Bridging the quality gap: Becoming a peer-reviewed blog

We are now a peer-reviewed blog.
Starts today.

I have been frustrated (in a good way) by the recent social media discussions (see BoringEM.com) about how social media content is viewed with a skeptical eye by medical educators, academicians, and professionals because of the lack of formal quality-control mechanisms.

Common questions from skeptics:

• "Is it peer-reviewed?"
• "How can I tell that it is a quality blog post?"

These are reasonable questions to ask. These questions, however, can not be answered with traditional answers.

• Blogs with greater web traffic most likely have higher-quality content by word of mouth and external linking from other websites. 
• The power of the crowd "course-corrects" for errors, such as Wikipedia. 

Still these are not very satisfying answers. Can we do better?

Social media-based medical education (FOAMed = Free Open Access Meducation) has gained much popularity through a grass-roots approach, but now faces a glass-ceiling effect. Learners gravitate towards it, but traditional educators still shy away from it. Blogs often fall short when compared to the gold standard of print journals, which have a formal peer-review editorial system for quality control. This remains the gold standard despite known faults and biases in the system.

So this past weekend, I was frustrated into action!

I experimented with several blog models (example) to create a more formal peer-review process. The basic premise is that the power of the crowd should not be undervalued, as demonstrated by the star ranking system on commercial sites such as Amazon, Yelp, and Netflix. Think about the last time you revised your purchases based on reviews. Similarly, our star-rating system, which will be seen at the top of our blog posts, can now help readers assess the quality of each blog post, to assist less discriminating readers regarding content quality.

To make this work, I hope that our readers will help the FOAMed community by rating each blog topic that they read using the following criteria, which mirrors similar metrics for journal manuscripts:

At the bottom of each blog post, raters will be asked to give optional, anonymous demographic information about themselves to help demonstrate external validity.

Under this form will be a public link to the Demographics results (sample Google Docs sheet), in case people are interested.

In this past weekend's experiment, I received 6 peer reviews in the first 4 hours, which included 1 medical student, 1 resident, 3 practicing physicians, and 1 paramedic from 2 countries. (Thanks to those who responded!) How amazing is that? Contrast that to print journals who typically have 2-3 peer reviewers read your manuscript.

Now the question is: How many crowd-sourced reviewers will be needed to demonstrate an adequate quality-control process? I don't know. The more the better, I assume.  

Comments?

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/

Twitter is the digital watercooler in Medicine

I just don't have time to join Twitter.

Are you serious, Twitter?

Being in the minority of medical providers who use Twitter for work, these are common responses I hear. I would make the counter argument that it has given me opportunities to learn, collaborate, and share on a much more efficient level. 

The best argument that I can come up with is that it is the new digital, global watercooler in Medicine. The difference from your current watercooler area is that this area includes global thought-leaders and educators. Seriously, who wouldn't want to eavesdrop on conversations and learn from leaders like Amal Mattu, Scott Weingart, and Mike Cadogan?

• It's where we hear of interesting new studies or controversial clinical tips. 
• It's where we bounce ideas off each other so that we go off and learn more on our own. 
• It's where we see practice variations worldwide.

Question to the collective: 

What has been your best argument for why one should join Twitter? 

Here's my recent "Digital Watercooler" article in Emergency Physicians Monthly. This will launch a new EP Monthly column capturing Twitter conversations, written by our very own Dr. Javier Benítez! Keep a lookout for it.

To debrief or not?

Learners have limited time. Residents have work hours restrictions, practicing physicians have work / life demands, and the list goes on. Time is valuable. Therefore, educational interventions must be hard-hitting, effective, and worthwhile.

We discussed previously "What is debriefing?" Debriefing is a facilitated discussion and reflection about objectives previously chosen by the educator. Dr. Ernest Wang (NorthShore Center for Simulation and Innovation) states that it's about getting learners to that “aha!” moment.

NCSI CSTAR Facilitative Debriefing Video from Ernest Wang on Vimeo.

According to Fanning and Gaba [1], deciding when to debrief is twofold:

1. Do participants lack a sense of closure? 
2. Can we derive useful insights through a discussion of the experience? 

Therefore, we debrief to give participants a conclusion to their learning experience, a manner by which to derive conclusions. We also debrief to provide insights as a group that may not be possible to derive as individuals.

Dr. Roger Greenaway is a UK PhD who specializes in training organizations on the benefits of active and experiential learning.  His website has published a list of 10 reasons on why to review (aka debrief).  These are some of the important points:

• Getting unstuck: Debriefing helps the learner to progress in the cycle of learning and development. 
• Opening new perspectives: Learners can understand complexities in medical management and realize that there is more than one right answer. 
• Developing observational awareness: We all want to become thoughtful and observant physicians able to gather subtle patient clues and condense medical information quickly. Debriefing helps to point out missed clues.

Think of debriefing as a way of accelerating knowledge acquisition and takes learners to the next level. So it is definitely hard hitting!

This is the second of several blog posts on debriefing. Future write ups will discuss the evidence behind debriefing, debriefing techniques, and where to get formal training in debriefing.

References

1. Fanning RM, Gaba DM. The role of debriefing in simulation-based learning. Simul Healthc. 2007. Summer;2(2):115-25. PMID 19088616.
2. Thiagarajan S: Using games for debriefing. Simul Gaming 1992;23: 161–173.

Teaching internationally: More than just a language barrier

I recently traveled to San Salvador to help teach a pediatric and adult ultrasound course. The course was well received and it was wonderful traveling around San Salvador.

I wanted to share some of our experiences, and discuss some challenges to educating internationally. More importantly, I want to engage you, the readers to share some of your experiences when educating internationally as well.

The language

The first challenge and major road block was attempting to lecture in a foreign language. Although I studied Spanish for many years, I was definitely rusty. While I learned the history of the Argentinian Dirty War in school, I never mastered vocabulary sufficient to discuss the physics of ultrasound. We translated the majority of the presentations into Spanish by using the aid of colleagues who were from El Salvador and Google translator. Imagine how difficult this would be for languages that are not based on the Roman alphabet or if there were no native language speaking colleagues to assist. Even with that, there were still some funny hiccups.

Delivering presentations

Creating the presentations is half the battle. Delivering the presentation is even more daunting.

We all know that good lecturers don’t read off of their slides.  They can ad-lib, interact with the crowd, and make adjustments as necessary.  This becomes more difficult in another language.  No one wants to deliver a bad presentation simply because it is in another language.  Or worse, give a bizarre answer to a question because of translation issues.  I definitely practiced my presentations more than I would usually.  The butterflies in my belly before presenting were palpable!

AV equipment

A major challenge was ensuring that the AV equipment worked properly.  Although traveling with 5 other EM physicians in my group, none of us remembered to bring a dongle to connect our laptops with the AV equipment in the hospital.  Luckily, we were able to find a store and could buy the necessary missing equipment.  However, you may not always be so lucky when traveling internationally to be near an urban center.  It is important to be organized to try to limit as much AV malfunction as possible.  Remain flexible and know that there may be some level of malfunction and be prepared to address it.  Having a backup plan such as hard copies of the lecture could be life (and reputation) saving.

Ultrasound equipment

Finally there is the challenge of traveling with the portable ultrasounds internationally.

• Customs doesn’t always know what a portable ultrasound machine is. Plus, it takes coordination to organize carry-on luggage as the ultrasound, check in your suitcase, and manage your souvenirs-- all without incurring additional travels charges.
• Don’t forget how heavy the ultrasound machines can be on your back!  
• Ultrasound machines are expensive. We always knew their locations to avoid losing them.

Ethical question
There was the ethical dilemma of using our high tech portable ultrasound donated by companies for international education versus using the machines that the hospitals already had.  Our equipment was definitely more advanced, but what purpose does it serve to not teach familiarity to what is available?  This is a thought that definitely can be pondered upon and argued over.

Lessons I learned:

•  Practice, practice, and practice again when delivering a presentation that is not in your primary language
•   Think about AV equipment - consider backups
•   Ultrasound machines are heavy and costly
•   Always consider sustainability

Please share any lessons you may have learned while traveling and educating internationally!

The secret to patient presentations

So there’s a patient, and umm...  they are in the hallway, they came to the ED today for breathing problems, I mean dyspnea.  They also don’t speak any English.  So, uh the respiratory rate is normal, and they had a blood clot, er... I mean PE, in the past, but not on coumadin anymore.  Shoot, I forgot to tell you my exam...they had pitting edema for 3 months.  By the way, the labs came back on that other anemic patient in the other hallway, and they are really anemic...

Sounds familiar? Perhaps a medical student or intern-level presentation of a patient in the ED?  Imagine working in a hectic ED while listening to this chaotic presentation. 

What's the secret to presenting patients?

We, as attendings or senior residents, often assume that increasing knowledge will lead to improved presentations, and so focus on broadening their medical knowledge. That's only part of the solution.

What's the other part? Polishing the trainee's public speaking skills.  This is just like recommending to a lecturer that to improve their lectures, they should develop public speaking skills. In this case, the lecturer (trainee) is lecturing to an audience of one (attending).

Think of presentations as mini-impromptu speeches.  

Important qualities in public speaking:

• Lack of fillers (um, so, uh, really, like)
• Knowledge of content
• Brevity
• Organized structure
• Eye contact
• Subject matter of pertinence to the audience
• Practice (go over the presentation in your head once before giving it)

As a senior resident or attending taking patient presentations, imagine a presentation that is succinct (less than 1-2 minutes), where the trainee avoids filler words, with an organized history, physical, assessment, and plan.  Imagine a presentation that does not deviate but remains true to the topic and tells a coherent story.  This type of presentation would almost be like a gentle relief in an over-stimulated ED environment.

Just as how you probably would not interrupt a good public speaker in the middle of his/her speech,  you should hold your questions until the end of their presentation. Remember this, and try to allow the trainees to finish speaking.  It may help them to keep their train of thought and structure.

For the senior resident or attending:

• I challenge you to consider these aspects of public speaking the next time you listen to a patient presentation from a student or resident. See if you can make recommendations to improve his/her presentation style as well as the content.

For the trainee:

• Work on being a better public speaker. 
• As a side note, I was a part of Toastmasters International which is a nonprofit public speaking organization while in college.  Although I am no longer with the organization, I credit them with significantly improving my confidence and public speaking skills in both prepared and impromptu styles. Plus it was a lot of fun!  This is definitely something to consider if you are looking for a way to improve your public speaking skills.

Losing faith in "evidence-based medicine": Etomidate and sepsis

In an era where evidence-based medicine is the goal, it is vitally important for practitioners to understand how to prioritize and interpret the onslaught of data coming at us. 

This fact was driven home for me with a recent publication. Several weeks ago an article was published in Critical Care Medicine entitled "Etomidate is associated with mortality and adrenal insufficiency in sepsis: A meta-analysis."

The point of this post is not to debate if etomidate should be used to intubate septic patients. Etomidate very well may kill people with sepsis. I just don't know from the data currently available. Using this meta-analysis as an example, the goal is to point out two important areas where we could stand to sharpen our literature evaluation skills.

Point #1: Choose (and interpret) your titles wisely.

It is an overwhelming task to skim through several journals' Table of Contents each month. In a specialty such as Emergency Medicine, many relevant articles appear in non-EM journals making it even more challenging. It's tempting to think we know what an article concluded, based solely on its title.

This point particularly applies to those who publish. But readers also should use extreme caution if only reading titles and abstracts. Given that the last several articles on this topic found that etomidate did not increase mortality when given as an induction agent to septic patients, I was quite surprised to see this bold title declaring etomidate is associated with mortality. We're all so busy that it would be very easy to simply see this title and assume it to be true, without ever reading the article. That is very dangerous medicine, in my opinion. And, this principle extends far beyond this one meta-analysis. 

I've already seen etomidate avoided in a hypotensive, septic patient based on this article. I've also heard colleagues giving a quick summary of the article to students and residents saying this article "confirms what we already knew." What?!? When did we definitively "know" this? I still can't believe a highly regarded journal such as Critical Care Medicine would allow this article to be published with this title.

Point #2: The meta-analysis is not the end-all-be-all of publications.

We've all sat through some sort of literature evaluation class back in school. When the meta-analysis was described to me as a student, I remember thinking how awesome it was. Let me get this straight... people way smarter than me are going to take all of the articles published on a given topic, perform some fancy (way over my head) statistics, and give us an evidence-based conclusion? Sign me up. Coming out of pharmacy school, I pretty much thought meta-analyses were the cream of the crop when it came to the published literature. How wrong I was.

I shouldn't have to go back and analyze each of the articles the authors used, but that is exactly what I did in this case. Here is what I found:

With regard to mortality, 5 trials were included. The 4 smaller ones mostly demonstrated that etomidate did not increase mortality compared to other agents. However, the one larger trial encompassing 499 of the 865 total patients (58%) did show an increase in mortality. It was published by Cuthbertson, et al in Intensive Care Medicine in 2009.

Let's take a closer look at this ICM study. 

It was such a large contributor to the meta-analysis outcome, it seems important to understand what that trial was all about. Despite the authors calling it an a-priori sub study of the CORTICUS trial, it was actually a post-hoc analysis looking at etomidate's association with mortality. You can read the two published commentaries to the Cuthbertson study by Pallin and Andrade, which each highlight several major issues with the data in this trial. 

The bottom line is that the trial by Cuthbertson was highly flawed and really doesn't give us any insight as to etomidate's contribution to mortality. In fact, one of the biggest critiques was that physicians in the CORTICUS trial were instructed to avoid etomidate due to its propensity to suppress cortisol production. So, when physicians did use it, there was likely a reason for it (ie, the patient was hemodynamically unstable and they didn't have many other good induction agent options). Therefore, etomidate was probably given to the sicker patients already more likely to die from the start. 

If you dig even deeper, you'll find that the Cuthbertson group used two logistical regression models. One showed a nonsignificant increase in mortality while the other showed a significant increase. Of course the statistically significant one was reported in the abstract. The bottom line is that if you use bad data to construct a meta-analysis, you'll end up with a bad meta-analysis.

So where does this leave us?

In part, it means we have to remain as skeptical as ever when reading published articles. We already know titles and abstracts don't give the full picture. Taking into account reporting biases, funding sources, and even authors' personal/professional agendas, it seems we can't always rely on the peer-review process to uphold the highest standards of integrity. The best journals out there aren't immune. One reason I love Free Open Access Meducation (FOAMed) is that the peer-review process is instant and no holds barred. If you post something that is inaccurate or controversial on Twitter or a medical education blog, you will get called out on it. The best part is that the ensuing conversations inevitably lead to knowledge sharing and learning. Isn't that what research is supposed to be about after all?

Dr. Joe Lex said it best on Twitter:

I couldn't agree more.



References:

1. Chan CM, et al. Etomidate is associated with mortality and adrenal insufficiency: A meta-analysis. Crit Care Med 2012;40(11):2945-53. [PMID 22971586]
2. Cuthbertson BH, et al. The effects of etomidate on adrenal responsiveness and mortality in patients with septic shock. Intensive Care Med 2009;35(11):1868-76. [PMID 19652948]
3. Pallin DJ, Walls RM. The safety of single-dose etomidate. Intensive Care Med 2010;36(7):1268-70. [PMIS 20405278]
4. Andrade FM. Is etomidate really that bad in septic patients? Intensive Care Med 2010;36(7):1266-70. [PMID 20405279]

What is debriefing in simulation education?

Debriefing at the Univ of New England

Medical education high-fidelity simulation allows for deliberate practice in a safe environment. We are able to miss the intubation repeatedly or botch up the management of aspirin overdose without the demise of the patient.  At the end of each session, we gather in a pow wow and debrief….

I have been involved with debriefings, and often wonder what residents are thinking:

• Do they understand what debriefing means? 
• Do they think this is the time where they are scolded for mistakes? 
• Do they think it is a valuable part of the simulation?

What does debriefing even mean? 

Debriefing is a broad topic, and definitions vary depending on the field of reference such as medical education versus aviation.  My goal is to provide an overview and only discuss what is debriefing within the simulation medical education context. 

According to Fanning and Gaba [1], debriefing is “facilitated or guided reflection in the cycle of experiential learning.”  Harvard’s Center for Medical Simulation describes debriefing as a conversation among participants with the ultimate goal to improve performance in real situations. [2] It is a process by which to identify and address gaps in knowledge and skills. [3] 

Debriefing (post-experience analysis) is thought to be one of the most important features of simulation based medical education. Simulation can lead to an experience that is emotional and thought provoking - aka experiential learning. (Think of how you feel when you poorly execute the resuscitation of the manikin in a simulation session.)  Debriefing plays a role in the reflection and analysis of that experiential learning.

The following elements are usually involved in debriefing: 

• Facilitator
• Participants to debrief
• Experience
• Impact of the experience
• Recollection
• Report
• Application

The Participants go through the simulation case (Experience) and develop an Impact from the experience.  During the debriefing they Recollect the impact, and Report upon it.  Although reflection often happens regardless, debriefing allows the Facilitator to organize the reflection in a productive manner. 

Think of the last resuscitation that you felt was botched up.  You probably reflected on it alone, hopefully not in the local bar.  Your reflections may have been scattered and perhaps included unproductive self-criticisms that didn’t aid learning.  Compare that to your last simulation session where there was a useful structured reflection with a facilitator, learning points were discussed, and hopefully lessons were retained for a longer period.

Ultimately the goal of debriefing is to engage in a conversation where learning happens. It is an open format for discussion of the events that occurred, how we felt about it, and understanding the thought processes.  It allows for identifying areas where perhaps knowledge or skill was missing so that it can be corrected in the future.  So maybe debriefing is a little touchy-feely, but what’s wrong with a little human contact?!

The purpose of this post was to discuss what is debriefing; future posts will discuss why we debrief.  I would love your thoughts on this subject.  Please feel free to discuss!

References

1. Fanning RM, Gaba DM. The role of debriefing in simulation-based learning. Simul Healthc. 2007. Summer;2(2):115-25. PMID 19088616.
2. "DebriefingAssessment for Simulation in Healthcare (DASH)." DASH. Center for Medical Simulation, 2009. Web. 03 Nov. 2012.
3. Raemer D, Anderson M, Cheng A, Fanning R, Nadkarni V, Savoldelli G. Research regarding debriefing as part of the learning process. Simul Healthc. 2011 Aug 6; Supple:S52-7. PMID 21817862.

Thanks to Dr. Stella Yiu and Dr. Javier Benitez for letting us know about Dr. Hart's and Dr. Ernest Wang's videos on Debriefing, respectively:

High Fidelity Cased Based Simulation Debriefing from Academic Emergency Medicine on Vimeo.

Facilitative Debriefing Techniques for Simulation-based Learning from Academic Emergency Medicine on Vimeo.

Eavesdrop into LIVE International EM Faculty Development Conference

Today is the second day of the International EM Faculty Development and Teaching Course hosted at the University of Maryland by Dr. Rob Rogers and Dr. Amal Mattu. Although unable to attend, I have been able to be a virtual participant in real-time for many parts of the large-group didactic sessions.

Have you heard of Livestream?

Although I am always a little wary of these real-time video captures of lectures because of all the problems that might arise and the logistics with joining in, I decided to try the provided link:

http://new.livestream.com/iTeachEM/theteachingcourse

It was surprisingly hassle-free. With one click, I started immediately to view the talks and read the comment stream without logging in. The video and audio are surprisingly clear and smooth. Give it a try. I'm a convert. Would love to see more conferences utilize this technology!

I caught a talk by Amal on the nuts and bolts of bilding an academic niche. I wish I had heard these talks when I first started out as a faculty member!

Planned Livestream times (Eastern Standard Time)

Today, Nov 13 - this afternoon

Wed, Nov 14 -

• 1-2 pm
• 2:20-3:45 pm
• 3:45-4:45 pm

Thu, Nov 15 -

• 10:20-11 am
• 1-2 pm
• 2:30-3 pm

Fri, Nov 16 -

• 8-10 am
• 10:20 am-12 pm

Trick of the Trade: Searching for Comments to a Published Article

One day back in 2005 during my PGY-1 pharmacy practice residency, I remember a conversation with my residency director. He was a Surgical/Trauma ICU pharmacist. There had been a recent article published (I think it may have been one linking 'tight' glucose control to decreased mortality in ICU patients). Funny how times change...

Anyway, he mentioned all of the 'discussion' surrounding the article in terms of comments submitted to the journal. It was my first introduction to the idea that published literature could be challenged through an avenue provided by the journal.

Just this past week during EM residency journal club, we were discussing the recent Etomidate/Sepsis Meta-Analysis published in Critical Care Medicine (more to come on that soon in another post). I mentioned to my group how one could search for submitted comments. Most seem surprised to learn this trick of the trade.

Medical Education Trick of the Trade: Look for comments at bottom of Pubmed citation

• Locate the article of interest on PubMed.
• At the bottom will be any comments submitted to and published by the journal.
• Click on the link and it will bring you to the comment.

Test out these "Comment In" links from the above example:

• Comment: frequency of medication errors with intravenous acetylcysteine for acetaminophen overdose. [Ann Pharmacother. 2009]
• Comment: Frequency of medication errors with intravenous acetylcysteine for acetaminophen overdose. [Ann Pharmacother. 2008]

Some comments are written to suggest solutions to a problem identified by the article (see above). Others are more contentious when controversial topics are published and/or subpar methods, statistics, results, or conclusions are reported (see below).

Links for the "Comment In" section:

• Safety of etomidate bolus administration in patients with septic shock. [CJEM. 2011]
• The safety of single-dose etomidate. [Intensive Care Med. 2010]
• Is etomidate really that bad in septic patients? [Intensive Care Med. 2010]

I highly recommend reading them. The tone is generally more pointed then the original article. Typically, the author(s) are given a chance to reply and those are also listed. It's a great learning exercise to read how other experts in the field critique a study and how the author responds.

New blog section on Medical Education by Dr. Nikita Joshi

Introduction of a new section on Medical Education

Sir William Osler, renowned physician and believer in bedside medical education, once stated:

“I desire no other epitaph…than the statement that I taught medical students in the wards, as I regard this as by far the most useful and important work I have been called upon to do.”

And with this quotation I would like to introduce a new segment to Academic Life in Emergency Medicine.  One of the most important job descriptions we have as physicians is to be a clinical instructor… while simultaneously running cardiac arrest codes, managing agitated altered mental status patients, and avoiding documentation errors.

It is a tremendous task, especially considering the multitasking, organizational, and time management skills that are already demanded of us.  However, the ED is the perfect setting to provide medical education at levels including medical students, residents, and junior faculty as well.

With this blog, I hope to discuss issues such as:

• Bedside teaching tips
• Relevant medical educational theories
• Small and large group lecturing tips
• Effective use of technology, such as iPads in providing medical education.  

This section will ideally provide a forum for discussion as a place to share ideas, concepts, and successes from other readers. Ultimately, I hope to excite passion for medical education and to provide practical ideas for teaching.

Additional reading:

• "Oslerisms" from Life in the Fast Lane medical education blog
• "William Osler - Biography" from Medical Archives at Johns Hopkins

I joined Twitter. Now what? (Tutorial video #1 - iPhone)

There has been a recent groundswell of interest and support for using Twitter purely for medical education. After getting several requests to get a quick tutorial of how I use it, I thought I would do a quick, on-the-fly video in my hotel room of how I use it on my iPhone (Echofon app) and on my laptop (Hootsuite). This is the first video on using the iPhone for Twitter.

Hashtags I have been following recently:

• #MeduTOT: Medical Education Tricks of the Trade. I introduced this hashtag during the AAMC 2012 conference this week in San Francisco. This hashtag labels all things related to practical teaching tips in medical education, such as powerpoint design, giving feedback, curricular design, bedside teaching, etc. Thought it appropriate since there were so many educators all gathered together using Twitter!
• #EMTOT: Emergency Medicine Tricks of the Trade. This hashtag labels all things related to tips in the clinical practice of EM. 
• #AAMC12: A conference hashtag for Association of American Medical Colleges meeting in 2012
• #EssentialsEM: A conference hashtag for Essentials of EM conference 

Pearl:

• Start by following just a few people and build up a bigger list. If often feels like you are drinking from a firehose if you start too quickly. Start with this list by @FOAMstarter. 

P.S. It was surprisingly challenging to type on an iPhone without being able to see the iPhone or my fingers because they were behind the video-recording iPad.

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.

Top 10 reasons why Yoda would be a terrible mentor and teacher in medicine

This is based on an article from GeekWire that lists the top ten reasons why Yoda would make a terrible teacher. Let’s see if I can make a derivation and convert these reasons as to why Yoda would make a terrible mentor/teacher in medicine.

10. Micro-manage much? 

Yoda never took into consideration the mentee’s motivations, desires, and mental states, which made for a very inefficient relationship. It also looks bad when Yoda is on Luke’s back and directing all of his moves. That level of micromanagement does not lend itself to the best situation for communication, which is a very complicated process and of essence in a learning environment.

9. Lack of transparency

It’s always important to tell your mentee what your reasoning is behind your decisions as an attending. They should learn how you go through the process of formulating answers so that they can do the same when challenged with similar problems or questions. If your reasoning is not explained, the student will never know why you arrive at a particular conclusion. Transparency also makes you more approachable.

8. The importance of goals

“Because I said so” should not really be an answer. Explain why and how the exercise/ activity/ challenge will make them better doctors. Jointly come to a decision as to what the goals of the shift are; be it seeing more patients, managing more critical care patients, working on procedures, or teaching medical students. The ultimate goal is to make of them a better doctors, take better care of patients, and be more proficient at skills. There should not be a hidden agenda. All cards should be on the table. Yoda was so secretive, and for some reason things needed to be figured out as riddles.

7. Communicate clearly

This has to overemphasized. Communication is everything. Everybody needs to be on the same page. The Geekwire article states “finding a way to minimize information friction should be job one for all mentors.” As you remember, Yoda did not communicate clearly, I mean really, who talks like that?

6. Authentic assessments

The mentor/teacher should be aware of the learner's knowledge and where that falls within the standard for that level of training. If the student hasn't met these expectations, a plan should be laid out to delineate how to get there. There should also be benchmarks to let the student know whether s/he was successful. These assessments and benchmarks were not made clear by Yoda, which I would imagine made Luke more frustrated. 

5. Authority problems
The mentee/mentor relationship is a delicate one, and all the authority should not fall on just the mentor. The relationship should be seen as a respectful collaboration going both ways. Without respect, the relationship suffers and the communication fails. Yoda was very frustrated at what appeared to be Luke’s lack of respect, but the respect did not come from Yoda either. Mutual respect leads to better communication and a conducive learning environment.  

4. Constructed learning from existing contexts
Basically Yoda did not know how to motivate Luke to learn. Criticism needs to be well directed, specific, constructive, and connected to experiences that the mentee can relate to. Sometimes criticism are more welcomed when they come from a person that the mentee can relate to culturally, chronologically, etc. The point is that there has to be some common ground beyond the mentor/mentee relationship.

3. Dispel cult auras
Mentors might be too detached from the students. When the mentee or the mentor cannot relate to each other, the learning is more difficult. I’ve heard great podcasts where the attendings sound very down to earth, and this in turn makes the students feel more comfortable to learn from them. I went to a conference where Amal Mattu was lecturing, after lecture I approached him and called him Dr. Mattu, the first thing he told was to call him Amal. After that my conversation with him felt more like I was talking to a friend even though I knew how well renown he was.   

2. Accessibility in all ways
The mentor creates a better learning environment when the mentee sees him/her as being approachable. This is much easier with technology in the present time. When we have a question, we can just go ahead and text or email someone. In contrast, Yoda was pretty inaccessible.

1. There is nothing magical about learning new things
All students should know that learning is hard, and that they need to put in a lot of work. No matter how stellar a mentor is, if the mentee does not put in the time, s/he will not get to master the skills necessary to be successful. The name of the game is repetition, there are no shortcuts. 

The mentor-mentee relationship is a very complicated one. If basic principles are followed, however, the process of learning and mentorship can be a mutually beneficial and joyful experience. Clear communication and mutual respect are the foundation in this relationship, which both parties should strive for. 

Basically, don't be Yoda.
Javier Benítez, M.D.