LIFT Collection
Little. Informative. Faculty. Tips.
Focus Area: Attending & Resident Wellness
Date: May 18th, 2022
BASICS (Pictured) is the Wellness Framework that I have been teaching the TY’s for 6 years. It is also the basis of the longitudinal TY wellness curriculum. My question for the faculty is: What does each letter of “BASICS” stand for? Anyone willing to guess a letter?
(Answer: Body, Affect, Social, Intellect, Community, Spirit)
Focus Area: Quality
Date: May 20th, 2022
W. Edwards Deming (Pictured), is considered one of the original grandmasters of quality improvement. In 1986 he published a 14-point program for conducting real quality improvement. One of my favorites is point # 12 which says, “The institution must remove barriers that rob workers of pride of workmanship”. How well do you think the medical community has done regarding this point? What can we do to improve in this area?
Focus Area: How to be a better Teacher
Date: May 24th, 2022
What are some answers to the question pictured? *note: diagnosing the learner is the practice of determining the learner’s wants and needs. If you want more detail on this, visit this link http://kaweahem.com/gme-faculty-development/3t/setting-the-table-for-teaching/diagnosing-the-learner/
Focus Area: Quality
Date: May 29th, 2022
The 10th point from Dr. Demings 14-point QI framework is very interesting. It states that leadership must “Eliminate exhortations for the work force” for QI to actually work. This point touches on a very deep and important concept. In short, it hits on the stupidity of thinking all quality problems are due to lack of human motivation and using motivation tactics to try and fix all problems. Like using tPa to treat pneumonia, it’s not a good idea. Dr. Deming understood this. Refer to this very short blog post link for a little more background on Deming’s 10th point. Please take the time to read it and share your opinions on the slack site.
Focus Area: Resident and Attending Wellness
Date: June 3rd, 2022
A “Wellness of the Spirit” question to ponder: A faculty member and I recently had a great discussion about “What could make doctor feel unfulfilled”.
What does everybody think?
Focus Area: How to be a Better Teacher
Date: June 7th, 2022
I want to spotlight a great teaching technique that Emergency Physican and EM Residency AMD, Dr. Schaefer uses during high volume situations…the following is the technique in his words quoted directly…
“Essentially, if I see a patient contemporaneously with a resident, I will often flip the role with the resident. I will do the note or at least the HPI and orders on the COW and go through the orders with the resident before submitting them. It’s essentially a time saver, decreasing the documentation burden and having to badge in and get orders in which are the thing that interrupt seeing several patients at once effectively”. Thanks, Chris, for sharing this technique!
Focus Area: Attending Wellness
Date: June 15th, 2022
A post on the “Wellness of Community”. This “Wellness Domain” often confuses people, so this seems like a perfect time to discuss what it means. Wellness of Community can be thought of as your work family. The partners, staff, and residents. Yesterday had many examples of great measurable displays of “Wellness of Community.” Starting with the Graduation of another great residency class. I am so proud of all our faculty, everyone worked very hard to produce our top-notch graduates! Our graduates are our future partner’s and potentially our future doctors (this already happened to my family with one of my former TY’s, so it really can happen). All the faculty clearly understand this long-term connection with our graduates as evidenced by the commitment all show to education. Everyone in our group has added value to medicine, the community, and our group. I wanted to thank Kona for helping to get Carli off shift for the fellowship graduation. I know it involved, multiple people, Will, Renee, and others who did more work so we could celebrate. I even heard that Dries was willing to do a double shift!!! All of this highlights the fact that there are no real boundaries between us, clinical, core, admin… we are all a team and our actions time and time again show that “we got each other’s backs”! Thank you everyone!!!
Focus Area: How to be a Better Teacher
Date: June 27th, 2022
Time for a LIFT (Little Informative Faculty Tip). Evaluating residents on their personality traits should be avoided. These traits are hard to change. These types of evaluations can easily be interpreted as “Mean” or an “Attack”. Instead, aim to evaluate the residents on the specific behaviors you would like them to start doing. If you want to know more about personality traits in general, read the following “OCEAN” personality traits article by clicking the link: https://www.indeed.com/career-advice/career-development/ocean-personality
Focus Area: How to be a Better Teacher
Date: June 28th, 2022
The above LIFT disscusses the Sign Out DUMP. The DUMP mnemonic was developed (by Dr. Winston and I) as a simple way to keep aware of several risks inherent in the sign out process. Using this framework, I have noticed a type of “DUMP” that pops up often. This is where the signing out resident “DUMP’s” her/his bias into the brain of the oncoming resident. All the components of DUMP may be at work…Distraction, failure to highlight Unstable vitals (or abnormal labs), Misunderstanding, and failure to Predict problems. I am sure everyone has seen this “Cognitive bias transfer.” One intervention point I found is to focus on was what the oncoming resident does during sign out. Typically, the oncoming resident opens the chart and writes down “word for word” what the signing out resident says. This puts them at risk for writing down and cementing any bias coming from the exhausted outgoing resident. My favorite intervention is to make sure the receiving resident is looking at the patient’s triage note, vitals, orders, and lab/imaging results during the sign out discussion. I encourage important clarification discussions during this time. Only after this is done, do I allow them to write the sign out note in the chart. I would love to share and discuss any other tips and tricks everyone does to prevent problems at sign out?
Focus Area: How to be a Better Teacher
Date: July 6th, 2022
It is instinctive to think about medical knowledge/patient care competencies when thinking about the RIME model (pictured). My question for the group is…How could you (or how do you) use the RIME model for professionalism competencies?
Dr. Winston answers: “Recognizes professionalism, interdisciplinary team member, manages (leads) a team and e is for educates others about leadership”
Focus Area: Quality
Date: July 15th, 2022
Health Care QI Leaders promote the “Quadruple Aim” approach for QI. I listed the four “Aims” in the picture. It was not always the “Quadruple Aims”, it used to be the “Triple Aims”. Which “Aim” do you think is the new one? What reasons do you think it was added to the original triple aim?
Focus Area: How to be a Better Teacher
Date: July 19th, 2022
Feedback strategy: Sometimes it can be hard to find the time needed to give feedback to residents at the end of the shift (for several reasons). One thing I have done in these situations is… I ask the resident if it’s ok to do feedback the next day via a quick phone call. If they say yes, I text them the next day to set up a quick feedback session by phone.
Focus Area: How to be a better Teacher
Date: July 25th, 2022
Hi all! Sometimes it can be challenging to teach an advanced learner. “Flip the Script” is a tactic that works great for these situations. It works like this…When your resident is on point with the patient care plan, simply agree and then hypothetically change something about the case. For example, if the resident wants to treat the patient with amoxicillin, ask the resident what they would do if the patient had a penicillin allergy. This forces them think beyond the specific case they are presenting. You can change anything about the case like…allergies, symptoms, signs, responses to treatment. The limit is your imagination.
Focus Area: Quality
Date: July 29th, 2022
This is the simple framework that I am using as the foundational base for the QI education for my TY’s. It consists of 3 steps. Very straight forward. (Taken from “The Improvement Guide: A Practical Approach to Enhancing Organizational Performance” as cited in “Continuous Quality Improvement in Health Care, fifth edition”)
Focus Area: How to be a Better Teacher
Date: August 5th, 2022
I am curious what this SBP milestone means to each of us. “The resident participates in changing and adapting practice to provide for the needs of specific populations”.
This is the SBP level 4 part 3 milestone from the EM milestones. I would love to know what different perspectives we have in regards to the meaning of this milestone. So, what does everyone think? What would qualify as a “yes” for you?
Faculty Answer: “Getting prescriptions delivered from the pharmacy to a homeless patient before discharge is one example of this”
Faculty Answer: “Specific populations” doesn’t have to be delimited by things like SES, race/ethnicity, language, etc. Adapting practice for specific populations could literally be as straight forward as using keflex empirically in our area for UTIs instead of Bactrim (which is first line for empiric treatment). The specific population is people with UTIs in Kaweah’s catchment area, the specific need is the antibiotics, the changing practice is using a different first line empiric antibiotic, and adapting one’s practice comes from just being aware that an Antibiogram exists and one should be tailoring treatment based on it.”
Focus Area: Quality
Date: August 16th, 2022
This week’s faculty development Slack Post deals with QI. LEAN management is one of the major Quality Improvement models. People often think that LEAN is about “doing more with less”. This is not correct. LEAN truly centers around decreasing the “Waste” in the system as the primary way to improve efficiency. DOWNTIME (pictured below) is a mnemonic that can be used to help spot “Waste”.
Discussion topic: Do you have any examples of waste in the department that you have spotted? I will go first! I think that the fact that we can’t put the “order sets” on our launch point favorites goes into the “Waste of Motion” category. It takes too many clicks to order an order set!
Focus Area: Wellness (Resident & Faculty)
Date: August 25th, 2022
I am going to put this under Wellness, specifically, under wellness of community (our work family). As attendings, we often are in the business of delegating tasks to others. Two pathologic forms of delegation exist: Micromanagement and Abdication (abandonment). What methods does everyone use to prevent doing either of these types of delegation?
Focus Area: How to be a Better Teacher
Date: September 9th, 2022
Lions, Tigers, and Bears.
This simple teaching technique is great for early learners (medical students, interns, and off service residents). Essentially, you ask the learner to think about come up with all the emergent/serious conditions/causes (the Lions, Tigers, and Bears) for a given chief complaint. One application is to have the learner think about these prior to seeing the patient. A second application is to have the learner think about these prior to their presentation of the case to you. I like to have them think about these when I have them do the “Think again” of “Think and Think again”. Does anyone have any similar techniques or creative applications of this technique that they want to share?
Faculty Answer: “I like the idea of running this list before they see the patient and again afterwards. It gives us the chance to ask how the list may have changed after talking to the patient. Also gives an opportunity to explore the concepts of anchoring and cueing, as it acknowledges that we enter every clinical encounter with some preconceived judgements.”
Focus Area: Quality
Date: September 30th, 2022
I have been encouraged to share this on the slack. It is some QI education. Some of you have already seen/heard this. For the best experience watch the video and use good speakers. Keep being Heroes!!!
Focus Area: Quality
Date: October 21st, 2022
In the LEAN philosophy, the primary goal is to improve efficiency by removing waste. Muda is waste in the form of non-value-added activities, Muri is waste in the form of overburdening the people doing the work. I teach my TY’s to look for waste by finding and removing the “DIRTS” (see picture). For example, the “Tasks” component focuses on finding and removing the burdensome “Non-Physician” tasks that add cost to the system. This includes things like “too many clicks”, “constantly putting paper in the printers”, and “making endless phone calls”.
Taiichi Ohno, the father of the Toyota Production System (where LEAN came from) used this approach to significantly cut costs and make Toyota competitive. He realized that the only way to sustain the cost cutting was to remove burden on the workers. He knew that making his workers do more for less would have driven the company into bankruptcy.
Focus Area: Resident Wellness
Date: October 31st, 2022
This is the first post in the faculty development category focused on resident wellness (a new faculty development category measured by the ACGME). The following concept goes into the “I” of the BASICS wellness framework. “I” stands for “Intellectual and Occupational Wellness”. Several residency programs scored low on the resident survey in “Education negatively affected by non-physician tasks”. I know that this is a widespread issue that is not limited to any one program or even limited to residency education. This stuff also affects all of us attendings. So, my question to the faculty is: What non-physician tasks would you love to see removed? These can be tasks you have to deal with and/or tasks that you have heard the residents complain about.
Focus Area: How to be a Better Teacher
Date: January 9th, 2023
This is one of my favorite teaching techniques. It is called “Think & Think Again”.
First “Think”. Here you get the learner to commit to what condition they think is occurring.
Then “Think Again”. Here you get the learner to come up with other conditions that could be occurring, other conditions that need to be screened for, and other conditions that need to be ruled out.
Think & Think Again encourages learners to commit but not but not anchor or premature close.
There are many forms that this technique can take. What are your favorite applications of it?
Focus Area: Quality
Date: January 16th, 2023
Some feel that Quality Improvement (QI) is just an annoying list of core measures and metrics that will be used against them. I don’t feel this way, I teach my TY’s that QI, if done right, is one of the most powerful aspects of leadership. My TY QI education centers around my paradigm mental model for QI. I teach the TY’s to break QI down into three domains, which I call the “Three E’s of QI”. The “E’s” are improving Efficiency, improving Effectiveness, and Error trapping. The Efficiency domain is where LEAN management is found. LEAN originally came from the Toyota Production System, and it increases efficiency by removing waste. The Effectiveness domain is where the model of Six Sigma lives. The Six Sigma approach decreases defects by decreasing variability in a system or process, which increases the quality of the product/care. Error trapping consists of two main ideas. The first is the “Theory of constraints” which targets and attacks bottlenecks. The second is contingency planning, which deals with the extremely variable chaos that we encounter in nature. Of course, these three “E” domains overlap with each other which makes each powerful both individually and collectively!
Focus area: Quality
Date: January 23rd, 2023
Intellectual/Occupational/Spiritual Wellness… leadership theme. This post is about being an “Agent of Change”. The concept of “Change agency” could belong to several of the faculty development domains, especially the quality domain, because it is an important aspect of implementation science. However, I am posting it under the wellness domain because when change is done incorrectly, all people involved suffer. If done correctly it can improve everyone’s wellness (i.e., residents and attendings). I teach my TY’s a mnemonic that I made based on my research on “implementing change”. It is as follows, “You need to DARE to Change!”. DARE lists what humans need to initiate and sustain change. See the attached picture below for an explanation of what each part of DARE stands for. I have found that the ”R” of DARE is usually neglected by people who implement change. My questions for everyone are, 1. How do you implement change in your world? 2. What ways can we improve each part of DARE in our institution?
Focus Area: Better Doctor
Date: January 30th, 2023
EM Articles: The first is titled “Musculoskeletal Ultrasonography to Diagnose Dislocated Shoulders: A Prospective Cohort” and the second is titled “Intra‐articular lidocaine versus intravenous sedation for closed reduction of acute anterior shoulder dislocation in the emergency department: a systematic review and meta‐analysis”.
Anesthesiology Articles: Achieving Competency in Fiber-Optic Intubation Among Resident Physicians After Higher- Versus Lower-Fidelity Task Training: A Randomized Controlled Study – PubMed (nih.gov)
Psychiatry Articles: Inconsistency and incongruence: the two diagnostic pillars of functional movement disorder – PubMed (nih.gov)
Surgery Articles: Diagnostic accuracy of a pragmatic, ultrasound-based approach to adult patients with suspected acute appendicitis in the ED – PubMed (nih.gov)
Date: 2/6/23
Focus Area: Better Teacher
In the EM faculty meeting we discussed an article about a feedback model. The article recommended combining the “Advocacy-Inquiry” model with “Good Judgment” when giving feedback. It also recommended incorporating reflection into the discussion. I have attached the article if you are interested. I also attached a feedback “Primer” which depicts a practical approach for combining “Advocacy-Inquiry” and “Good Judgment” feedback. It is the “Ask-Tell-Ask” feedback method, it’s a learner driven style of feedback. It can become sophisticated, which will be the topics of future posts, but what I have attached is enough to get started with applying the article’s recommendations. If you have any questions, feel free to reach out. (PS…Dr. Sokol is really good at this, since these concepts are foundational elements of simulation debriefing sessions).
Article: https://pubmed.ncbi.nlm.nih.gov/17574196/
Date: February 13th, 2023
Focus Category: Diversity, Equity, & Inclusion
This is my first official post targeting the Diversity, Equity, & Inclusion ACGME faculty development category. A few years ago, at the ACGME national conference, an article regarding racial health disparities was presented as a keynote presentation. I remember discussing it with Dr. Winston in the lobby after the presentation. The article highlighted a new perspective on the subject. In the past, we were mostly exposed to research on the “amount of care provided by doctors”. This article was the first time I was exposed to the perspective of “the amount of care accepted by patients”. The article found that African American men had a statistically significant greater amount of seeking/accepting health care treatments/advice when their doctors were African American. The authors have proposed that this knowledge could lead to significant health care benefits. I think they are on to something. It makes sense. I have included the last paragraph of the article, which articulates the authors predictions. The authors state “Our back of the envelope calculations suggests the increased demand induced by black doctors could reap substantial health benefits. Specifically, we calculate that increased screening could lead to a 19% reduction in the black-white male cardiovascular mortality gap and an 8% decline in the black-white male life expectancy gap. Given the current supply of black doctors, a more diverse physician workforce might be necessary to realize these gains”. I have included the article in the post, it is a good one.
Article: https://www.nber.org/system/files/working_papers/w24787/w24787.pdf
Date: February 21st, 2023
Focus Category: Wellness (Attending & Resident)
The focus of this post is on “Community” wellness. Community Wellness is about the wellbeing of your “Work Family”. It pertains to building and maintaining healthy relationships with partners, colleagues, staff, and residents. A good way to build “wellness of Community” is to focus on a couple major human interpersonal needs. I have found that humans have two root interpersonal needs, the need for “Care” and the need for “Value”. Humans all need to feel “cared about” and “valued”. If you establish these, magic happens! if you threaten these, the clock starts ticking! Conveying appreciation is a very simple, yet effective, way to establish “Care” and “Value”. How do you do this for the people you work with? Please think about your favorite techniques for making your partners, colleagues, staff, and residents feel appreciated.
Date: February 27th, 2023
Focus Category: How to be a better Doctor
Anesthesiology Articles: “New RCT – Remifentanil Vs. Neuromuscular Blockers For RSI First-Pass Success”. https://pubmed.ncbi.nlm.nih.gov/36594947/
EM Articles: Association between delays to patient admission from the emergency department and all-cause 30-day mortality
https://pubmed.ncbi.nlm.nih.gov/35042695/
How are Patient Order and Shift Timing Associated With Imaging Choices in the Emergency Department? Evidence From Niagara Health Administrative Data. Ann Emerg Med. 2022 Aug 8;S0196-0644(22)00412-7. doi: 10.1016/j.annemergmed.2022.06.002.
FM/TY Articles: “Metronidazole-associated Neurologic Events: A Nested Case-control Study”. https://pubmed.ncbi.nlm.nih.gov/32303736/
Psychiatry Articles: “A Longitudinal Study of COVID-19 Sequelae and Immunity: Baseline Findings”.
A Longitudinal Study of COVID-19 Sequelae and Immunity: Baseline Findings. Ann Intern Med. 2022 Jul;175(7):969-979. doi: 10.7326/M21-4905. Epub 2022 May 24
Surgery Articles: “Comparative Effectiveness and Harms of Antibiotics for Outpatient Diverticulitis: Two Nationwide Cohort Studies”.
Comparative Effectiveness and Harms of Antibiotics for Outpatient Diverticulitis : Two Nationwide Cohort Studies. Ann Intern Med. 2021 Feb 23. doi: 10.7326/M20-6315.
Date: March 8th, 2023
Focus Area: Better Teacher
Post Part 1: So, we just had an ACGME CLER visit. Some may be unclear on what exactly this CLER thing is. CLER stands for Clinical Learning Environment Review. It is an ACGME initiative that was developed to address patient safety and health care quality concerns that were discovered from Institute of Medicine studies done in the 1990’s. Very little had been done to improve the problems found in the studies in the decades after they were published. The ACGME knows that physicians are key levers to improving health care, so they decided to incorporate a focus on addressing healthcare problems into GME educational architecture via the CLER initiative. In my opinion, the ACGME is also using the CLER initiative to teach our future doctors to “be at the table, so you are not on the menu”. The CLER program designed is based on 6 focus areas. 1. Patient Safety. 2. Health Care Quality. 3. Teaming. 4. Supervision. 5. Well-being. 6. Professionalism. Each of these focus areas can be broken down into multiple pathways, which act as sub-focuses. A lot of ACGME survey questions are related to these pathways. The ACGME knows that “toxic programs” are a direct threat to patient safety and health care quality, which is why you see Well-being, Supervision, and Professionalism on this list of key focus areas.
Date: March 10th, 2023
Focus area: Better Teacher
Part 2. It is interesting to know that the six ACGME focus areas (listed in part 1) have changed over time. In 2014 they were 1. Patient Safety. 2. Health Care Quality. 3. Care transitions. 4. Supervision. 5. Duty Hours/Fatigue Management & Mitigation 6. Professionalism. In 2017 the Duty Hours/Fatigue Management was changed to Well-being. In 2019, the transitions of care focus, was replaced by a focus on “Teaming”. The ACGME decided to use “Teaming” to place greater emphasis on the clinical care team (and resident and fellow physicians as members of the team). As per the ACGME, “The concept of teaming recognizes the dynamic and fluid nature of the many individuals of the clinical care team that come together in the course of providing patient care to achieve a common vision and goals. It also recognizes the benefits of purposeful interactions that allow team members to quickly identify and capitalize on their various professional strengths –coordinating care that is both safe and efficient.” Dr. Winston has a lot of insight into how the hospital is using teaming to try and improve patient care.
Date: March 20th, 2023
Focus area: Quality
The waterfall method and the Scrum method are two widely used project management methodologies. They become useful in QI during the implementation stage of a project. While both approaches aim to achieve project goals, there are significant differences between them. Waterfall: The waterfall method is a linear, sequential approach that emphasizes the importance of planning and design upfront. In this approach, project requirements are gathered at the beginning, followed by the planning and design phases, which are completed before the implementation stage. The implementation is followed by testing and maintenance. The waterfall method is suitable for projects with well-defined and fixed requirements, where changes are minimal. Most safety critical systems, like aircraft flight controls, are designed with the waterfall approach.
Scrum: On the other hand, the Scrum method is an Agile approach that focuses on flexibility, adaptability, and continuous improvement. This approach emphasizes iterative development cycles, with each cycle consisting of planning, design, implementation, testing, and review. The Scrum method prioritizes delivering working aspects in shorter time frames, and the team adapts to changes throughout the project lifecycle. The Scrum method is suitable for projects with evolving or unclear requirements, where change is expected. This is my preferred approach when I design software. What are your thoughts about which one of these would work best at Kaweah for implementation of QI projects?
Date: March 27th, 2023
Focus Area: Wellness (Attendings & Residents)
Human interaction is one of the fundamental aspects of our job. During our day, we interact with patients, colleagues, staff, residents, and medical students. The quality of these interactions can greatly affect the “Wellness” of everybody involved. Understanding the components of human interaction can help us maximize wellness (and not damage it!) for ourselves and for the people we interact with. I teach my TY’s (and the EM seniors on the teaching elective) that every human interaction has 2 fundamental components, these are the “Climate” and the “Content”. The “Climate” is the mood and feelings involved in the interaction. The “Content” is the thoughts, opinions, and ideas involved in the interaction. A familiar example of the” Content” part of an interactions is when we explain diagnostic results, go over treatments, and provide our recommendations. Best Use Strategy: The goal is to control both the “Climate” and the “Content” of every interaction. The secret for success lies in the order of priorities. Always control the “Climate” before you dive into the “Content”. Humans will not hear your “Content” in a storm! Scripting is one great way to control the climate of the interaction. What else does everyone do for “Climate” control.
Date: April 5th, 2023
Focus Area: How to be a Better Doctor
Anesthesiology Articles: Which agent (Etomidate or Ketamine) causes more post intubation hypotension? This study tried to answer that question. https://pubmed.ncbi.nlm.nih.gov/36096015/
EM Articles: Both articles are focused on OB/Gyn. One looked at CT vs US in diagnosis of ovarian torsion. The other article looked at racial inequities in emergency department wait times for pregnancy-related concerns. https://pubmed.ncbi.nlm.nih.gov/24480106/
https://journals.sagepub.com/doi/pdf/10.1177/17455057221129388
FM/TY Articles: This study looked at treatment of hypokalemic patients. It compared patients who received either oral or IV magnesium within 4 hours of potassium administration versus those who did not get magnesium. https://pubmed.ncbi.nlm.nih.gov/36241476/
Psychiatry Articles: This update focuses on “Droperidol’s Reintroduction”. This drug had been “Black Boxed” for years. https://pubmed.ncbi.nlm.nih.gov/35063889/
Surgery Articles: This study, published in the J Trauma Acute Care Surg looked at treatment of acute traumatic liver lacerations. They compared angioembolization, observation, or operative management (with initial management decided by the attending surgeon). https://pubmed.ncbi.nlm.nih.gov/36149844/
Date: May 22nd, 2023
Focus Area: Quality
I spoke about the agile vs waterfall approaches to innovation and improvement in a past post. The literature and general philosophy is that the agile model is more productive in most settings. However, it is not the best approach in all settings. It is felt that the waterfall approach still has a role in the design of critical systems (like a flight control system for an airliner). The key is that the waterfall approach, although slower and more expensive to build, often allows for greater dependability (which is critical for critical systems). Dependability = Availability + Reliability + Safety + Security. A very cool concept that is used to achieve all four aspects of dependability is a principle called “Isolated Diverse Redundancy”. This concept is very important when dealing with chaos in a high stakes environment. A great example of this is the Airbus flight control system. The Airbus 302 flight control system uses five flight computers, and only one is needed to fly the plane. The different computers, processors, and microchips are all made by different companies each using different hardware. In addition, the algorithms and program codes are made by different groups, each using different algorithms to create even more diversity. Finally, diagnostics are built in, with the computers having the ability to identify faulty calculations and adjust as needed. These components are all isolated from each other to add the third layer of safety. You can see the this is very expensive…but it does not have to be. When at Stanford for my son’s cardiac cath and EP study, my wife and I noticed a very cheap “Lean” safety measure that tapped into the power of “Isolated Diverse Redundancy”. They simply placed paper on both the wall and the bed with his information about rescue medications (see below). I loved the fact that they placed it in two places (not just one).
Date: June 5th, 2023
Focus Area: Better Teacher
This faculty development post is aimed at “Making your Teaching Stick”. As teachers, one of the fundamental challenges we encounter is making our teaching material not only engaging but also memorable. I want to spotlight one of my favorite ways to make teaching more persuasive and more memorable. This is the technique of storytelling. “Storytelling is the most powerful tool for delivering information.” This phrase underscores the importance of a teaching method that may seem unconventional but is deeply rooted in human history. Long before formal educational systems, our ancestors used stories to pass down knowledge and shape behavior. Their wisdom is a testament to the effectiveness of narratives in capturing attention, enhancing memory, and driving understanding. There is a common belief that cold, hard facts, like statistical evidence, are the ultimate persuaders. But in reality, stories are often more successful at changing opinions. As the saying goes, “numbers numb, stories sell”. We remember experiences more than raw data, and a well-told story can provide a context that makes the related concepts easier to understand and remember. “When there is an opposing viewpoint, consider using a story.” We all know that complex medical issues often come with multiple viewpoints. When discussing these, a story that illustrates your perspective can be more influential than merely presenting facts or statistics. This approach can foster more open, reflective conversations and encourage trainees to think critically about different clinical scenarios. It also works with consultants and the nurses. One simple and effective way to construct a compelling narrative is by using the SPS model: Setting, Problem, and Solution. It’s a formula that lends structure to the storytelling process. 1. Setting: Describe the context or environment. This might be a specific patient case, a community health scenario, or a research question. 2. Problem: Outline the challenge or issue that arises within that setting. This could be a medical diagnosis, a patient’s social determinants of health, or an unmet research need. 3. Solution: Finally, present the resolution, whether it’s a treatment plan, community intervention, or research findings. The SPS model can be used to turn any clinical experience into a story to teach your residents!
Date: June 12th, 2023
Focus Area: Better Teacher
We recently had a faculty development session with USC educator Kathy Jalali (organized by EM for EM). There were some great points that are relevant to all specialties. So I am going to share what we discussed. Kathy discussed two teaching concepts. This post will cover the first concept, the next post will cover the second concept. The first teaching concept we discussed is something called the “1 minute preceptor”. It was developed to help teaching in busy environments (like an FM clinic or EM department). This clinical teaching tool consists of five steps (see picture below). Here are some of my own personal insights that I have learned over the last 12 years of using this tool. 1. Doing all five steps in sequence looks easy on paper, but it is tough to apply all these steps in a busy emergency department. 2. Each step, individually, is very powerful and they can be used alone to improve teaching (i.e., you don’t need to do all five to improve your teaching!). During our session, we talked about how you can pick and choose which of the five steps to use based on the context. Furthermore, we talked about the power of combining 2-3 of the steps to enhance your teaching. My favorite combo is step 1 + step 2 + step 3. It is quick, easy, and powerful. Kathy really emphasized step 3, “Teach a general principle.” I can’t agree with her more, this technique, which I like to call “Take them to the Principles office.” is one of my absolute favorites (stayed tuned for a dedicated post on this in the future). Teaching a general principle can be added on to any step of the 1-minute clinical preceptor or it can be used as a stand-alone technique.
Date: June 6th, 2023
Focus area: Better Teacher
Post 2/2. The second point that Kathy Jalali discussed during the faculty development session was something I have shared previously. It is the RIME model (does anyone remember that post?). I wanted to highlight an interesting perspective that we discussed regarding this model. It is tempting and almost instinctive to use this model as a summative tool, to summarize where the student/resident is based on several interactions. As Dr. Jalali pointed out, this works best (becomes more accurate) if you have a lot of contact with the learner over time (a big N value), otherwise, trying to use it to summarize where the learner is along the continuum feels incomplete. So, another way to use this model is to use it as a formative tool. Here, you use the model in real time during a specific case to advance the learner along the continuum. You take a very small scope view of the learner and look at where they are for the specific case and context of the situation. For example, if the learner is managing a patient with abdominal pain, you would look at where they are on the RIME model and try to advance them to the next level during the case (or for the very next case). For example, when I was a resident I remember, my attending pushing me from an Interpreter to a Manager, by telling me that I as walk out of the patient’s room I need to have a management plan thought out before I get to her (i.e., I had to develop the plan on my walk from the room to my attending). Then she directed me to see a patient that was literally in the closest room to her. She then said, “the challenge is on”. Do you use the RIME model, if so, how do you use it?
Date: July 1st, 2023
Focus Area: Quality
When trying to improve our environment, we unfortunately face many challenges. These challenges act as bottlenecks to progress, smooth flow, and improvement. One of my favorite approaches to combating bottlenecks is the FOCUS approach (picture attached). Here is some insight into this approach. Humans often focus on Optimizing what we have, which if not done with care can lead to burnout of the people and equipment. After optimizing, the next aspect that gets most of the attention is the Curate aspect. Curate deals with decreasing the demand on the bottleneck. System scientist Albert Rutherford has found that humans instinctively focus on inflows into a system (in this case, into the bottleneck). In some industries, the demand can be easily controlled, however, in many industries, controlling demand ends up being very difficult (some say it is wishful thinking). Think about the inflow of tests and treatment orders as well as the inflow of patients into our system. In complex systems, it can look like the best solution, for a bottleneck, is to “turn off the faucet”. Unfortunately, this approach, if done wrong, often shows the fastest regression to the mean. With system function returning right back to its previous state. On the other hand, system experts have found real sustainable solutions (the magic) are often found in the Coordination and Collaboration components of the FOCUS approach. These can take longer to implement (as compared with the curate option) but are often more sustainable. In summary, all options have value and should be explored but some have more lasting effects.
Date: July 14th, 2023
Focus area: Resident well-being.
Sometimes during sign outs, something that seems simple can be deceptively painful. For example, “All that is needed is a phone call”. Residents, especially interns, often fall into a rabbit hole of cascading tasks, for example, the “one phone call” turns into many calls. In many situations this can create a lot of burnout (this is a common problem in the emergency department…affecting all EM rotators). What type of sign out practices do your residents do on your service to combat these types of situations? How do the attendings assist the residents in preventing Sign-out Burnout.
Date: August 1oth, 2023
Focus area: How to be a better doctor
Anesthesiology: An article examining how to get the best view of the vocal cords when intubating children. The Importance of Median Glossoepiglottic Fold Engagement on Laryngeal View and Tracheal Intubation Success in Children. Ann Emerg Med. 2023 Jun;81(6):658-666. doi: 10.1016/j.annemergmed.2022.12.027. Epub 2023 Feb 15
Emergency Medicine: Several studies looking at the YEARS score and how it can reduce CT scans on patients with positive D-Dimers.
Family Medicine and TY: A study comparing adverse outcomes of syncope vs near syncope in older adults. Comparison of 30-Day Serious Adverse Clinical Events for Elderly Patients Presenting to the Emergency Department With Near-Syncope Versus Syncope. Ann Emerg Med. 2018 Dec 7. pii: S0196-0644(18)31420-3. doi: 10.1016/j.annemergmed.2018.10.032. [Epub ahead of print]
Psychiatry: A study looking at the out-patient follow up rates of children after an emergency department mental health visit. Follow-up After Pediatric Mental Health Emergency Visits. Pediatrics. 2023 Mar 1;151(3):e2022057383. doi: 10.1542/peds.2022-057383.
Surgery: A study looking at the diagnostic accuracy of ultrasound for acute appendicitis in adults. Diagnostic accuracy of a pragmatic, ultrasound-based approach to adult patients with suspected acute appendicitis in the ED. Emerg Med J. 2022 Dec;39(12):931-936. doi: 10.1136/emermed-2019-208643. Epub 2022 Mar 17
Date: 8/23/2023
Focus Area: Quality Improvement
We are all probably aware of the fact that the success of QI projects (especially in medicine, especially at Kaweah) depends on teamwork. However, what type of “work” actually drives success? This has been studied extensively. The best practice “work” traits, which I call “Task-work” traits, are easiest to see when studying teams operating in high stakes environments (Airline flight crews, firefighters, etc.). Researchers found 6 “Task-work” traits that allow good teams to “land the plane when the engine falls off”. Furthermore, the absence of these traits leads to plane crashes. Here are the 6 best practice Task-Work traits…Good teams 1. Make sure all members maintain situational awareness (what is going on). 2. They make sure each member has the same shared working mental model (what we are doing next and why). 3. They make sure they do constant plan updates 4. They focus on workload management/fatigue mitigation. 5. They focus on optimizing option evaluation (including looking at the risks of each option), 6. They do extensive reflection based on results. This all applies to QI projects. To be successful, QI initiatives must have a heavy investment in all 6 of these traits. Starting with systems in place to maintain situational awareness and shared mental models while also managing workloads. An easy example of this is automatic triggers for changing modes of operation (so people don’t have to remember to activate a process), coupled with easy to see signage/alerts that allow all members to know what is happening, and easy to use communication that allows for plan updates and option evaluation (i.e. single sign on Cerner messaging). Do you or your faculty have any best practices to share or ideas on how any of these could be improved?
Date: September 23rd, 2023
Focus Area: How to be a better Teacher.
When at work we are busy and throwing a lot of tasks at our residents is part of the norm. While our experienced residents have a knack for juggling tasks, it is a lot different for the newcomers. They’re still getting the hang of things, and their understanding of the entire workflow isn’t fully baked yet.
Here’s where a bit of science mixed with old-school wisdom comes in handy. Our brains are wired to hold just 3-5 tasks in working memory and under stress, this number shrinks to 1-2. So, it’s easy for tasks to fall through the cracks, especially for our less experienced residents.
So, here’s a small suggestion: when you have more than a couple of tasks for our residents, encourage them to jot them down. It sounds basic, but a quick scribble can go a long way in keeping things on track which helps all of us.
Date: October 11th, 2023
Focus area: Wellness (For attendings and Residents)
Mental, Emotional, and Psychological Well-being: We’re all human, and as much as we strive for perfection, mistakes are inevitable. Often, when we err, we spiral into negative self-talk, typically beginning with “I should have done this” sentiments. Such introspection can trap us in past events, analyzing what we did or didn’t do. Although this reflection is a natural response, I’ve found it counterproductive both immediately and in the long run. In the short term, it can lead to feelings of inadequacy and incompetence, even when such perceptions are unfounded. Over the long haul, it hinders growth by anchoring us to past events, consuming our mental energy and leaving us drained.
To counter this, I employ a strategy termed “Look Back and Leap Forward.” If a mistake occurs, begin by “looking back” to understand its cause. Then, “leap forward” by channeling your efforts, thoughts, and attention towards crafting a solution or strategy that ensures the error doesn’t recur. Shift your thinking by framing it as, “In the future, I will do ___” or “Next time, I’ll __” instead of lingering on “I should have ___.”
How do you navigate and learn from your mistakes? I’d love to hear your strategies.
Date: October 26th, 2023.
Focus area: Resident and Attending Wellness.
Here is a quick overview of what the BASICS Wellness categories are about.
Date: November 19th, 2023
Focus area: How to be a better doctor/DEI
AI may (NOT) help you be a better doctor.
There is a lot of talk about AI right now. As a programmer, I have found that it is best to think about AI as a carless assistant. There is huge potential with AI but great skepticism must be used when using AI in high stakes settings. We need to understand the inherent risks associated with AI. There is a push for having AI help out with medical chart writing. I can’t wait to see what this software allows us to do, and I am all for it (if it works). However, we should stay vigilant to what bad things AI can do. Here is an article I found that may be eye opening for anyone that is unfamiliar with AI’s weaknesses. https://fortune.com/well/2023/10/20/chatgpt-google-bard-ai-chatbots-medical-racism-black-patients-health-care/
Direct Supervision: The supervising physician is physically present with the resident during the key portions of the patient interaction; or the supervising physician and/or patient is not physically present with the resident and the supervising physician is concurrently monitoring the patient care through appropriate telecommunication technology.
Indirect Supervision: The supervising physician is not providing physical or concurrent visual or audio supervision but is immediately available to the resident for guidance and is available to provide appropriate direct supervision.
Oversight: the supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered.
So, what’s new? One major change is the allowance of “Direct Supervision” through telecommunication technology. This is new. In the past, the supervising physician had to be physically present for direct supervision. However, it should be noted that the ACGME review committees of the different specialties may have further specific requirements regarding direct supervision and the use of telecommunication for direct supervision. Some may choose not to permit the use of telecommunication as a form of direct supervision.
- In addition, PGY-1 residents must initially be supervised directly. The Review Committee may describe the conditions under which PGY-1 residents progress to be supervised indirectly.
- The program must define when physical presence of a supervising physician is required.
- The privilege of progressive authority and responsibility, conditional independence, and a supervisory role in patient care delegated to each resident must be assigned by the program director and faculty members.
Faculty DeveLOPMENT Supervision
Date: 4/9/2024
Focus Area: How to be a better Teacher
Recently, there has been a lot of discussion about supervision, especially when it comes to procedures. It feels logical to also include some discussion on how to teach procedures. I would like to share a very interesting method of teaching procedures that comes from a non-medical environment. It is called Training Within Industry (TWI). This system was used by the US in the 1940’s to teach thousands of ordinary Americans (non-factory workers) how to build the military machinery needed to support the war effort. Building all these weapons, vehicles, and equipment was done by having operators perform many procedural operations. TWI proved to be a very efficient and effective method for teaching procedural skills to novice practitioners. After the war, Dr. Deming (one of the pioneers of QI) shared the TWI system with Japan. Toyota took this concept and sharpened it into an even more powerful system of teaching procedural skill. Toyota has something called TWI Kata that encapsulates how the system works. A complex procedure is broken down into small parts, then for each small part, the following occurs: Step 1: the supervisor demonstrates the correct method for that small part of the overall procedure. Step 2: The learner then performs this part of the procedure. Step 3: Then the supervisor then demonstrates the small part again but this time adding in explanation of the key points. Step 4: The learner now performs the procedure steps again, but now the learner explains the key points to the supervisor. Step 5: The supervisor demonstrates the procedure steps for a third time, with key points, but now adds in the reasons behind the key points. Step 6: The learner now repeats performing the procedure, including explaining the key points and reasons behind them. After this, the six steps are repeated on the next small part of the overall procedure. This is repeated, until the entire procedure is completed. BTW…this is how I was taught martial arts. What other ways of teaching procedures do people like?
