Gestalt & Go

Gestalt & Go
MDM

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  • Accordion Title

    Key is to understand that all signs and symptoms are not equal.

    So how do we know how much weight to place on each sign or symptom?

    Most attending’s do this based on experience. They use their intuition. 

    But there is another way…you can build Gestalt

    There are some important terms you need to understand in order to build a gestalt

    • Sensitivity & Specificity
    • Predictive Values (Positive and Negative)
    • Pretest & Post Test probabilities
    • Pretest & Post Test Odds
    • Likelihood ratio’s

    There is a hierarchy of statistics in terms of utility. 

    Sensitivity & Specificity

    • SPIN = Specificity Rules IN: A positive test makes the disease likely
    • SNOUT = Sensitivity Rules OUT: A negative test makes disease un- likely

    Issues with SPIN & SNOUT:

    • With sensitivity and specificity, we use a cutoff point to divide the test into (only) two results: positive or negative.
    • In real life, diseases present in gradations of severity
    • By limiting a test result to “positive” or “negative”, we stand to lose important diagnostic information.

    • Thinking in terms of “Yes” or “No” is a good way to miss the diagnosis.

    • Sensitivity and specificity are independent of disease prevalence
    • Sensitivity and specificity are dependent on disease severity
    • In early disease, it is difficult to differentiate between health and illness (sensitivity/specificity decrease)
    • Sensitivity and Specificity increase in severe disease (as the difference between health and disease become more clear).
    • So, reported sensitivity/specificity for a disease may not always reflect the sensitivity/specificity for the individual patient (because they may be early in the disease)
    • Sensitivity and Specificity are tough to apply to the individual patient
    •  

     

  • Predictive Values

    Predictive Values

    Positive Predictive Values

    • Probability of patient having disease when test is positive
    • In other words, it is the percentage of patients with a positive test who actually have the disease

    Negative Predictive values

    • Probability of patient not having disease when test is negative
    • It is the percentage of patients with a negative test who do not have the disease

    Problem with Predictive Values

    • Disease prevalence has a significant impact on the positive predictive value (PPV) and negative predictive values (NPV).
    • Therefore, despite a high sensitivity and specificity of a given test, the PPV will be very low in a disease with a very low prevalence
    • PPV & NPV can only be applied to population that was in the study.
    • You can not apply these to individual patients, and thus, does not help you build gestalt
    •  

Love the Likelyhood

  • Big Picture

    Likelihood ratios are the best STAT for building gestalt and making decisions. To use likelihood ratio’s you need to use incorporate pre test probability and post test probability. Below will discuss these in more detail.  

  • Before testing

    Pre-test Probability

    This is the probability of disease prior to testing

    • If you don’t know the Pre-Test Probability for a given disease….
    • PRE-TEST PROBABILITY = DISEASE PREVALENCE
    • Once the history and examination are completed. The pretest probability may remain the same, decrease, or increase
    • When experienced clinicians evaluate a patient they intuitively place a pre-test probability on a decision bar 

    You can think of probability of disease as a ruler. This is the decision bar. 

    On the left is 0% probability of disease, on the right (10 cm) is 100% probability of disease. Each millimeter is a 1% probability. 

    Now we will set the rule out threshold which will determine the rule out zone.

    Next we will set our Rule In Threshold, which will determine our Rule In Zone

    The area between the rule out threshold and the rule in threshold is the testing zone. 

     Once the zones are in place, the next step is to place a pretest probability on the ruler. 

    The pre-test probability can be obtained in many ways. Clinical scoring systems (i.e. Wells score) can give you the pre-test probability. However if you don’t know this, just use the disease incidence as the pre-test probability. 

  • After Testing

    The post test Probability

    • This is the Probability of disease after testing is resulted

     

    Or your post test probability could be somewhere in this area (does not cross threshold)

    Next I will show you how to adjust your pre-test probability to get a post test probability

  • How to use it

    Next I will show you how to adjust your pre-test probability to get a post test probability

    Likelihood ratio’s

    • Most useful STAT 
    • Unlike Sensitivity, Specificity, PPV & NPV; Likelihood ratio’s CAN be applied to individual Patient
    • Best Representation of Accuracy of Test
    • Can alter pre-test to create post test probability
    • Signs and Symptoms can also have associated LR ratios
    • Can multiply LR’s
    • NOT affected by Disease Prevalence or Disease Severity

    A likelihood ration is essentially a number telling you how much weight you should give each sign, symptom & test.

  • Math Behind Likelyhood ratio’s

    It is the ratio of probability of test result in patient with disease to the probability of same test result in patient without the disease

    • LR > 1 means that a positive test result is more likely happen in a patient with the disease (i.e. can suggest that the disease is present)
    • LR < 1 means that a positive test result is more likely to happen in a patient without the disease (i.e. can suggest that the disease is not present)

    The further away from 1, the stronger the influence on disease probability

    There are 2 types of likelihood ratio’s: LR + and LR –

    • LR+: This is the change in pre-test probability caused by a + test result. The higher the number, the more likely the disease.
      • LR + of 1-5 is NOT helpful
      • LR + of 5-10 is moderately useful
      • LR+ of > 10 can change decision making
    • LR-: This is the change in pre-test probability caused by a – test result
      • LR – of 0.5 to 1 is NOT helpful
      • LR – of 0.1 to 0.5 is moderately useful
      • LR – < 0.1 is very useful

    Pre-test probability and LR’s can be used to calculate a POST TEST probability. You need to convert the probabilities to ODDS for calculations with Likelihood ratio’s. 

    1. Change Pre-test Probability into Pre-test Odds
    2. Multiply Pre-Test Odds x LR which will give you Post Test odds
    3. Change Post test odds into Post Test probability

    NOTE: You can combine LR’s to get a combined post test probability

    • Posttest Odds = Pretest Odds × LR1 × LR2 × LR3 … × LRn
    • Then turn this cumulative Post TEST odds into a POST TEST probability

  • End Result

    If post test probability does not cross either line, don’t do the test

PE Example

  • Background

    • 30 year old female just got off an airplane. She just returned from Europe. She presents complaining of chest pain.
    • She now has pleuritic chest pain
    • She is mildly tachycardic but not hypoxic
    • VS are stable
    • You have basic lab services (including a D-dimer) but no imaging at your hospital
    • She is on birth control

  • Step 1: Set Pre- Test probability

    • Wells criteria gives you a score of 3.0
    • This is a Pre-test probability of 20% but since she is on OCP use let’s raise this to 30%

  • Step 2: Pick Discard & Accept Thresholds

  • STEP 3: Get Post Test probabilities

    We can use the Fagen NOMOGRAM

    • This uses PRE TEST PROBABILITIES and the LR’s to give you a POST TEST PROBABILITY

    Or we can turn the pre-test probability into pretest odds and calculate the post test probability:

    1. Pre-test Probability > Pre-test Odds
    2. Pre-Test Odds x LR = Post Test odds
    3. Post test odds > Post Test probability

     

  • The old DDimer test in action

Cardiovascular ICU Selective/Elective

Teaching Chief: Kartheek Nagappala MD

Description: Advanced Cardiovascular Critical Care rotation will allow residents to further develop their skills, knowledge and attitudes obtained during their previous rotations, specifically expanding on their critical knowledge to patients that are post cardiac surgery, major vascular surgery, and critically ill due to compromise of their cardiovascular system. The rotation will involve 21-22 12-hour shifts, similar to the EM core ICU experience. 

Availability: Generally available year-round and will occasionally share the experience with an Anesthesia co-rotator.

Scheduling: Schedule to be made by the rotator with final schedule approval by the teaching chief

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Community Emergency Medicine Elective

(PGY-3 only)

Teaching Chief: Various (depending on location)

Description: This is an opportunity to experience medicine across the care spectrum in a completely different cultural, social, and economic environment. From learning how to deliver sustainable care in critical access areas of the world, to experiencing Emergency Medicine as it is practiced elsewhere, the possibilities are endless. Previous residents have set up unique experiences in Uruguay, Thailand, Vietnam, and Tchad. Prior to thinking about an international elective the resident should consider travel, safety, health (vaccinations etc.), and financial concerns. Dr. Sukhija can help you guide you with strategies to set up an experience as each one is highly individual. 

Availability: Variable

Scheduling: Variable

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Palliative Care Selective/Elective

Teaching Chief: Ryan Howard MD

Description: The Palliative Care Selective or Elective is a 2- or 4-week inpatient rotation designed to expose the rotator to all aspects of inpatient palliative care. Residents will work alongside the palliative director and/or the palliative fellow along with the interdisciplinary palliative team throughout the rotation. The goal is to provide either PGY2 or PGY3 residents with an immersive clinical experience to learn more about inpatient palliative services.

Availability: Generally year-round, those interested in applying to Palliative Fellowship get precedence on the rotation as space is limited

Scheduling: M-F, 8am-5pm, with call shifts if required/desired per Dr. Howard

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Intro and Advanced Pharmacology Selective/Elective

Teaching Chief: Chadi Kahwaji MD, PhD and Savannah Lail PharmD

Description: A 2 or 4-week rotation where the resident works and learns alongside the ED pharmacists on assigned shifts. The Pharmacology rotation is designed to provide training concerning the application of pharmacology knowledge, pharmaceutics, drug information, medication safety, communication skills, critical thinking, pathophysiology, and therapeutics to the care of patients in an emergency department setting. The advanced rotation is for those who have already had the introductory Pharmacology rotation experience.

Availability: Generally year-round, but must contact PharmD teaching chief prior to choosing the rotation to ensure availability. 

Scheduling: Variable shifts, 10-shifts per rotation, to be assigned by PharmD teaching chief

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Pulmonary and Ventilator Management Selective/Elective

Teaching Chief: Leland Beggs MD

Description: This is a 4-week rotation based in the ICU, CVICU and ED. Residents will work side-by-side with designated respiratory therapists as well as core faculty physicians. The goal of this rotation is to focus solely on vent management and non-invasive ventilation techniques in patients with a wide variety of disease processes. Residents will be expected to manage vent settings for intubated patients in the ED, ICU and CVICU. Residents on service should gain an in-depth understanding of the events surrounding intubation, including strategies in pre oxygenation as well as the various drugs used for RSI and post intubation sedation. In addition, they will learn when to initiate, and how to manage non-invasive ventilation.

Availability: Generally year-round

Scheduling: M-F, 6am-4pm

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Radiology Selective/Elective

(Two-week experience) 

Teaching Chief: Ashkan Shahkarami MD

Description: The two-week Radiology rotation will provide the resident with an opportunity to learn normal and abnormal radiographic anatomy, recognize radiographic findings of common diseases, understand the indications for commonly ordered imaging studies, and learn the appropriate use of IR procedures. The goal of the rotation is to help the resident become competent in the use of imaging in the evaluation and treatment of disease.

Availability: Generally year-round, but must contact teaching chief before choosing the rotation to ensure availability

Scheduling: M-F, 8am-4pm, or as adjusted by the Radiology attending

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Wilderness Medicine Selective/Elective

Teaching Chief: Various

Description: The one-week wilderness medicine selective is offered twice a year at Kaweah Health, usually once in the Spring and once in the Fall/Winter. If not available during the allocated selective/elective block, previous residents have participated in 4-week experiences in Utah and Redding, CA. Experiences are variable and depend on the chosen course, so for this one touch base with Dr. Sukhija to see what is feasible both locally and away.

Availability: Highly variable, see description above

Scheduling: Highly variable

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Emergency Medicine Admin Selective/Elective

Teaching Chief: Kona Seng DO and Khoa Tu MD

Description: This is 2-4-week rotation in conjunction with the Department of Emergency Medicine Medical Director. The purpose of the ED Administration rotation is to provide an understanding of the administrative components of EM clinical services and operations. This will allow early exposure to ED administration to determine if the resident is interested in the administration and business of emergency medicine. The EM residents will attend all assigned meetings and participate in administrative projects. 

Availability: Generally year-round, will share the rotation with the PGY3 on their core admin rotation

Scheduling: M-F, 9-5pm, or as adjusted by the teaching chiefs

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Patient and Physician Advocacy and Street Medicine Selective/Elective

Teaching Chief: Kunal Sukhija MD, Omar Guzman MD, Lori Winston MD

Description: The Advocacy 2- or 4-week rotation is designed to be a self-directed customizable experience that will provide immersion into various aspects of physician and patient advocacy. The resident will be able to participate in local, state-wide, and national (schedule permitting) advocacy efforts while simultaneously learning about effective strategies to engage community leaders, legislators, and the local constituency. The rotation will offer experiences in both the legislative and community advocacy (the latter will be based in the Street Medicine program). 

Availability: Generally year-round, however certain months tend to be better given the yearly CMA, AMA, CalACEP, ACEP schedules. Touch base with Dr. Sukhija prior to choosing this elective in order to ensure you can get the individualized experience you desire.

Scheduling: Highly variable depending on advocacy events and meetings, Street Medicine tends to hold its events on Friday

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Performance and Quality Improvement (PI/QI) Selective/Elective

Teaching Chief: Chadi Kahwaji MD, PhD

Description: The Performance Improvement (PI)/Quality Improvement (QI) selective rotation will provide exposure to ongoing PI and QI efforts at KDHCD and provide opportunities for the PGY2 or PGY3 EM resident to become involved in PI/QI projects on an individual, departmental, or institutional level. The resident will join the Emergency Medicine PI director in the regular duties of chart review, M&M conference coordination and presentations, and committee meeting attendance as appropriate. It also offers time for the resident to work on their PI/QI project as part of residency graduation requirements. 

Availability: Generally year-round

Scheduling: Variable depending on meetings and current on-going projects

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Public Health Elective (PGY3 only)

(PGY3 only)

Teaching Chief: Karen Haught MD MPH, Tulare County Public Health Director

Description: This is a 4-week rotation with the Tulare Public Health Department designed to expose the rotator to all aspects of public health. Residents will work alongside the Tulare Public Health Director and/or the epidemiologist throughout the rotation. The goal is to provide PGY3 residents exposure to the role of the local public health department in the community. Residents will be expected to work at the Tulare Public Health Department and contribute to a community health project of the resident’s choice.

Availability: Generally year-round, though an interested resident should first contact Dr. Haught prior to selecting this experience (Dr. Sukhija will help you with contact information)

Scheduling: M-F, 9-5, though historically it’s been less than this as independence is given to work on the resident’s chosen project

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Research Selective/Elective

Teaching Chief: Chris Patty DNP, Director of Research

Description: The goal of the resident research rotation (2 or 4 weeks) is to improve the resident’s understanding of how new knowledge is created and translated into practice.  At the end of the rotation, the resident will present a deliverable which demonstrates ACGME competencies in knowledge development and translation. Many residents choose this rotation in order to work on their chosen Scholarly Activity as part of residency graduation requirements. 

Availability: Generally year-round, the resident must contact the director of research 4-weeks prior to the rotation in order to state deliverables and set up the rotational requirements.

Scheduling: Variable, generally self-directed independent work

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Simulation and Education Selective/Elective

Teaching Chief: Kim Sokol MD

Description: This is a 4-week rotation includes developing simulation scenarios, teaching simulation-based educational sessions, and assisting in daily operations in the simulation center. The rotation’s purpose is to develop skills associated with teaching. The rotation will provide an introduction to simulation with multiple adjuncts such as high and low-fidelity mannequins, task trainers, and the use of standardized patients.  A basic understanding of simulation-based education and debriefing will be taught along with basic principles associated with adult education. The resident must choose teaching shifts as their clinical experience.

Availability: Generally year-round

Scheduling: Variable, to be determined with the teaching chief prior to the rotation start date

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Teaching Elective with Dr. Stanley

(PGY3 only)

Teaching Chief: Michael Stanley DO

Description: This 4-week rotation is a highly-desired advanced elective rotation for PGY3 EM residents. It is intended only for those residents who are serious about improving their ability to teach AND lead. This rotation is as much about leadership as it is about teaching because both utilize the same skill sets. Residents will gain knowledge in effective communication techniques while learning about the underlying psychology of teaching, learning, and leadership.

Availability: Generally year-round

Scheduling: 12 10-hour shifts to be scheduled in accordance with Dr. Stanley’s clinical schedule, along with didactics (also to be scheduled with Dr. Stanley prior to the start date). If Dr. Stanley has less than 12 shifts, then the remainder can be completed with either Dr. Oldroyd, Dr. Sokol, or Dr. Alexeeva.

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Advanced Ultrasound Selective/Elective

Teaching Chief: John Hipskind MD

Description: This 4-week rotation is designed to augment the resident’s diagnostic (and therapeutic) skills in relation to the ultrasound, and to explore more advanced US modalities such as TEE. The resident will gain experience with nerve blocks, enhanced approaches to the core EM ultrasound studies, and explore novel ways to use the ultrasound in the ED setting. They will work alongside the teaching chief as well as the ultrasound fellows.

Scheduling: The expectation is to be scanning daily M-F, with weekends off. Due to PGY1 EM rotators and the popularity of this selective/elective, there may be many residents on rotation, and thus scheduling must be in conjunction with Mia Zavinovich and Dr. Hipskind prior to the start of the rotation. 

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International & Global Medicine Elective

(PGY3 only)

Teaching Chief: Various (depending on location)

Description: This is an opportunity to experience medicine across the care spectrum in a completely different cultural, social, and economic environment. From learning how to deliver sustainable care in critical access areas of the world, to experiencing Emergency Medicine as it is practiced elsewhere, the possibilities are endless. Previous residents have set up unique experiences in Uruguay, Thailand, Vietnam, and Tchad. Prior to thinking about an international elective the resident should consider travel, safety, health (vaccinations etc.), and financial concerns. Dr. Sukhija can help you guide you with strategies to set up an experience as each one is highly individual. 

Availability: Variable

Scheduling: Variable

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Patient Callbacks and PBLI form

Patient callback instuctions - complete 12/block when you are on the emergency medicine service

PBLI form - complete 4/year to reflect & self-evaluate your patient care

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