you can look up.”
3. Access any course, anywhere, anytime in the world when you want to take it.
This is an example of asynchronous learning such as Coursera.
4. Precise focused education instead of mass batched stuff.
I think this is one of the most important goals in medical education. Our education needs to be specific as to what is relevant when it comes to patient care. Information has exploded in the past few decades, but medical school still modeled as it was created 100 years ago when there was not as much information around.

• No more multiple choice exams: According to Seth Godin these were made because they are easier to score, but now computers are smarter.
• Measure experience, instead of test scores: “Experience is what we really care about”
• Cooperation instead of isolation: Seth Godin states when we finish school we go out in the world to collaborate with others so we should value collaboration and not so much isolation.

5. Teachers will transform into coach(es).

6. Lifelong learning with work happening earlier in life.

7. Death of the "famous college". 
Seth Godin puts emphasis on defining the "good colleges", but he also states we don't know what a good college is.

     
8. Teach students to create something interesting and ask if you need help.
Things we should not be telling students according to Mr. Godin:

• Do not to deviate from the curriculum
• Better, better, better, better comply
• Do not ask questions I do not know the answers to
• Do not figure it out
• Do not look it up
• Be like your peers

The concept is that the more the student deviates from the "standard" the more difficult it is for the teacher to process the student.

Seth Godin ends the video by busting two myths:

1. Great performance in school lead to happiness and success. If that’s not true, we should stop telling ourselves it is.
2. Great parents have kids who produce great performance in school. If that’s not true we should stop telling ourselves it is.

Mr. Godin states we don't teach students to connect the dots, but rather to collect dots and memorize facts. He also declares that passion and insight are reality, while grades are an illusion. He returns to the question "what is school for?" and if we don't know, then we should have a conversation about it.

I think this is an important talk by Seth Godin and we must find which points we can apply to improve our medical education. Which points from Mr. Godin's talk do you think can be applied to improve medical education? Do you already know examples in medical education in which his points are already implemented? What is school for?

Links and references:
Seth Godin’s homepage
Seth Godin’s page on TED
Seth Godin’s blog
Seth Godin's wikipage

Image 2 source: http://northernfactoryworker.blogspot.com/2010_12_01_archive.html

Take the quiz: Do you know your antihypertensive agents?

Identify the antihypertensive agent:

1. Rapid acting systemic and coronary artery vasodilator with minimal effects on cardiac conductivity or inotropy. Well studied in pregnancy. Caution in patients with left ventricular failure, liver cirrhosis

Answer

Nicardipine


2. Predominantly dilates the venous system. Useful in patients with cardiac ischemia, pulmonary edema, or congestive heart failure. Caution in patients with right ventricular failure

Answer

Nitroglycerin


3. Drug of choice in eclampsia, pre-eclampsia, and aortic dissection. Contraindicated in patients with congestive heart failure and heart block  

Answer

Labetalol


4. Decreases peripheral vascular resistance and increases collateral coronary blood flow in an uncontrolled and unpredictable manner and may result in serious complications. Drug of choice during pregnancy

Answer

Nifedipine


5. Direct arterial vasodilator that increases cardiac output and heart rate (Reflex response). Patient may develop lupus like syndrome. Not to be used as first line in the ED

Answer

Hydralyzine


6. Arterial vasodilator that delays atrioventricular conduction and has a negative inotropic effect

Answer

Verapamil


7. Rapid onset of effect after oral administration (30 mins) with little change in cardiac output or reflex tachycardia. Adverse effect may include cough, angioedema. Toxic during first trimester

Answer

Captopril


8. Only for patients with subarachnoid hemorrhage. Not to be given IV only PO or NG tube  

Answer

Nimodipine


9. The only parenteral angiotensin-converting enzyme inhibitor. May cause azotemia in older patients after MI

Answer

Enalapril


10. Oral or transdermal decreases peripheral vascular resistance. May cause sedation and bradycardia  

Answer

Clonidine


11. Used in patients who are volume overloaded but not in patients who are hypertensive and  volume depleted

Answer

Diuretics


12. Drug of choice  for pheochromocytoma, MAOI crisis, and cocaine overdose

Answer

Phentolamine



Reference:
1.  Richard S. Irwin, James M. Rippe. Manual of Intensive Care Medicine; 4th ed
2. Marx: Rosen’s Emergency Medicine, 7th ed (Chapter 82- Hypertension: Richard O. Gray)

Image 1 source: http://www.dancinggiraffe.com/feature/20121005/over-counter-painkillers-are-we-paying-premium-packaging

Image 2 source: http://www.minnpost.com/second-opinion/2011/08/minnesotas-children-too-often-receive-ineffective-or-harmful-antipsychotic-me

Tweet Pearls of the Week 11/2 to 11/9

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Learn pearls on electrocardiograms, toxicology, intubation, pelvic ultrasound, xrays, and more.  

The mystique of direct laryngoscopy: Learning and teaching the procedure

This post is about an editorial comment by Dr. Richard Levitan on an article (1) about pulmonary critical care doctors performing intubations in the ICU (2). The study states that pulmonary critical care doctors can successfully perform this procedure. Dr. Levitan reports that intubation in elective anesthesia has a success rate between 98-99%, but when failure occurs the consequence can be catastrophic. The initial success rate of beginners is usually 50%, and it takes about 50 attempts in elective intubations to be 90% proficient.

The mystique of direct laryngoscopy, explains Dr. Levitan, is in the visual restrictions of the procedure. Due to this, difficult direct laryngoscopy can only be learned through trial and error, and each operator has to figure out the subtleties of the procedure. Time is also an issue, and the structures should be visualized within 10-15 seconds. As the beginner gains more experience, the brain pays more attention to the dominant eye while ignoring the visual field from non-dominant eye; a phenomenon called binocular suppression. Dr. Levitan goes on to explain the distance between the larynx and the eye, accommodation distance, is not necessarily determined by experience, but rather by age and intrinsic ocular issues.

This procedure can be learned more efficiently by understanding how visual restriction affects performance. This is learned by “using imaging from the operator’s perspective.” The best approach to learn this, as per Dr. Levitan, is by emphasizing the importance of:

• Epiglottoscopy
• Ear-to-sternal notch patient positioning
• Bi-manual laryngoscopy
• Straight-to-cuff stylet shaping
• In-depth understanding of laryngeal anatomy

It was no surprise to Dr. Levitan that doctors, if trained well, can perform this procedure adequately. But he also reports that in order to demystify the procedure, we must get better at teaching the best approach. Videolaryngoscopy is a helpful tool for teaching the operator’s perspective, Dr. Levitan then states that videolaryngoscopy is a great aid to augment initial direct laryngoscopy to improve patient safety. 

The performance goal should not be plastic in the trachea, but first-pass success and avoidance of hypoxemia, regurgitation, hemodynamic instability, and other untoward effects that accompany repeated intubation attempts. -- Levitan

What aspects of laryngoscopy do you usually emphasize when training novices? Do you use videolaryngoscopy when you train novices?

References:

1. Vianello AM, et al. Management of tracheal intubation in the respiratory intensive care unit by pulmonary physicians. Respiratory Care. 2007 Jan;52(1):26-30. PMID: 17194314
2. Levitan, RM, The Mystique of Direct Laryngoscopy. Respiratory Care.  2007 Jan;52(1):21-3. PMID: 17194312

For further learning on Direct Laryngoscopy please visit Dr. Weingart’s video on the Steps of laryngoscopy


Image source 1: http://www.sciencedirect.com/science/article/pii/S0196064406000709
Image source 2: http://www.airwaycam.com/Ocularity-and-Biomechanic-of-laryngoscopy.html
Image source 3: http://www.ojhas.org/issue38/2011-2-16.htm