Emergency Medicine Program Highlights

Emergency Medicine Program Highlights

This part of the Medical Students Section is dedicated to student-driven works that highlight some of the unique initiatives occurring in Emergency Medicine programs across Canada. Students who are interested in EM have liaised with a local faculty member when creating these articles. This section is in no way meant to be a complete reflection of how EM is practiced at the specific institution that is profiled in the student article. Rather, it is meant to provide Canadian students who are interested in EM with a bit of a flavour of what’s happening in EM across the country. For those who are interested in contributing an article, please email caepmedicalstudent@gmail.com for details.

Articles

Jasmine Liu, McMaster Class of 2019

How McMaster’s Emergency Medicine Program is Geared for the New Era of Competency Based Medical Education (CBME)

Jasmine Liu, McMaster Class of 2019

McMaster University has a well-known history of being a pioneer in medical education. Starting with the work of Dr. John Evans in the late 1960s that led to the introduction of problem-based learning (PBL) into the medical undergraduate curriculum, that innovative spirit lives on and is evident at McMaster’s Emergency Medicine FRCP Program.

During her residency at McMaster, Dr. Teresa Chan, who is the current Competency Committee Director for EM, recognized potential improvements to the way residency training is done. “You spent eight hours toiling in the emergency [department] and you learned from the cases maybe and talked a little around [them], but you didn’t really walk away with a sense that you knew what to do next”, says Dr. Chan. The opportunity came up for Dr. Chan to rethink the way McMaster does teaching & learning at the bedside and between 2010 and 2011, she was a part of the team that developed the McMaster Modular Assessment Program (McMAP).

McMAP is a work-based assessment (WBA) system that includes 42 task-based assessments specific to EM as well as global assessments that are mapped to a physician role from the CanMEDS competency framework at the junior, intermediate, and senior levels. After every shift, residents are rated by the attending physician using behaviorally-anchored scales that ensure assessment that is appropriate for the learner’s training level in addition to consistent expectations from different faculty raters. This was a drastic improvement from the previous system, which included end-of-rotation assessments done by a single faculty member.

The residents and program have benefited greatly from the implementation of McMAP. From the learner’s perspective, McMAP has provided real-time formative feedback that is based on tangible tasks, without the potential bias of a single-rater feedback system. From the program administration’s perspective, McMAP has provided hundreds of data points on a resident’s performance over the course of their training that’s in line with the concept of programmatic assessment. The idea of programmatic assessment proposes that no important decisions or assessments should be made on a single data point. Rather, when all data points are viewed together, this provides better tools to assess a learner’s needs and allows adjustments to be made to help them succeed. “In the past…we had a cap glucose…We were really good at testing diabetes and hypoglycemia…that’s it! We’re entering an era where education science in medical education is going to need to mirror the diagnostic understanding that we have…We have to mirror the way we diagnose [diseases] based on a lot of data in the workplace with the way we diagnose our learners,” says Dr. Chan.

Despite the innovative work put into its development, McMAP will not align perfectly with the Royal College mandated change to Competence by Design (CBD). The entrustable professional activities (EPA) will be published sometime next year and the assessment system at McMaster will undergo yet another makeover. “At the end of the day, what we have been doing here at McMaster Emergency is probably realistically about half a decade premature. But it has given us time to beta test what works and what doesn’t work.” The work done on McMAP has informed the EPA development process as many program directors across the country were given the McMAP workbooks to look through for inspiration.

In addition to having a head start to sorting out the details involved with CBD changes, McMAP has successfully shifted the culture at McMaster’s EM department. “Our faculty & residents are already embedded in a culture of feedback. So now all we have to do is give them a software update,” says Dr. Chan. This culture of feedback has been built on a two-way relationship. Many changes are driven by residents, especially by education fellows who are given the broad mandate to critically examine and recommend changes to parts of the program every year. For example, Dr. Alex Chorley, a PGY5 education fellow is spearheading the revamp of McMaster’s EM academic half day that will be implemented starting this July. It will be systems-based and will have more aspects of active, team-based, PBL learning and integrate additional resources that include podcasts and blog posts. Other examples of these resident-driven changes include Boot Camp style sessions for residents at key transition points in their training, as well as an integrated junior and senior Simulation curriculum that has rolled out over the past two years.

On the other side of the feedback equation, these changes have only been successfully implemented because the program is very responsive. “Our program director, Dr. Alim Pardhan, is a driving factor in making the changes we suggest.” Says Dr. Alvin Chin who is currently a PGY1 EM resident. “He is always available and takes initiative to ask residents what is and isn’t working,” says Dr. Chin.

When asked what medical students can do to prepare themselves for the new era of CBME, Dr. Chan said, “get good at coaching your elders and the people that are more senior than you to give you useful feedback that’s actionable tomorrow. If you can get good at that skill, you will thrive…Feedback isn’t a passive sport. It’s [a] put on your protective gear and mouth guard and get in there kind of sport.”

Currently, McMAP is implemented at McMaster University and University of Saskatchewan. The University of Calgary has adopted some aspects of McMAP into their current WBA system.

Virginia Robinson M.D., CCFP

Life as an EM Physician

Not Far From the Maddening Crowd

Virginia Robinson M.D., CCFP

Read more of Dr. Robinson’s ER Diaries at CBC.ca

I never expected to become an emergency physician. I always thought I would be a rural family doctor. And every once in a while I make an attempt to go back to family medicine, thinking it will reduce the stress in my life, but so far it hasn’t stuck. Emergency medicine is my calling. And when I am doing it things feel right. How is it that I came to know that? How did I know that medicine, specifically emergency medicine, is where I am supposed to be?

When I was at your stage I didn’t know. I did not like the emergency shifts I did as a student. They managed to be both scary and boring at the same time. I remember getting a failing grade for not being able to get a blood gas on a patient. Nobody came and showed me how to do the blood gas, they just gave me a failing grade for that shift. But many decisions, and years, later, after ruling out a lot of what I didn’t like, I settled on emergency medicine.

When contemplating the life of an emergency physician I think one has to look at who you are and who you want to be. I have noticed that the really good emergency physicians uniformly have certain characteristics.

First of all they have confidence in making clinical decisions, and by and large, enjoy clinical medicine. They do not consult four other specialists and order a dozen tests. They take a good history, formulate a differential, do a focused physical exam to fine tune their differential, maybe do a few tests to come up with a diagnosis and management plan. And then they go on to the next patient. At the end of the day they have done this twenty or thirty times.

Like family physicians, emergency physicians are comfortable with a relative degree of uncertainty. “I don’t know what is causing your chest pain, but you are not going to die from it. We say this with a high degree, but not 100%, of certainty. If you are one of those people that cannot go on to the next patient until you have figured out every last detail of every one of your patients medical problem then perhaps it would be best if you ran along into internal medicine. Once there you can order pulmonary angiograms on patients with non-pleuritic chest pain, who are not hypoxic, have no thrombolembolic risk factors, and are not tachycardic. When one in three thousand patients actually does end up having a PE with no clinical criteria you can congratulate yourself for being such a star. And those poor emergency physicians will just have scratch their heads and look at you with awe. “Well doggone it, who would have thought.”

Emergency physicians are high energy people who don’t mind, in fact would rather be, running around a department than sitting at a desk. If you like sitting at a desk, and even dream of the clothes you will be wearing while you sit at your desk, perhaps surrounded by some nifty little pieces that you picked up on the advice of your art dealer – emergency medicine is not for you.

We used to call ourselves ED doctors until the acronym became more widely accepted in reference to that urological diagnosis. Now, we refer to ourselves as emergentologists, or emergency specialists. Whatever the name, we all suffer from an underlying need for immediate gratification. This is one of our negative attributes. Nonetheless, I like to see results – now. If you can wait, maybe you could trade off the night shifts for the lower stress levels and long term rewards of office practice.

One of the greatest advantages of emergency medicine is the time off. Many emergency docs like to be outdoors, and they love that they have half the month off to do it. While procedures are fun, we could never be surgeons, there is too much else going on in life to be in the operating room all day.

As a general rule emergency physicians are considered the scut bunnies of that big waiting room of the hospital. We are neither respected nor appreciated. Is admiration what you are looking for? Try neurosurgery (and during those seven years of residency dream of all those people at cocktail parties who will be looking up to you). The truth about the job of emergency medicine is that it’s the job that’s worth it, not the image.

Some of these things you might figure out by working in the emergency room. Does the pace give you a headache? Are you irritated when the staff person is always getting called away to do something else? Chances are you will also be irritated when you are the staff person and the nurse comes to drag you away from what you were doing. When a big trauma comes in are you excited? or do you run to find something else to do?

Where is emergency medicine going? I have no idea. I think those who claim they do are deluded. The resources that you will have available to treat patients, the degree of professional stress you suffer because sometimes it is hard to get satisfactory treatment for your patients is largely at the whim of politicians. If you really want to change the face of illness care in Canada, run for office. If you have accepted that what you really like to do is use that stethoscope then by and large politics doesn’t matter? Get in there and start caring for people. If you like what you do and believe in it then the rest is details. To me emergency medicine is like putting money in the bank. Everyday I go to the emergency room to give my patients my very best. And at the end of the year I have a lot of memories of people I helped, and some lessons from people I couldn’t.

There are things I hate about emergency medicine. I hate that I work ten hours in artificial light in a department with no windows. Night shifts, are like living in a basement apartment: they make you feel like a troll, and shorten your life. Apparently as much as smoking half a pack a day, but I find that hard to believe.

If you have not found any of this very helpful remember, no doubt the universe is unfolding as it should. You have a right to be here. Strive to be happy. Take an interest in your career, whatever it turns out to be. Some days that is as good as it gets. Never become numb to what you feel, and follow your heart.

Douglas Sinclair M.D., FRCPC

Still Sane After 20 Years

Douglas Sinclair M.D., FRCPC

I do have a few thoughts on practicing Emergency Medicine, since I am now in my 20th year of practice and still relatively sane. I entered a family medicine residency at Dalhousie in 1980 after graduating from Uof T. My goal was to practice family medicine in a small town. During my residency, I found myself drawn to the emergency medicine aspect of family medicine, and I learned that I did not want to live in a small town. So I began a full time practice in EM in Halifax.

After two years, I went back to Uof T and completed residency training in EM. I still enjoy the clinical practice of EM, and accept the shift work aspect. It is actually interesting to be working when others are not, and off when others are at work. When my children were pre-schoolers, EM practice was excellent to allow me to spent time with the little ones. Once they entered school, weekends become more precious, but our large group adjusted shifts to minimize the number of weekends for everyone.

Every shift continues to be different. How many people can honestly say that they have no idea what they will face every day at work. That is what keeps me interested. The ability to solve an enormous variety of clinical problems is appealing. And of course a sense of humour and a love of the human condition is important.

Over the years I have moved more into academic and administrative practice, which again is one of the advantages of emergency medicine- career flexibility is important to maintain interest over a period of 20-30 years. I still feel that the practice of medicine is a privilege and responsibility to be taken very seriously.

Perspective does change with time and experience. I could care less if I never put in another chest tube, but I am excited when a postgraduate trainee is able to do it, and I would rather spend my time comforting an elderly confused patient that running a trauma code.

Emergency Medicine Career Issues

Preparing emergency physicians for the future
J. Ducharme. CMAJ. 2003, 168(12), 1548. Full text

Emergency medicine practice and training in Canada
I. P. Steiner. CMAJ. 2003, 168(12), 1549. Full text

Factors influencing resident career choices in emergency medicine
A.B. Sanders, J. V. Fulginiti, D.B. Witzke. Ann Emerg Med. 1992 Jan; 21(1): 47-52. Abstract (BROKEN)

Medical student career advice related to emergency medicine
H.A. Blumstein, D.C. Cone. Acad Emerg Med. 1998 Jan; 5(1): 69-72. Abstract

You’re interested in emergency medicine…now what? A year-by-year guide
M.A. Phelps and B. Lubavin. J Emerg Med. 2001. 21(1): 99-100. Abstract

A survey of Canadians enrolled in American emergency medicine residencies
S.J. Socransky, G. Obst, G. Swart. J Emerg Med. 2000 May; 18(4): 473-6. Abstract

An applicant’s evaluation of an emergency medicine internship and residency
E.M. Koscove. Ann Emerg Med. 1990 Jul;19(7):774-80. Abstract

What characteristics of applicants to emergency medicine residency programs predict future success as an emergency medicine resident?
S.R. Hayden, M. Hayden, A. Gamst . Acad Emerg Med. 2005 Mar;12(3):206-10. Abstract

Selection criteria for emergency medicine residency applicants
J.T. Crane and C.M. Ferraro. Acad Emerg Med. 2000. 7(1): 54-60. Abstract

American Academy of Emergency Medicine’s “Rules of the Road for Medical Students”
A. Antoine Kazzi and Joel M. Schofer (eds).

(An excellent medical student resource on all aspects of Emergency Medicine Education and Career Issues- Link (BROKEN) note: access requires online registration)

Emergency Medicine Undergraduate Medical Education

Report of the task force on national fourth year medical student emergency medicine curriculum guide
Task Force on National Fourth Year Medical Student Emergency Medicine
Curriculum Guide. Ann Emerg Med. 2006 Mar;47(3):e1-7. Abstract

Clinical activities during a clerkship rotation in emergency medicine
Robert McGraw and Jason Lord. J Emerg Med. 1997. 15(4): 557-562. Abstract

The unique educational value of emergency medicine interest groups
Cory J. Pitre. J Emerg Med. 2002. 22(4): 427-428. Abstract

Pearls of wisdom for your emergency medicine rotation
Boris Lubavin and Molly Phelps. J Emerg Med. 2001. 20(2): 211-212. Abstract

Emergency medicine patient presentations: A “How-To” guide for medical students
Kerry B. Broderick, David E. Manthey, and Wendy C. Coates. Produced by the SAEM Undergraduate Education Committee. Full Text (BROKEN)

The outstanding medical student in emergency medicine
S. Mahadevan and G.M. Garmel. Acad Emerg Med. 2001. 8(4): 402-403. Abstract

Emergency Medicine Ethics, Communication and Political Issues

Ethical principles- emergency medicine
K.V. Iserson. Emerg Med Clin North Am. 2006. 24(3): 513-545. Abstract

The general approach to the difficult patient
J. Adams and R. Murray. Emerg Med Clinics North Am. 1998. 16(4): 689-700. Abstract

Research ethics
J.B. Shahan and G.D. Kelen. Emerg Med Clinics North Am. 2006. 24(3): 657-669. Abstract

Stop the waiting!!!
CAEP’s Website and Position Statements on ED Overcrowding

Emergency department crowding: old problem, new solutions
S.L. Bernstein and B.R. Asplin. Emerg Med Clin North Am. 2006. 24(4): 821-837. Abstract

IOM report: The Future of Emergency Care in the United States Health System
Institute of Medicine. Acad Emerg Med. 2006. 13(10): 1081-1085. Abstract

The Future of Emergency Care: key findings and recommendations
Institute of Medicine. 2006. Full Text (BROKEN)

Geriatric emergency medicine and the 2006 Institute of Medicine reports from the Committee on the Future of Emergency Care in the U.S. health system
S.T. Wilber, L.W. Gerson, K.M. Terrell, C.R. Carpenter, M.N. Shah, K. Heard, and U. Hwang.Acad Emerg Med. 2006. 13(12): 1345-1351. Abstract

Clinical decision-making: opening the black box of cognitive reasoning
H. Sandhu, C. Carpenter, K. Freeman, S.G. Nabors, and A. Olson. Ann Emerg Med. 2006. 48(6): 713-719. Abstract

From the Trenches

Tips and advice on applying for EM Residency

Tips on applying, electives, research:

  1. Get out and do as many electives as you can – not just in EM (things like Pediatric EM, trauma, anything else you are interested in) – use this time to decide what really interests you!Electives enable you to gain an appreciation of what emergency medicine, as a field, is all about. Electives also provide opportunities to understand issues that may be unique to EM. Hanging out at EM rounds, talking with staff attendings, and browsing through EM research literature may provide insight into topics such as clinical decision rules, overcrowding/waiting times, inner city health, triage systems, rural emergency medicine, patient satisfaction, medical error. etc. Exposure to these ‘real life’ issues will allow you to ask interesting research questions, but more importantly may help you to determine what kind environment you will be working in as well the challenges you might face.If EM is the only specialty you are interested in, try to arrange as many electives across the country (or in places you really want to end up) particularly during clerkship to allow PDs and residents to get to know you. Exposure and contacts with people in the field is crucial for 4th year medical students if they really want to pursue a career in EM.
  2. Be yourself in your application – not what you think the program directors will want.
  3. Research is good but not essential, it’s more important to show that you have special interests and are motivated to pursue them; this can be working at the needle exchange, running the EM club, looking at quality improvement – find something you like and that excites you.
  4. Do something different to distinguish yourself from the rest of the EM applicants. For example, a trauma/ER elective in the US [particularly useful because there are few liability insurance problems as a medical student], toxicology in New York, Denver, ER in South Africa, publish an original piece of research, present at a conference will help you stand out from the pack of applicants.
  5. Start developing your Emergency Medicine knowledge base (start going through Tintinelli’s…its useful for both emerg and medicine in general) [can’t impress anyone if you don’t know anything or be a good clinician]
  6. When applying, consider the programs and locations where you would be comfortable living for 5 years. Write a strong personal letter that demonstrates your knowledge of what EM is all about and this is the field you would like to get into. (finding some friendly residents to help you through the editing process is extremely useful). A strong resume is also important in securing an interview position. The best way to have a strong application is to have a solid EM experience during medical school and clerkship. Good writing skills are useful. remember to proofread your resume and letters prior to submission.

To explore EM as a career option:

  1. Get out there and work some shifts
  2. Take your ACLS and ATLS early
  3. Do some EMS/aeromedical transports
  4. Talk to people you respect in EM and get their honest opinion

Clerkship Application Advice

1. Be yourself in the application.

As several people are generaly involved in the selection process, once you get to the interview stage, the application (and therefore all the stuff that’s on it, like research and electives) is much less important, and is generally only used as a tiebreaker. The trick, therefore, is to come across in your application as someone who really wants to do EM, and as someone who is not super arrogant or an axe murderer. Outside interests and activities, are important in demonstrating a well-rounded person.

2. Do your research and electives in EM.

Research and electives certainly have a role to play in documenting your interest in EM. The people that look the most dedicated have done their research in EM, and have done most of their electives in EM. Completing electives in more than one place may indicate an honest recognition that EM is a competitive specialty, and that candidates are willing to go wherever it takes to get the training. Although candidates may have a first choice of city, it is more important to demonstrate commitment to be in EM than it is to be in Toronto (for example). After all, residency is just 5 years and working as an Emerg doc when you’re done is for many, many more. You can move to your perfect city later.

3. Be honest in your application and demonstrate thoughfulness about your career choice.

If you have decided to apply to EM somewhat later in med school, you may have missed research opportunities. However it is not too late. Although time may be at a premium, try and pick up on a project at any stage of your academic experience. Be honest within your application and explain that you decided to do EM sometime later in medical school. Not everyone is fortunate enough to know what they want to do right from the start. It may be that experiences in electives provided insight into EM. Exposure to other specialties may have enabled a well educated and informed decision to pursue a career in EM.