May 21
The ability to present patients succinctly and effectively is one of your most important skills. I go over some of my thoughts on the subject, and give a variety of sample presentations to demonstrate how I think it should be done. Thanks for listening. JY
(original podcast screwed up at end, please re-download)
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Just saw something fairly stupid on a pre-med site as I was looking up some stuff with my son. Someone was asking whether it was worthwhile to pursue ALS training after EMT, and whether that would improve their chance of getting into med school. The incredibly experienced pre-med who posted a response said “every pre-med is an EMT so its meaningless”.
While this college student undoubtedly has tremendous experience with med school admissions (remember I’m a med school professor and was on the admissions committee of my med school), lets put a few things in perspective. First, not every pre-med is an EMT, probably fewer than 10-15%, but there’s no real data to go by. Second, when looking at an application, we look for these things: good grades, good MCAT’s, familiarity with medical care, and research. To have all four, you need not worry about getting in. If you’re not going to have one of the four, skip research, since it is only in rare instances that a college student is really going to contribute to a research project. So we know you’re following orders, maybe doing some preps, and learning about scientific investigation, which is great.
I would not skip clinical experience. I would personally be very suspicious of a candidate who had never touched a patient or interacted with one. Many undergraduate experiences can check that box, including hospital volunteering (should be low on your list, that’s a high school thing), scribing in an ED, and EMS.
So you can do anything clinical and check that box, and many admissions committee members don’t know an EMT-B from and EMT-I from and EMT-P. Some do, but you can’t guarantee that person will see your app. So you shouldn’t me a medic to get into med school. You should be a medic to be a better clinical medical student and a better physician.
While I understand many are worried about just getting into med school, you should also consider what will put you ahead of other students, get you better recommendations from med school faculty, and get you a residency in the specialty you want at the hospital you want. EMS experience, especially ALS, where you will be in command of a clinical situation, have to think on your feet, weigh options, and commit to a treatment plan, and carry it out, will provide invaluable experience that many of your fellow med students will not have. I can tell you that my wife’s and my experience as medics helped us immeasurably in our clinical years. We knew how to approach patients, how to talk to them, how to do procedures on them, how to deal with the pain and fear, etc., etc. While your colleagues will be dumbfounded, you will be helping the team put in IV’s, taking vitals, and doing a ton of other things that will make you an accepted member of the team and not the “med student” who stands in the back watching.
So if you like running EMS, and you want to be a doctor, advance to ALS. Finally, I can also tell you I am pretty suspicious of college students that stay EMT-Bs for 3-4 years. Were they not interested in more training? Were they running EMS just to check the box? If you like medicine, you will want to do more clinical stuff. ALS is the only opportunity you will have as an undergrad to do that.
Second part of pt safety discussion focusing on the pt safety issues for the trauma patient in the field. What problems can arise in extrication and transport.
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Mar 21
Discussion of an expanded definition of patient safety and strategies to keep patients from harm throughout their course. JY
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Medicine is about telling stories. The story is how the patient was yesterday, how they are now, and how you think they will be tomorrow. EMR’s are tables of data. Tables of data do not tell stories, hence the problems.
When you think about how we practiced medicine just 5 years ago, you would go examine a patient you knew (since there was a good chance you took care of them yesterday and the day before), you already had a feel of their trajectory so you pulled the data you needed to confirm or throw out your impression of their progress. You then grabbed a sheet of paper and wrote that story. If you were a good doctor, you scanned the other data that may relate to their progress, just to make sure something wasn’t sneaking up on the patient.
How do we do it today? The patient is admitted and 30 demographic fields are checked and filled in, then ~50 clinical fields from the nurse, then 20 fields from the MD, then, depending on the clinical status of the patient, another 50 or so lab, study, and consult fields are filled in. This data is placed in tables in a database so it can be displayed and retrieved.
When the doctor comes in, you review 20-30 of these 120 fields and the fields you look at are greatly affected by how they are displayed (the things right in front of you are seen first, the ones under the bottom of the screen are not. There is no synthesis of data, just upper and lower limits to the field data that will turn the font red is the datapoint is on either side of the cutoff.
It is amazing today to see people valiantly take this process, and try to tell a story. Nurses try to do it, but they are hampered by the number of fields they need to fill in during their shift. I see this every day, sitting in front of the computer checking boxes instead of doing assessments. This would be OK if the box checking actually improved your situational awareness of the patient’s condition, but it almost never does.
Medical students have essentially given up trying to learn when they need to present. There is so much data they need to deliver, especially in the ICU, that they have almost no inkling of how to formulate a hypothesis and tell a story. I am constantly asking students “what do you think is going on?” and I constantly get blank stares.
As residents move through training, they adapt to this process change, but it takes more time for them to become facile with assessment. They too often have to sift through reams of data, and through that search they forget what they were looking for in the first place, or miss the kernel of truth in the mountain of data.
I just saw a YouTube video for a new product that allows you to render your patients monitor on your iPhone. Great idea, but more un-synthesized and uncorrelated data for you to deal with. Are you supposed to look into your iPhone and switch between patients monitors while walking down the hall? What are the nurses for? How do you reconcile the data on your screen with the true state of the patient? How many false positive and false negative will there be for detecting serious deviations from the predicted course.
What do we need out of EMRs and patient data systems? SITUATIONAL AWARENESS. The “state of the patient” at this point in time. This will truly be different for every patient, but it is not impossible to codify. What I find funny, is that when I tell physicians we need to put these things down on paper, they say “that’s impossible, it comes from experience and it’s a gestalt” but many studies have shown that is not the case. People think in algorithms (if A, then B, if not B, then C). We all do it. What you need is the data to tell you that the state of the patient is “A” (that is a story) then you decide that you want the state in 8 hours to be “B”. You picture in your mind how you are going to get to B and you tell that story to the nurse, who implements the plan. It is very possible to quantify these states, but there needs to be room for judgment since patients will reflect their state differently. That doesn’t mean that we cant do a “Mad lib” for a certain state, where you would have to fill in the blanks to tell the story. If the story makes sense, you are at that state, if not, then not.
For instance, you have a post-operative heart patient. The story is “this 78 year old woman had an MVR-CABG yesterday. She is awake and talking, her chest xray shows some lower lobe consolidation, she is afebrile, her WBC is normal, and she is making good urine. She is not doing well on spirometry (250cc) but she denies pain (her pain scale is 4)”. That is this patient’s story. An experienced practitioner reads into that story that she is doing well, but she is at risk for pulmonary complications. You fill in the story for today:
“We need PT to see her and get her out of bed and even walk her if possible, she needs to do spirometry 10 times an hour and hit a goal of 500-750cc. We may need to get a pain consult, or give her a PCA since she may be stoic but is really in discomfort. If she has a fever she needs to be cultured. Lets get a white count and a CXR if there are any problems, and definitely get both in the morning.”
This story focuses on her pulmonary toilet, but leaves room for negative deviation, where she may be manifesting signs of pneumonia, and what we will do if that happens.
How do the EMR’s get us to this situational awareness? I believe they hinder it by presenting data in an unfocused way, and by forcing practitioners to spend time obtaining data that brings little or no value. It is also the fallacy of our current regulatory environment in medicine. More discrete data allows us to do more measurement. The measurement allows you to be graded, and grading allows you to be rewarded or penalized. In the end, it makes it easier to measure what we’re doing, but harder to get better. It also makes it easier to give you a grade.
We need to work to adapt EMR’s to what we need, and less to adapt clinicians to the EMR’s. There is still little data that EMR’s improve safety beyond certain discrete areas (medication safety and accurate electronic ordering). There is no evidence that information transfer is enhanced or that the EMR’s augment our ability to quantify the state of the patient.
Thus, we must look into the way we practiced before the EMR to identify what allowed us to get situational awareness. We then need to talk to each other to align some general principles, and work with the programmers to get the EMR to enhance this process, not detract from it. Additionally, with the large number of handoffs in patient care, it is VITAL that we be able to relate accurate stories to each other, and not just regurgitate data. If we don’t do that, I think there will be serious consequences for the safety of our patients.
Virginia OEMS New 2012 Regulations Discussion with Michael Berg, Regulations & Compliance Manager, Virginia OEMS and Assistant Chief Tom Joyce, County of Orange Department of Fire and EMS. Can be viewed on YouTube http://www.youtube.com/watch?
Podcast I did with EMS Chief Tom Joyce of Orange County Fire Rescue concerning the ideal characteristics of a high performing medic. These characteristics apply to all clinicians.
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I begin a series discussing the crashing patient. We discuss how to approach the situation, what to do first, and how to stay out of trouble and keep the patient alive.
JY
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I would like to thank Orange County for inviting me to this panel. Please check it out.
http://www.facebook.com/photo.
So…if you’ve got a GPA over 3.8 and MCATs in the top 5 percent, you don’t really need to read this. As long as you don’t come across as a shut-in or an axe murderer, you will probably be accepted to at least a few, if not all of the medical schools you apply to. But for the rest of you, let’s talk about the other parts of the application, namely what you did with your spare time in college.
First thing, no one cares what you did in high school. Eagle scout, all-county football, whatever don’t embarrass yourself by putting that on your med school application. They don’t care what you did when you were 16. Now as far as what you did (or should do) in college to prepare yourself, and make yourself attractive to medical schools, here’s my take on it. I gave you my qualifications to make these opinions in my previous post.
Clinical experience: I think it is vital that you touch patients enough to know whether being a doctor is the right thing for you. Even if you think you are going to be a pathologist, you are going to spend a whole lot of time with patients in med school, and you better at least tolerate it. Volunteering in the hospital is more of a high school thing, and is not looked upon with favor.
The choices are: follow a doc around (maybe your parent if you’re lucky) enough to be able to write in your essay how much you feel medicine is a “wonderful mix of science and art where I get to combine my love of the scientific world with my humanistic nature”. Don’t copy that, but I must have seen it on 75% of the applications I reviewed.
Next: be a scribe. This is something that was not around when I was in college and is an interesting choice if you don’t want to expend the effort to become an EMT, or an ER tech, or something else more hands on. You get paid, and you get to be a transcriptionist. Don’t mean to belittle this experience, but you are not making medical decisions, you are not examining patients and synthesizing their history, physical, and lab data into a diagnosis and formulating a treatment plan. It does demonstrate that you went to the effort to actually work in the hospital, and you get to hang around with docs and residents and maybe get invited to a few parties. Many people do this, and a lot of them get into medical school, but I’m not sure if that’s true, true, and unrelated.
Next: be a lab tech, ED tech, burn tech, etc. These jobs require some training, and you are actually working on the front lines, touching patients, drawing blood, changing dressings, etc. There is a possibility this will turn you off from being a doctor, but better to find out now than when you start your third year. This is impressive because you were willing to get your hands dirty and get in the fight.
Next: be an EMT, Medic, and/or firefighter. This is what my wife and I did, and it pretty much changed our lives for the better. We met people who are our friends after 30 years, it gets you around great guys and gals that you wouldn’t normally be with in college, and it gives you the best possible clinical experience. This experience is that you get medical training, you apply it through direct patient interactions where you actually have to make critical clinical decisions, and most importantly you are exposed to medical error and corrective actions, which are very important to see. It requires you to take time to get trained, to study, take tests, demonstrate your competence, and run shifts. Needless to say, this is my recommendation.
Finally, to make yourself the ultimate triple threat, you need research (grades, clinical experience, and research is the triple threat). It is not hard to find research opportunities if you go to school near an academic medical center, but it takes effort to get something worthwhile out of the experience. I have been the “mentor” for quite a few college students who didn’t do squat, and a few that worked their butts off. It is pretty much up to you. When I did this, I just looked in the back of the scientific journals, and wrote letters to people I wanted to work with. Usually they know people where you are and can hook you up. Also, many colleges have summer and school year research programs that are easy to get into. Research is also interesting. It is important to learn the scientific method, and how to design and interpret an experiment. My research experience has made me a better doctor by teaching me how to evaluate scientific evidence. I think if you can do it, research is very important. You probably will not get to publish anything unless you get real lucky, but the letter of recommendation from the research mentor will be helpful.
Well that’s it. Hope this was helpful. Don’t hesitate to contact me if I can help.
JY
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