The essay of all essays: "The biology of emergency medicine" (2 of 2)

Dr. Peter Rosen

This is part 2 of my review of Dr. Rosen's 1979 article on "The Biology of Emergency Medicine" (see part 1).

According to Dr. Rosen, there are 3 broad categories of ED patients:

• The emergent
• The urgent
• The non-urgent 

We must know how to identify and prioritize these. Medical students and residents are poorly taught the differences. “There are two shocks to residents: not every patient is sick, and many patients are sicker than they first appear”, he writes.

There are 3 critical ingredients which define a valid residency experience, according to Dr. Rosen who trained in surgery:

• Pathology
• Adequate faculty
• Adequate number of residents

Uniquely, the specialty of EM is not defined by diseases, but rather by the level of acuity. Per Dr. Rosen our most important responsibility in the ED is proper assessment and stabilization. As emergency physicians (EP), the proof of the diagnosis is not as important as the assessment and stabilization. He states, “The quality, appropriateness and timeliness of the initial care is the biology and responsibility of our specialty.” Thus, EM training cannot be learned under someone else’s service.

The article has many other important points that every EP should keep in mind. This article is at the top of my list of reading whenever I encounter a medical student interested in EM. Even though it was written many years ago, many elements still hold true in our profession.

Dr. Rosen ends the essay by quoting Oliver Wendell Holmes:

“I find the great thing in this world is not so much where we stand, as in what direction we are moving: to reach the port of heaven, we must sail sometimes with the wind and sometimes against it - but we must sail, and not drift, or lie at anchor.”

Javier Benitez, M.D.

References:

1. Rosen P. The biology of emergency medicine. JACEP. 1979 Jul;8(7):280-3. Pubmed.
2. Peter Rosen’s lecture at UCLA. All L.A. Conference May 5, 2011: Reflections on 40 Years of Emergency Medicine. (Need to download actual video)
3. Zink BJ. The Biology of Emergency Medicine: what have 30 years meant for Rosen's original concepts? Acad Emerg Med. 2011 Mar;18(3):301-4.  Pubmed . 

The essay of all essays: "The biology of emergency medicine" (1 of 2)

Dr. Peter Rosen

This post is based on one of the most interesting articles I have ever read in EM. The article written by Dr. Peter Rosen in 1979 and published in The Journal of the American College of Emergency Physicians (later become Annals of Emergency Medicine) is a landmark piece. It defines the specialty with so much precision that even contemporary authors find very little discrepancy of what Dr. Rosen wrote and the state of EM in present time.

There is a very clear opinion of what Dr. Rosen believed the unique biology of EM should be. He explains the birth of EM, which was not validated by other specialties in the house of medicine. It was more a reaction from multiple factors, which included financial incentives, growth of urban centers, need of a doctor in a geographic region, and the decreased numbers of physicians house calls.

One of my favorite sections in the article is when he writes “Defining The Specialty.” He states that the responsibilities of the emergency physician (EP) entails differentiating the sick from the non-sick patient, handling multiple patients at the same time, and instituting life/limb saving interventions. He uses the analogy of a climber who for whatever reason has fallen from a precipice and the job of the EP is to get the climber to a much safer place as possible, assuming 100% safety is not attainable.

Interesting enough, he also states that prehospital care should also be managed by the EP. This is an aspect of EM in which EPs are more directly involved. In Dr. Rosen’s opinion, the hardest task of an EP is sending home a patient with a potentially life-threatening diagnosis when the patient presents with nonspecific signs or symptoms.

• I have worked with some amazing clinicians, and their diagnostic skills are impressively accurate. They arrive at the correct diagnosis with very little information due to the patient's altered mental status, his/her being a poor historian, or even how atypical the disease is presenting.

In the essay, he states that stabilization takes priority over diagnosis. This contrasts medical school teachings where the emphasis of education is on primary care. Consequently, the priority is to take a history, do a physical exam, and then treat the patient-- in that order.

• This statement reminds me of a web search that I did last year on how to think like an EP. I came across Dr. Reuben Strayer's (@emupdates) 30-minute video "How to Think Like an Emergency Physician" delineating how an EP should go about seeing patients in the ED. I think this is what Dr. Rosen envisioned the specialty should focus on. Treat the patient first when indicated, and then do a history and physical.

The hardest thing to teach residents, according to Dr. Rosen, is to “assume the worst even if statistically improbable”. I believe that Dr. Amal Mattu (@amalmattu) refers to this as a “healthy paranoia”. This means that we still need to rule out life threatening diagnoses for seemingly non-emergent patients. We must also have enough knowledge of NON-life threatening diagnoses in order to address these in the ED, if possible. If we feel confident that the patient has no life threatening diagnoses and can be discharged the patient home, then we should ensure appropriate follow up.

In tomorrow's post (part 2), we will look at how Dr. Rosen categorized ED patient visits and his views on EM administration and research.

References

1. Rosen P. The biology of emergency medicine. JACEP. 1979 Jul;8(7):280-3. Pubmed.
2. Peter Rosen’s lecture at UCLA. All L.A. Conference May 5, 2011: Reflections on 40 Years of Emergency Medicine. (Need to download actual video)
3. Zink BJ. The Biology of Emergency Medicine: what have 30 years meant for Rosen's original concepts? Acad Emerg Med. 2011 Mar;18(3): 301-4.  Pubmed . 

Top 10 tips to building a productive academic team

I have been meaning to share this list of great tips about building a productive academic team. Major projects often require an interdisciplinary team of experts who are equally motivated towards a shared goal. I was recently at the 2012 Society of Academic Emergency Medicine where Dr. William McGaghie gave an inspiring CDEM keynote speech. He has been on a myriad of successful academic teams and he shared with us his top 10 list of pearls for team-building.

William C. McGaghie, PhD

• Jacob R. Suker, MD, Professor of Medical Education
• Professor of Preventive Medicine
• Director of Evaluation, Northwestern University Clinical and Translational Sciences (NUCATS) Institute
• Northwestern University Feinberg School of Medicine Center for Education in Medicine

I am in the process of building a big academic team myself, comprising of rheumatologists, software engineers, instructional design experts, and an education research expert. This list came in quite handy for me and so I thought I'd share.

The team should have:

1. Shared goals—common mission & vision
2. Functional diversity (everyone should have different defined roles)
3. Clear leadership—may change or rotate
4. Shared mental models & language
5. High standards, recognition, & credit
6. Sustained hard work / commitment
7. Physical proximity
8. Minimize status differences within the team
9. Maximize status of the team
10. Shared activities that breed trust

While these tips may seem obvious, they are a worthwhile reminder nonetheless. Dr. McGaghie shared examples where different members took the lead on different manuscripts within the overarching project and that everyone's opinions were valued. I found it interesting that he felt that physical proximity contributed to the success of his projects. In-person meetings and check-ins seem to have provided added value.

Remembering Dr. Robert Buckman

For those who trained in Canada (especially Toronto), the name of Dr. Robert Buckman always brought a chuckle.

He filled his lectures with his signature British wit and humour. Yet, the message was always loud and clear. Being an oncologist, he had great insight in communication with patients.

He was the first to teach us medical students about communication and professionalism: Kindness, empathy, delivering bad news, what to say when you don't know what to say. A decade later, out of the countless hours of lectures, his stood out.

Truly a big loss to the medical educators community.

Dr. Buckman's website

References
Buckman R. Communications and emotions. BMJ. 2002 Sep 28;325(7366):672. BMJ website

Buckman R. Words that make a difference: enhancing the "how" in "how we say it". Support Cancer Ther. 2006 Jan 1;3(2):127. Free PDF

Buckman R, Tulsky JA, Rodin G. Empathic responses in clinical practice: intuition or tuition? CMAJ. 2011 Mar 22;183(5):569-71. Pubmed

Faculty hero: Dr. Jim Adams (part 2)

Continuing from the Part 1 (Aug 2, 2011 post), here is the rest of my conversation with Dr. Jim Adams:

What cool things are you working on right now?
The big projects that I am working on include:

• The second edition of the textbook for which I serve as Executive Editor. It will be published in 2012. 
• I am President of the Association of Academic Chairs of Emergency Medicine. There is so much happening nationally in emergency medicine and in healthcare in general. Health policy experts often rightfully criticize the US healthcare system for spending the most money without being the best in the world. The US is ranked somewhere around 32nd best. But there is consensus that the emergency care system in the US is indeed the best in the world. There is great training, skilled EM specialists, strong networks, and it is all fully accessible to anyone. We need to take pride in this as a specialty. We also need to be sure that it does not get broken. Nobody intends to, but there certainly can be unintended consequences given the rapid pace of change.

What advice do you have for junior faculty?

• My advice is to learn the good messages that were delivered to me by mentors and colleagues.
• We all appreciate that this is serious business, so there is no easy way to learn it. We just have to work hard and become good.
• We need to stay humble, because none of us are as good as we need to be or as good as we can be. We need to stay rested because the work is relentless.
• We need to make sure that we take care of ourselves. Working in an emergency department is a really hard job. We underestimate how tough it really is.
• And most importantly, if we put it all together, we do a super job for the patients.

What advice do you have for EM residents?
I tell all the residents that we selected them, because we know they are smart and now their job is to become comfortable being stupid. They need to be able to admit when they do not know, they need to become comfortable admitting their weakness because that is harder for them than being tough. Such healthy admission prevents arrogance, allows us to ask questions, permits us to continually learn. With that attitude, we and the patients are better, safer, happier. We are, paradoxically, can then be more confident.

__________________  •  __________________

What a really amazing time this is, with excellent colleagues in EM and in every other specialty. I am so pleased that emergency medicine, and other fields, are attracting such great people. It is up to us to keep the profession great so the talent keeps coming.


Thanks for sharing these eloquent words of wisdom, Jim. Words to live by. 

Faculty hero: Dr. Jim Adams (part 1)

There are many leaders in Emergency Medicine but there are few who are true visionaries. Dr. Jim Adams (Chair at Northwestern's Department of EM) is one such visionary. He's given numerous lectures, providing sage advice to faculty, residents, and students. I've always thought it a shame these aren't more available to people. So I contacted Jim to learn more about him, his career path, and advice for young emergency physicians.

One thing that you are known for is your commitment to teaching professionalism and communication skills. How did that come about?





When I was  a resident in 1990 at the University of Pittsburgh, responding to the field on tough EMS calls to back up the medics, there were a lot of troubling cases. Patient who were really sick refused care. Patients at the end of life had paramedics attempt resuscitation, but not because it was warranted or desired, but because state law mandated it.



I worked with Paul Paris, then the Department Chair and also then President of the National Association of EMS Physicians (NAEMSP). I said that NAEMSP needed an ethics committee. Three months later, after checking with the NAEMSP Board, he said, "Ok, you are the chair." I was a senior resident.



My earliest academic work was to profile ethical dilemmas that occurred in the out of hospital setting. I also worked to ensure that each state and jurisdiction developed laws or guidelines to honor out of hospital DNR orders. My career in ethics was born. The ethics work morphed into professionalism, communication, and related areas that I work in to this day, more than 20 years later.

You mentor so many people around the country, including myself. What have you learned from your mentors?



Don't be lazy.

Work hard.

Be honest.

Do something good.



The residency at Pittsburgh taught me to go-- go to the field, move on the ethics problems, contribute energy to good things. It is a high energy place. Mentors, friends, colleagues in the United States Air Force taught the value of ultimate discipline. The military is remarkable. Those are people that I really would trust my life to. The Brigham and Women's Hospital colleagues and mentors taught the value of thinking more, being more rigorous, becoming deeper, understanding the value of true excellence. I have learned a huge amount from every setting and I am quite aware and grateful for that.





Stay tuned for Part 2 on Thursday... [post]

What's on my mind: EBM Resource

Keeping up with the EM literature is difficult, particularly when we're also trying to stay ahead of the curve in our own subspecialties (Healthcare Simulation and Medical Education in my case). Last week I was listening to Scott Weingart's EMCRIT Podcast and at the very end of the show he mentioned a new EBM resource: TheNNT.

I said to myself, what the **** is The NNT? And then Scott explained:

www.thennt.com

"The Number Need to Treat is the simplest tool to understand the true potential benefits and harms of any of the treatment or tools we use in medicine. TheNNT.com site is a free resources that uses this tool to best communicate the results of high quality evidence"

I've looked at this site and cannot wait to use it in the clinical setting when I'm taking care of patients, teaching our residents (and off service residents) and collaborating with other specialist.

I hope its useful to some of you out there and I hope the New York-based, superstar group that put together the site continue to grow it!

Are there EBM or on-line teaching resources that you love? Let us know!

Demian

The NNT group is: Jarone Lee, David Newman, Josh Quaas, Ashley Shreves, and Graham Walker, all Academic EM Physicians and rockstars in their own right.

Faculty hero: Ernest Wang (part 2)

Clinical Assistant Professor, NorthShore University HealthSystem
Academic Director, Center for Simulation Technology & Academic Research (CSTAR)
Associate Program Director, University of Chicago EM Residency

Read Part 1 of Faculty Hero post.

Successful faculty often have amazing mentors. Ernie, who were your mentors? What have you learned from them?
I have had a ton of mentorship throughout my career in many aspects of my professional development, each significant in its own way. It's probably easiest to divide by areas of influence, really.

Emergency Medicine
I have to acknowledge Drs. Jeffrey Graff, Jorge del Castillo, and Morris Kharasch - the leadership of our division of EM for providing me with all the support I needed to be successful, both clinically and academically.

Dr. Graff has shown me how a successful group should be managed and imparted the importance of being active in the specialty outside the walls of the ED. As a past president of ABEM, he gave me the opportunity to participate in the organization as an item-writer and starting in 2010, as an oral board examiner. I consider these to be some of the most valuable EM experiences of my career.

Dr. del Castillo has shown me what it takes to navigate hospital administration successfully and how important inter-departmental and administrative relationships are in order to be successful with your own academic activities. Both he and Dr. Graff are selfless and tireless promotors of the sim lab for our benefit.

Dr. Kharasch taught me how to be a doctor and how to be an excellent educator. He believed in me from the beginning. Probably the most influential mentor of anyone in my career. He, along with Pam Aitchison, RN (our Clinical Coordinator for CSTAR) provided Voz with a tremendous amount of support to allow CSTAR to get off the ground in its initial phases and their continued efforts allow us to remain productive. These two have also shown me the extent to which simulation really requires a team effort to be truly successful.

Simulation
Voz obviously is a big influence as we worked together for many years. He shared his vision for sim we with me and from this I observed how he applied that vision, his enthusiasm, his ingenuity, and his tremendous organizational skill set, into transforming himself into a simulation leader nationally within SAEM and the greater simulation community. He and I co-authored my first simulation paper and he gave me several opportunities to participate in sim on a national level that helped me develop the confidence to succeed.

From Jim Gordon, Bill Bond, and Steve McLaughlin, I learned about what it takes to successfully cultivate and grow from a fledgling organization into an influential one. Jim and Bill are tremendous leaders and visionaries and I have admired their ability to shoulder the weight of the simulation agenda over the 6-7 years. Steve brought me on as an instructor in a scenario design work shop at the International Meeting on Simulation in Healthcare and as I tell everyone, much of what I know about scenario design, I learned from him.


Academics
From Mark Adler, Walter Eppich, and Bill McGaghie at Northwestern, I observed first hand the discipline and dedication it takes to design and execute a good research study. They have been tremendously influential in how I think about my own study designs and curricula and I know they are much better now because of what they have taught me.

Drs. Jerrold Leikin and Jim Adams have provided much academic advice as well as opportunity to write chapters for their texts. Dr. Adams impressed upon me the importance of not letting projects stop after the abstract presentation but to see them through to the publication of the work in a journal.

Over the years, Drs. Rita Cydulka and Rebecca Smith-Coggins have played a big part in how I think about academics in the context of my career. They are two examples of extremely successful academicians with tremendous core values and are wonderful people as people as well. Dr. Cydulka gave me my first opportunity as a peer reviewer for AEM and continues to mentor me in a variety of academic venues. Voz also provided me with an opportunity to peer review the AAMC's MedEdPORTAL, which has been a tremendously gratifying activity. I consider the innovative nature and volume of your work inspiring and I look forward to your Tricks of the Trade section in ACEP News every issue. Aw, shucks.


Mentorship
Drs. Wendy Coates and Cherri Hobgood (SAEM Undergraduate Medical Education Committee) were instrumental in helping me get started. And I am sure these individuals don't know this, but I learned how to write a CV by reading Rita Cydulka's, Becky Smith-Coggins', Amal Mattu's, Jerry Hoffman's, and Bob Hockberger's. Every year we hold an annual lectureship entitled the Thomas R. Mulroy Symposium at NorthShore and I have had the honor of introducing these accomplished individuals. So in preparation, I scoured their CVs and in the process, I learned what was important.


Life
And last but not least, my family has given me the ultimate mentorship, support, and inspiration to be successful in my career. My parents and my sister have shown me the value of hard work and unconditional love. My wife, Daria, inspires and supports me every day by giving me the "protected" time at home to be able to work on academic projects and has given me four lovely daughters who give me the motivation to be a good role model. She is also a practicing emergency physician and compared to what she accomplishes with work and the kids, this academic stuff is almost easy. I truly believe that having children has been one of the biggest motivational forces in my life.

Wow, you have proven the point that having multiple mentors is important to move ahead in academics. You've clearly had some wonderful mentors.

We worked on the SAEM Diversity Video together. What behind-the-scenes things do you remember from the project?
And I have you, Michelle, to thank for the creative match that sparked the Emergent Procedures Instructional Collaboration (EPIC) project. I remember in 2007 when you and I first talked about the possibility of the Undergraduate Medical Education Committee (which as since morphed into CDEM) collaborating with the Diversity Interest Group on a diversity video for recruitment. I thought it would be a neat little project.

With your initiative, we were able to line up 3 tremendous interviewees who would represent the interest group well. I remember going into the filming with a very naive understanding of what we needed to produce this video and in retrospect, probably would have been much better prepared and thought it out better. The filming was fairly ad lib as we scouted around the Caribe Royal lobby for a good spot to shoot. Our filming tech was basic by most standards - you brought your camera, tripod, and directional mic. And the conditions were very "suboptimal" (in retrospect) as there were people walking by, carrying tables, hammering in the next lecture hall putting together a stage, and intermittent music was blaring in the background.

Yeah, I totally remembered loud 80's music blaring intermittently, and regretting that we didn't have a quieter space.

I remember after you downloaded the video onto my computer, I thought, "now what do I do with this raw footage?" I had never done any videoediting before and I had just gotten this new Mac computer. So in the airport while I waited for my plane, I opened up iMovie on my Mac (for the first time), started cutting and editing, and found that it was something that I really enjoyed and had a knack for. When I got home, I had to commission my neighbor's kid's friend to show me how to perform post-production sound editing using Final Cut Pro and I watched her do it for several hours a day over two days as she tuned out the music in the background and painstakingly got rid of the "clicks" and "pops" in the rest of the audio track.

Yes, I learned a lot from these early mis-steps. I think the video turned out surprising well though. The magic of video editing! Nice work.

I learned a lot of helpful videoediting techniques by scouring the web and working on the video. The more I learned, the more I got into this as a form of art and expression as well as a method of information delivery. I learned that any videoediting problem you can imagine probably has been addressed by someone (usually under the age of 20) and posted on YouTube.

At about the same time, I was skimming an issue of Academic Emergency Medicine, and found an ad looking for submissions to a new section of the journal entitled "Dynamic Emergency Medicine." The combination of working on the diversity video, the opportunity for publication in AEM, and my interests in simulation, created the perfect storm for me and led to the idea of creating procedural videos for publication. I felt like all the procedural videos that I had seen in other venues were either not well filmed, too long, or too detailed.

I wanted to create videos of procedures that were not necessarily all-encompassing, but conveyed the essence of what someone needed to know to successfully perform a procedure and to successfully avoid the common pitfalls that I had observed over the years in students and residents. I felt that if I could capture those elements in an artistic way, that they may find an audience and if they help a physician successfully perform the procedure or avoid a complication, then feel I will have done a public good. www.emergentprocedures.com

So in summary, you basically served as the impetus for my informal apprenticeship into the world of videomaking. We were very fortunate that the video was well received by the Diversity Interest Group and SAEM. Ironically many have commented to me subsequently that the "spontaneity" and "casual nature" of the diversity video was really effective and part of it's appeal.

Thanks for your time, Ernie, for sharing your experiences and thoughts about your academic life in EM.

Faculty hero: Ernest Wang (part 1)

I've been writing several "Faculty Spotlights" to feature some really amazing EM faculty members. It has dawned on me that a much more appropriate name for the series is "Faculty Hero".

I have known Ernie Wang for many years now way back to when we were both on the SAEM Undergraduate Education Committee (which is now the CDEM Academy). I've been an admirer of all the amazing work that he's done in the past several years. In fact, there are so many things that I'd like to highlight that this post is divided into 2 parts. The second part will be posted next Tuesday.

Clinical Assistant Professor, NorthShore University HealthSystem

Academic Director, Center for Simulation Technology & Academic Research (CSTAR)
Associate Program Director, University of Chicago EM Residency

Ernie, what’s your academic niche in EM?
My main academic niche is simulation-based medical education. And I have to confess that I came about it mostly by serendipity.

My academic career was really an unplanned event and I took the "bent-arrow" route to it. I still consider myself a clinician first, an educator second, and an academician third because I really enjoy taking care of patients, doing the "work" of emergency medicine, and working side by side with residents and students in the ED. I spent my first three years working clinically exclusively. Then I was asked to be the associate medical student clerkship director, did that for two years, then took over for our site as the associate program director for the EM residency.

Somewhere about that time, I was introduced to simulation as a result of working with John Vozenilek at NorthShore. Voz invited Jim Gordon to come to NorthShore to give a grand rounds on this "new" teaching modality called "simulation" and really turned us on to the possibilities that sim could provide for our students and residents. I then went to SAEM to a simulation workshop conducted by members of the nascent SAEM simulation interest group.

I distinctly remember Steve McLaughlin giving a compelling talk about the strengths of simulation. There was a subsequent demonstration which in which I, along with several others, volunteered to be be in the hot seat. We went into the sim and proceeded to kill the patient in expert fashion. I was convinced at that point that this was going to be a cool way to teach and train.


So how are you involved with simulation now?
I have been active with the simulation lab at the Center for Simulation Technology and Academic Research (CSTAR) since 2003. As the current academic director of CSTAR, my main educational activities involve the provision of simulation-based experiential learning for medical students (originally from Northwestern University Feinberg School of Medicine and, since 2009, the University of Chicago Pritzker School of Medicine), residents, nursing, and pre-hospital providers, through our various programs at the Evanston simulation center and the Highland Park simulation center.

Our medical student program is 2-3 hour weekly simulation experience overviewing code resuscitation and management of fundamental emergent scenarios. Our resident simulation program is based on a modular curriculum consisting of procedural training, pediatric scenarios, medical and surgical scenarios, OB/GYN and trauma scenarios. We incorporate core competency learning objectives (particularly systems-based practice issues) into the cases which are often drawn from real cases in the ED.

While the medical students and resident simulation education comprises a majority of our educational programs, we are rapidly developing a robust nursing training program entitled “The First 5 Minutes” where we train nurses to recognize and provide immediate treatment for the acutely decompensated patient. The goal is to provide this program to all the medical and surgical nurses within all the NorthShore hospitals. The foci of the program involves improving situational awareness of decompensating patients, promoting effective communication, and enhancing patient safety. We have recently begun implementing programs to train the Lake County Health Department medical staff on the management of acute emergencies in the office setting. In addition we have initiated outreach programs with our local high school, Highland Park Hospital, providing simulation based medical exposure to Hispanic students to promote careers in the medical field.

Wow Ernie, I had no idea that you were teaching so many different learners! You also have many "virtual learners". I've seen your simulation-based educational videos. They are really professional-looking and extremely valuable teaching tools.
Our academic productivity at CSTAR has been a fruitful collaboration. Over the past five years, we have collectively published 24 peer-reviewed original works in the field of simulation-based education. The variety really has made it interesting - we have done some original research, participated in multiple consensus publications, reported our innovations in curriculum design and task trainer product development, and created a collection of procedural videos. We have three more publications that have been accepted and several more in process.

My personal work has focused on development of procedural expertise, simulation case development, curriculum design, and systems-based practice education with simulation.

Ernie giving an overview of simulation to incoming
medical students from University of Chicago.

You've definitely carved a huge academic niche in simulation and technology.
Yes, and I hope I can serve as an example of someone who took a non-traditional approach to academics and has been able to achieve my goals and have fun doing it. You don't always have to go straight into it right out of residency or work at the big University hospital to be academically productive.

Academia is a wonderful way to supplement your clinical career. It keeps you interested, it keeps you sharp, and it can provide more job satisfaction that will likely prolong your career. Academia is meaningful to me primarily in the context of relationships, mentoring, doing projects with others. You can't do it alone. You have to rely on and acknowledge those that helped you get where you are and do your part by passing the passion and lessons along to those who will follow you in the next generation.

I can't agree with you more, Ernie. We need more inspiring leaders in academics like yourself. Keep up the amazing work.

Faculty highlight: Dr. Lisa Moreno-Walton

A large part of the reason why I love academics so much is that I get to meet really inspiring emergency physicians, who are passionate about their cause. I can't imagine a more dedicated person than my friend Dr. Lisa Moreno-Walton, who is the Associate Program Director at LSU in New Orleans.

Dr. Lisa Moreno-Walton
Associate Program Director, Emergency Medicine
Assistant Professor, Louisiana State Univ Health Sciences Ctr, New Orleans
Clinical Research Scholar, Tulane University

Lisa, I know that you have your hand in lots of areas within Emergency Medicine, but what would you call your niche?
My academic niche is translational research. When I started my residency in EM, I had no clue that I liked research; in fact, I thought it was boring. My mission and my passion was providing excellent clinical care to under-served populations. I knew that I wanted to do academics, because the opportunity to teach residents to deliver good clinical care with compassion and respect is a great way to serve even more patients, indirectly.


How did you decide on translational research?
In my last year of residency, one of my mentors, Dr. Yvette Calderon, used her great persuasive powers to get me involved in a research project. And suddenly, I saw the light. Not only did I love doing research, but I also realized that by doing research and establishing best practices through evidence based studies, I would be able to improve the care of hundreds of thousands of patients during the course of my career. That is both humbling and exciting. Also, I am the kind of person who is always asking questions. I want to know why we do things the way we do them in the ED. I always wonder if there is a better way. And I wonder why certain diseases or injuries evolve the way they do. Research is the way you get the answers to your questions. So, now, I have three professional passions!

What are some things that you have learned during your time in academics?
The most important thing I've learned from my mentors is to choose the right mentor. I got the best advice on the characteristics of a good mentor when I attended the AAMC Minority Faculty Development Seminar, and I would be happy to share what they taught me:

• You need a mentor who is successful in his or her own career, otherwise how can s/he guide you towards success?
  
• S/he should be powerful at your institution or in EM; someone who other people know and respect, so that when s/he recommends you for committees, speaking engagements, etc. people will listen and respect the recommendation.
  
• S/he should be influential. That is not the same as being powerful. There are powerful people who couldn't get anyone to follow them to a water cooler during a drought!
  
• You want someone who can open doors for you, whose intellectual and professional currency is reliable, someone who can make things happen. Your mentor does not need to be the same sex or the same race or of the same cultural background as you are, but s/he needs to be someone who is willing to understand your world and your perspective and who wants you to reach your career goals just as much as you want to reach them.

Now, that being said, the second most important thing I learned from my mentors is that you must be willing to work very hard and you must follow through. It does no good to have your mentor opening doors for you if you don't walk through them, or to have him get you a speaking opportunity and then you show up unprepared, or for him to get you on a national committee by saying that you are enthusiastic and a hard worker, and then you turn out to be a slacker. You discourage him, you ruin your reputation, and you ruin his credibility for recommending the next mentee who comes along.

Dr. Peter Deblieux on PBS

Who is your mentor?
My mentor is Dr. Peter DeBlieux, and he is an absolute rock star. He is not interested in research, but he has a real gift for moving a young faculty member through all the right steps to achieve her career goals and get her from one success to another. He knows when I am taking on too much, when I am not focusing on the right things, when I am not organizing my tasks and dividing my time appropriately. I may not always love everything he tells me, but he tells it to me straight and his advice is always on target.

I remember Peter being interviewed on TV multiple times post-Katrina. He is consistently so poised and well-spoken. You are lucky to have him as your mentor. I totally agree about Peter being a rock-star, although he's got a mischievous side to him...



You are the Chair of the SAEM Diversity Interest Group (DIG). What is this group all about?
Well, I'm the Chairman this year, and thanks to Dr. Michelle Lin, we have actually recently realized one of our goals. For a long time, we have wanted to be involved in a virtual advisor program where we could be available to students who come from under-represented minority groups, who are interested in EM but may not have doctors in their family group or among their friends who can advise them, or who may not have had opportunities to be exposed to research or science in school.

We are also in the midst of doing a study to look at how women and racial minorities are represented in academic EDs around the country. A similar study was done just over ten years ago, showing that women and URMs are under-represented at all levels, but especially at the higher academic ranks of Associate and full Professor. We wonder if the disparities have in any way changed. And we wonder how leaders in EM feel about these disparities and whether there is a motivation to change them.

Eliminating disparities for our patients and within our profession is what the DIG is all about. We are dedicated to the concept that EM is better for everyone when health care disparities are eliminated and when there is parity in the work place. And our success depends on the continuous influx of committed, effective young students and residents. Everyone of us needs to have one hand up, reaching for the next rung on the career ladder, and one hand down, pulling the other folks up behind us.

So what are you working on this week?
Well, my major project is the study of the effects of moderate alcohol intoxication on the secretion of epinephrine, norepinephrine, and arginine vasopressin in the trauma patient. This week, I will also start to work with one of the basic scientists at the Medical School who is studying the effects of alcohol on the regulation of mononuclear cell tumor necrosis factor production in the murine model. Tumor necrosis factor is a significant marker for sepsis. Should this relationship prove to be significant, we will be developing a study to quantify this relationship in trauma patients. We know that intoxicated trauma patients develop sepsis more frequently than unintoxicated patients, but we don't fully understand why or what can be done to prevent it.

This week, I will also attend classes at Tulane, where I am studying for a Masters Degree in Clinical Research, I will work a shift in the ED side by side with my excellent residents, I will moderate a didactic clinical conference for our residents, and I will work with a few residents on their clinical research projects. One resident will start a project with me this week looking at the effectiveness of an educational intervention designed to encourage patients admitted for ROMI/ACS to modify their cardiac risk factors.

Yesterday, I completed the writing of a manuscript and did some of my committee work for the SAEM Diversity Interest Group. Later in the week, I will start the research to put together a lecture that I'll be giving at AAEM in February.

Wow, is this an average week for you?
So, by looking at my work week, this is a pretty average week for me. You can really see that Emergency Medicine provides me with a very well rounded professional life. I can see patients, do bedside teaching, do didactic teaching, and do both clinical and translational research. I get to be a learner and a teacher. I have the stimulation of working with students and residents, and of interacting with basic scientists who do work that is substantially different from what I do in the ED. I am able to serve my patients and my colleagues with work in national EM organizations, and I am beginning to have opportunities to publish and to lecture nationally.

I work with a really outstanding group of dedicated and really smart EM faculty and residents in a really terrific city, where I enjoy living and spending time with my family. I have a mentor, a Medical School Dean, and my Masters program advisory faculty who really want to see my career progress. I can't imagine that anyone who does anything else for a living could be as happy as I am doing EM at LSU. I mean, my work is not work...it's a pleasure!

I'm living my dream.

Wow, Lisa. You are indeed living the dream. You are the epitome of a classy academician. Keep up the great work.

Faculty spotlight: Dr. David Wald

I've had the pleasure of knowing Dr. Dave Wald for several years now, working on projects and committees in Clerkship Directors in Emergency Medicine (CDEM) and SAEM. He is a true advocate for undergraduate medical education, and it is no surprise that he is the natural choice to be this year's CDEM Chair. As much as those us on the Executive Committee of CDEM give him a hard time for his extremely long emails and gullibility (be sure to ask him about a recent $800 dinner bill we left him with), we can't deny that Dave is a true outspoken leader in medical student education.

David A. Wald, DO
Associate Professor of Emergency Medicine
Director of Undergraduate Medical Education
Associate Course Director - Doctoring Course
Temple University School of Medicine (Philadelphia, PA)

EM residency training: Albert Einstein

1. Dave, what’s your academic niche and how did you decide on it?

Currently, my interests lie primarily in undergraduate medical education. When I started at Temple University Hospital I became actively involved in our departments EM residency training program. At one time or another, I was involved in all aspects of residency administration. Although I still play a role in resident teaching, over the years I have transitioned the majority of my non-clinical time and emphasis to undergraduate medical education serving as Director of Undergraduate Medical Education in our department, EM Clerkship Director, and Associate Course Director, Doctoring Course for Temple University School of Medicine.


2. Wow, how did you manage to carve out this career path? At times just being in the right place and getting involved can make a huge difference. About 6 years ago, I volunteered to take on the role of Chair of the SAEM Medical Student Educators Interest Group. This was a great opportunity to perform research with faculty at multiple institutions and start to develop a name for myself outside of my home institution. The relationships that I developed ultimately led to friendships and other opportunities. In the past 2.5 years I have been lucky to work with some of the best educators in our specialty and have from the ground up have been able to assist in the development of the Academy of Clerkship Directors in Emergency Medicine. It is amazing what can be accomplished with even just a few hardworking and motivated individuals.

3. Who were your mentors?
Mentors to me were Douglas McGee, DO (Prior EM Residency Director at Albert Einstein Medical Center) and Kip Wenger, DO, years back served as EM clerkship director at Einstein Medical Center.

4. What’s a project that you are working on now?
Presently, I am working on a number of projects. At my home institution, I am working to further incorporate simulation into the undergraduate curriculum. This is primarily focused on initiatives in the MS I and MS II years. For the past 2 years, I have worked with a small group of basic scientists to develop and refine a set of problem based exercises using high fidelity simulators. We continue to refine these exercises and to date have developed 6 exercises; diabetic ketoacidosis, ventricular tachycardia, complete heart block, asthma exacerbation, opioid overdose, and hemorrhagic shock.


5. What words of wisdom can you share with those interested in or just starting out in academics?
For those of you contemplating a career in academic EM my advice is to get involved early. Often just being enthusiastic, hardworking, and showing interest goes a long way. Find a mentor, most often this can be someone who has similar interests to help guide you along the path. Emergency medicine is perhaps the most proactive specialty for those interested in an academic career. The sky is the limit.

Faculty spotlight: Dr. John Brown

Dr. John Brown is the well-known (infamous?) Medical Director of the San Francisco EMS Agency -- not a small task or for the weak of heart. He also practices at SF General Hospital and manages to keep level-headed in the midst of chaos. I'm constantly impressed by his clinical and political saaviness. You would never know how big of name he is when you meet him. Totally humble and understated, especially given all that he's done for the city and our specialty.

In January 2009, I was bragging about John to our EM residency applicants on the hospital campus tour. "He's an important leader in San Francisco AND works at the General... yada yada yada." And right on cue, he passed by us, riding his old bike and rang a cute little bicycle bell. Ding ding. "And he's the one of the nicest guys you'll ever meet."

John is in the light blue shirt at New Orleans as part
of the DMAT team after hurricane Katrina.

Medical Director, San Francisco EMS Agency
SFGH Emergency Department
EM Residency: Naval Hospital San Diego
EMS Fellowship: University of Arizona, Tucson

John, what’s your academic niche and how did you decide on it?
During my residency, I noticed that the patients who were the sickest were saved or lost by the prehospital providers; i.e. if they reached us in the ED with ROSC (return of spontaneous circulation) we had a chance to resuscitate them, but if they were pulseless and apneic we were never successful in our care. The practice of good Emergency Medicine is highly dependent on a good EMS System, and most Emergency Physicians don't concern themselves with this aspect of the practice! I saw a neglected opportunity and an area where a lot of heavy lifting needed to be done, and I went for it. Having a great EMS rotation as a resident helped as well, and my first job in EM directing the small Emergency Department at the US Naval Hospital in Subic Bay, Republic of the Philippines, both cemented my interest and so I pursued fellowship training.

Who were your mentors and what good advice did you get?
I have been fortunate to have many mentors in my career. Steve Monson and Gary Lammert at the Naval Hospital San Diego taught me the value of being a "dumb dedicated doctor", i.e. focusing on strong basics of care and constancy of attention to the mission at hand (instead of the politics du jour).

Doug Lindsey, Dan Spaite and Terry Valenzuela at the University of Arizona taught me the many permutations of EMS and disaster medicine, and an organized approach to the field, concentrating in those areas that are most important and need good medical oversight (instead of "data mining").

Bob Swor at the University of Michigan has given me good advice on EMS research. Mitch Katz at SF Department of Public Health has helped me to learn the political ropes. Andy Stevermer at the National Disaster Medical System has taught me a lot about providing medical care under austere conditions and having a good time doing it. And Howard Graves at SFGH has taught me how to flourish and thrive while providing patient-focused care in the sometimes chaotic environment of our Emergency Department.

Several of my mentors are still in my life, some have retired, one has died, but they all are an important part of my educational experience.

What’s a project that you are working on now?
A project that I'm particularly excited about is our combined efforts at UCSF/SFGH Emergency Medicine to provide a full spectrum of EMS/disaster education. We have had several medical students take an EMS/disaster elective supervised by Clement Yeh. We'll also be having two of our EM second-year residents, Swati Singh and Jennifer Wilson, start an Area of Distinction in EMS/Disaster this August.

Doing disaster training in Odessa, Ukraine
(Wait, is that the same light blue shirt as above, John?!)

EM relief work in Haiti

You were an EMS fellow and it sounds like you are starting your first EMS/Disaster Fellowship? Yes! On July 1, we'll have our first EMS/Disaster Fellow, Evan Bloom, join the program. With our connections with Disaster Medical Assistance Team CA-6 we have several disaster training and even an international medicine in developing country opportunities for our residents. I'm also particularly proud of our program having the first LGBT (lesbian, gay, bisexual, and transgender) health issues curriculum in the country. It is my hope that our graduates will have the best well-rounded education to practice in any setting they choose.

Faculty spotlight: Dr. Ghazala Sharieff

It's not every day that you get to meet and hang out with a fun, funny, humble, spirited, and super-smart person. I first got to know Dr. Ghazala Sharieff on the lecture circuit. She's one of the major go-to speakers for anything related to pediatric EM. When I'm stuck in a dilemma about a pediatric patient, I think - WWGD? What would Ghazala do?

Also if you're ever walking with her at an EM conference, you can't really get more than 10 feet before being mobbed by people wanting to say hi to her. So I wanted to introduce you to a good friend and genuine rock-star in medicine.

Dr. Ghazala Sharieff Division Director of Rady Children's Hospital Emergency Care Center Associate Clinical Professor, UCSD

Undergraduate: Univ of Michigan
Medical school: Michigan State
EM Residency: Stanford-Kaiser
Pediatric EM Fellowship: Children's San Diego

Ghazala, what's your academic niche and who were your mentors? My academic niche is in national and international speaking. I fell into this with the help of Mel Herbert, Larry Satkowiak and Mike Gerardi. I was pretty aggressive about being on the lecture circuit.

You can check out free previews of her talks from various conferences from CMEdownload.com (View previews)

What projects are you working on? I have a few projects underway. I'm the pediatrics section editor for Harwood Nuss and just published a textbook on neonatal and infant emergencies, by Cambridge. It came out last November!

I'm also working on some research projects with my fellows.

• A study on single dose decadron vs day 1 and day 3 decadron for asthma.
• A study on the use of a rapid medical assessment program in decreasing left without being seen rates in a pediatrics ED.
• A study on ketamine vs ketamine plus propofol for sedation in the pediatric ED

Faculty spotlight: Dr. Renee Hsia

There are so many interesting and inspiring EM faculty and none more so than in our own department at San Francisco General Hospital. Dr. Renee Hsia is a rising superstar in our department who has received numerous fancy awards and grants including the prestigious Robert Wood Johnson Faculty Scholar award. She makes me feel small, insignificant, and uncultured. For instance, I thought Eritrea was a rash. Anyway, read below to see what I mean. Good thing I can at least beat her in foosball.

Renee Hsia, MD MPH

Medical school: Harvard
Grad school: London School of Economics & School of Hygiene and Tropical Med
Residency: Stanford-Kaiser

What is your academic niche and how did you decide upon it?
I am absolutely passionate about the clinical practice of EM and, without a doubt, being in the emergency department forms not only the basis of my work, but also provides the impetus behind my research. Beyond the clinical practice, I spend a lot of time thinking about the development of health systems and its impact on populations, both domestically and globally. I can pinpoint when this broader perspective came alive to me to a brief period of my life when I lived in South Africa for six months. As a “colored” in that society, I realized on a very personal level that systems matter, and that almost all of the disparities I saw — and experienced — stemmed from policies that were intentionally and systematically designed to not only create, but also maintain, these injustices.

After that, I spent small bits of my life in different parts of the world between and after medical school, mainly in sub-Saharan Africa, from Rwanda to Senegal to Eritrea. After some pretty wild experiences (spanning the spectrum of becoming delirious with malarial fevers to ducking gunfire from the Congo), I decided to commit to developing my interests in health policy and finance at the London School of Economics and the London School of Hygiene and Tropical Medicine.

Since then, I’ve spent my energy in better understanding the health care systems and impacts of policies on underserved populations in domestic and international contexts. Some people wonder if doing domestic and global health work is contradictory, but I find that they mutually enrich my understanding of the other. Especially at San Francisco General, which is the county hospital for SF and where the majority of homeless patients receive their care, I find striking parallels in the barriers that patients who have few resources make, whether it be in the U.S. or in Africa. Examples range from patients who must decide whether to forgo medicine for food, where they should seek care, and how the context influences their behavior.

So who were your mentors?
Tough question; I think “mentorship” can range from those who, in the traditional sense of the word, teach you more in a certain discipline, to those who, on a broader scale, inspire you to be who you were to created to be. I’ve had incredible teachers who have been incredible mentors in both meanings of the word. But I’ve also been blessed to be challenged by people I wouldn’t necessarily think could or would lead me to think more deeply about my place in life. Many of the larger lessons I’ve been learning along the way have been taught to me by children.

For example, I remember once on a mission to Haiti, I was in a Jeep that was carrying bags of rice to remote and impoverished areas, and as soon as we drove up to the village, the Jeep was almost turned over by totally famished children who were overjoyed at the sight of the next food provision. There was one child who held back from the crowd and came up to me, rather than the bags of food, and noticed at the band-aid on my finger (covering a papercut) and asked, “Ca te fait mal?” (“Does that hurt you?”). The fact that he could, despite his own needs, actually care about mine, absolutely blew me away. I still am hoping to become more like him.

What are you currently working on?
A million things, but I’ll name a few!

One of my projects is looking at whether emergency services are less available to underserved populations – meaning, those who are poor, have no insurance, or are minority. Since health care in this country is largely driven by market forces, there are inevitable effects of this choice on certain populations. Practically, for example, many ED physicians and health care administrators would say that areas with high proportions of the uninsured will have fewer emergency services since hospitals in these areas can’t afford to keep these services open. And while anecdotally we think this is true, there’s been relatively little research to actually provide evidence for this. I’m working on a few projects that show that this is indeed happening in emergency departments and trauma centers.

In global health, there are a few projects in which I’m involved to shed more light on the need for emergency and surgical services abroad. While these have traditionally been thought of as “high-cost” interventions, there are actually many emergency and surgical conditions that are amenable to low-cost, curative care. How can we define these needs? How can we determine which interventions are cost-effective? How can we address these problems with practical solutions alongside governments who want to provide these services? There are a few collaborations through the Global Health Sciences at UCSF that I’ve been developing, specifically in Uganda and Niger, and perhaps Rwanda in the near future.

I think the underlying question behind my work, both on a clinical level and a research level, would be, “How do we treat people with dignity?” This can come in the form of treating patients in the ED with respect and caring for their needs as best as we can, as well as providing on a systems-level the resources they need to have physical health to be who, as I said earlier, they were created to be.

Wow. A perfect example that clearly one person CAN make a difference.