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Medical Education

Primary Survey June 2017.

8 Jun, 17 | by scarley

This month’s editor’s choice is actually a pair of papers: one, a study on the diagnostic characteristics of the T-MACS chest pain risk stratification score AND the other, a paper explaining a key methodological concept used in this and other studies of diagnostic tests, the receiving operator characteristic ROC) curve (Richard Body (an associate editor of EMJ) and colleagues previously developed the MACS rule, which classifies patients as very low risk or very high risk after the results of an initial set of biomarkers are known, TMACS relies on obtaining both high sensitivity troponin and heart-type fatty acid, but the latter biomarker not widely available. A modified rule, the MACS score, uses only high-sensitivity troponin and in the current study the authors evaluate this new rule’s test characteristics, using the ROC curve. Hui Zhe Hoo, Clinical Research Fellow at the University of Sheffield and a respiratory physician, explains the fundamentals of the ROC curve using this paper as an example. This is the third in EMJ’s occasional series of articles explaining statistical concepts frequently found in the emergency medicine literature.

Still a cinderella service

Demand for mental healthcare in the ED continues to rise. Sadly this rise increasingly includes children and the provision of child and adolescent mental health services (CAMHS) in most emergency departments falls well short of what is needed. Thus, a systemic review in this issue by Newton and colleagues from Canada on children’s mental health crises in the ED makes interesting reading. A previous review undertaken by these authors in 2010 provided some evidence to support the use of specialised care models to reduce hospitalisation, return ED visits and length of ED stay. In the current study they report increase in research over the past few years, yet most of the evidence is limited by weak methodology. It is evident that the specialised resources and skills needed are still not readily available and the authors reiterate the need for high quality evidence to guide mental health screening, early and effective interventions and on-going follow-up care after an ED visit. I suspect few of us would dispute this view.

Ladders or smiley faces?

Accurate assessment of pain due to an acute injury can be challenging especially when the child is distressed and anxious, but providing timely and effective analgesia is key to child and carer comfort and satisfaction.This issue includes an interesting paper by Ffion James and colleagues from Wales who set out to assess the inter-rater agreement of the Royal College of Emergency Medicine (RCEM) composite pain scale. The majority of pain assessment tools for children were designed for post-operative or chronic pain and not for sudden and acute pain due to injury. The RCEM composite tool combines the numerical rating scale (Ladder), a modified Wong –Baker Faces Pain Scale (Faces scale) and a Behaviour score which groups pain into four categories based on severity. To date the reliability of this scale has not been assessed. In their study, pain severity was assessed by the triage nurse doctor and child (depending on their age) using the composite pain scale. The Faces Scale demonstrated greater inter-rater agreement than the Behaviour Scale, while the Ladder demonstrated poor inter- rater agreement in comparison with the Behaviour score. The authors conclude the Ladder score could be omitted from this composite tool.

Using emergency data for public health interventions

Two studies in this issue demonstrate how data from emergency care can be used to inform public health interventions. Acute and chronic alcohol intoxication, a worrying global public health issue, is the cause of many health and social problems. Reunion Island in the South West Indian ocean is no exception. Reunion Island is among the four French regions where premature mortality due to alcoholism and cirrhosis is the highest and foetal alcohol syndrome is seven times higher than that of metropolitan France. Vilain and colleagues undertook an exploratory analysis based on syndromic surveillance data to describe the emergency department visits for alcohol intoxication and factors associated with their variation. Alcohol intoxication attendances were the second most common reason for ED attendances after trauma and these attendances increased significantly on benefit payday, weekends and public holidays. The authors conclude this kind of syndromic surveillance system for monitoring public health data other than infectious diseases can be used to inform initiatives to reduce morbidity and mortality from alcohol intoxication.

According to the WHO, interpersonal violence accounts for around half a million deaths a year globally. This figure will come as no surprise to ED clinicians and may even be regarded as conservative by those caring for victims on a daily basis. Addressing violence has traditionally been a police concern, so it was interesting to read of a cross sectional study by Quigg and colleagues in the UK which explored the potential of ambulance call out data in understanding patterns of violence to inform prevention activity. This paper is well worth a read as ED’s will see similar trajectories and trends. The majority of call outs were at night for young males in deprived and urban areas, and these calls increased on weekends and bank holidays but not for sporting events. 77.3% were assault/sexual assault while 22.7% were stab/gunshot/penetrating trauma. Interestingly, there were significant differences in call out characteristics between the two violence types. The authors conclude that ambulance call out data provides a rich source of information and sharing this data could be key in violence prevention programmes. Any information that can contribute to violence prevention programmes has to be worthy of consideration.

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Mary Dawood

 

Primary Survey April 2017.

18 Apr, 17 | by scarley

This month’s primary Survey is written by Mary Dawood. Don’t forget to visit the journal site to see more and keep in touch with us on Social Media.

Also, don’t forget to listen and subscribe to our podcast to keep you up to date on the journal and topics in emergency medicine.

Organ Donation in the ED

Possibly one of the most sensitive and daunting conversations that takes place in the ED is about organ donation. By virtue of circumstances this conversation usually occurs subsequent to breaking news of death or imminent death. Broaching the subject of organ donation can seem ill timed, insensitive and is difficult for even the most skilled clinicians. Even so, organ donation is a core competency in emergency medicine as is the management of patients in the final stages of life, furthermore we have a duty as healthcare professionals to explore this potential at the end of life. In the UK in 2015–16 a record number of organs were donated and transplanted but the consent rate is still one of the lowest in Europe. At the end of 2015 there were nearly 7000 people waiting for a transplant, 429 died while waiting and a further 807 were removed from the list most likely due to deteriorating health. Despite ongoing teaching of emergency staff and expert support from specialist nurses, opportunities for organ donation can still be lost in the urgency and fast pace of the ED as well as the perceived difficulties of managing the logistics of donation before death (DBD) or donation after circulatory death (DCD). Outcomes from DBD are better but an ongoing shortage of organs is seeing the reintroduction of a long abandoned practice of (DCD). This month’s issue includes a very informative paper by Gardiner and colleagues along with a commentary by Bernard Foex about organ donation. Gardiners paper describes current transplantation practice in the UK, associated ethical and legal issues, the classification of deceased donors and future developments promising greater numbers of organs. Foex’s commentary discusses withdrawal of life sustaining therapy and the case for delay.

Both these papers are a ‘must read’ for ED clinicians everywhere to remind us that the potential to change lives for better is enormous and the urgency for organ donation is greater than ever as we live longer.

Saving money

Containing the ever increasing costs of healthcare is both a challenge and a necessity in all health economies. We are constantly entreated by our ‘money masters’ to find not only more cost effective ways of delivering care but cheaper consumables. In the minds of many clinicians cheaper consumables often equate to poorer quality so it was very interesting to read of a study by Riguzzi et al from San Francisco comparing cost of commercially produced ultrasound gel which is relatively expensive with an alternative corn-starched based gel. They found that the corn starched gel which cost <10 cents per bottle produced images of similar quality to those using commercial gel which costs about $5 dollars. Given that point of care ultrasound is increasingly used in low resource settings, over time, this may represent a tidy sum that could be used elsewhere. Think about this the next time you liberally squirt expensive ultrasound gel!.

Sepsis again

Lifesaving treatment for sepsis is relatively straightforward–so many more lives should be saved every year if treatment is started in a timely way. It is therefore an ongoing concern that so many people still die from sepsis every year. The difficulty is spotting this complex condition as soon as a patient presents so we need to ask whether our triage systems are sufficiently sophisticated to support early recognition. Graff and colleagues in Germany undertook an evaluation of the Manchester triage system (MTS) to assess its effectiveness in identifying septic patients. They found the MTS to have some weakness with respect to priority in patients with sepsis and that discriminators for identifying systemic infection are insufficiently considered. In view of the fact that MTS and similar versions are so widely used it is well worth reading this paper to revisit our triage systems and how we can improve detection of sepsis at triage.

Weighing patients: a guestimate?

Some EDs are fortunate to have high specification trolleys that have built in scales for weighing patients. Most of us probably don’t work with such sophisticated facilities so we resort to roughly estimating a patient’s weight in emergency situations. This is a concern when using time critical drugs that require precise dosing according to weight. I was curious then to read of a study in this issue by Cattermole and colleagues in the UK that aimed to develop and validate an accurate method for estimating weight in all age groups using mid arm circumference.(MAC) They derived a simplified method of MAC based weight estimation from a linear regression equation: weight in kg=4xMAC (in cm)−50. They found that this formula is at least as precise in adults and adolescents as commonly used paediatric weight estimation tools are in children. The authors advise that a gender specific model would improve precision but this would require a tape or smartphone. This study is well worth a read as a more accurate way of estimating weight is to be welcomed especially as rising obesity levels will call for more consistent documentation of weight and precise dosing.

Adaptive design clinical trials in the ED?

Conducting and sustaining clinical trials in emergency settings can be difficult for a variety of reasons. One reason may relate to the fixed nature of the designs that are traditionally used in ED trials, where conduct and analysis are outlined at the outset and are not examined until the trial is finished. This fixed design may in many instances take too long and be costly both to patients and staff. It may be time to consider alternative way of conducting clinical trials in the ED that may be more effective and conducive to the ED setting. In this issue, Flight et al hypothetised that the majority of published emergency medicine trials have the potential to use a simple adaptive trial design where planned interim analysis is factored in to determine whether studies should be stopped or modified before recruitment is complete. Their study reviewed clinical trials published in three emergency medicine journals between January 2003 and December 2013. They found that out of 188 trials, only 19 were considered to have used an adaptive trial design. A total of 154/165 trials that were fixed in design had the potential to use an adaptive design. For those of us grappling with the challenges of clinical trials in the ED, this approach is worthy of consideration.

View Abstract

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Mary Dawood

  1. Emergency Department, Imperial College NHS Trust, London, UK
  1. Correspondence to Mary Dawood; Mary.dawood@imperial.nhs.uk

#FOAMed, credentials and a view from the college (sort of).

10 Dec, 16 | by scarley

156r09lpI found an amazing tweet on my timeline today that taught me many things. Firstly, I was not aware that students were publishing their own theses online and as an open access resource (this is fantastic), and secondly the topic in question is of great interest to me and everyone here, that is the development of #FOAMed.

Chris Walsh is a super chap who is head of e-learning at the Royal College of Emergency Medicine. He is an extremely intelligent man with a strong academic track record, initially in the humanities, and now also in the field of medical and digitial education.

He has now published his MSc thesis online looking at the development, current state and future direction of e-learning resources for the RCEM.

Click here to read the thesis online.

I am very interested in the view from a senior member of the college as my relationship with the college over e-learning has been difficult at times. As an advocate of #FOAMed I’ve always struggled with the requirements to meet the limitiations and restrictions of an overarching organisation whilst maintating the freedom, speed and open discussion that #FOAMed creates. This is a theme in the thesis and I found Chris’s analysis of #FOAMed as a dialogic process fascinating. This work also aludes to the changing relationships between organisations, traditions, curricula, members, technology and delivery. It’s complex and fascinating.Chris has used a mixed methods technique to look at the impact and future direction of e-learning for the College and for #FOAMed. The perspective is clearly from his position, and thus the influence of the College perspective is very clear, but there are many interesting elements for any producer or consumer of #FOAMed.So what are the main themes? Obviously this is my interpretation and you really should read the whole document.

    #FOAMed is here to stay.#FOAMed engages and invigorates elements of the EM community but some are not engaged.There is a desire amongst some for credentialing of activity related to #FOAMed (though the strength There is some confusion between e-learning and #FOAMed type activities and credentialing.The RCEM is developing a system to credential #FOAMed learning.There is a belief and understanding that #FOAMed will be incorporated into formalised learning and continuous professional development.

There are many other questions too of course. This study is based on small samples and almost all the interviews were conducted with those involved in college work. The survey data was sought through social media spaces which is good as they are #FOAMed consumers, but also limits the findings to those who are already engaged in this style of learning. The perspective is thus largely one of the college establishment and as a result may be a self-fulfilling one. However, I’m not sure that matters that much as the project is really aimed at those groups as opposed to those who are not currently engaged with College resources. It does therefore study a specific, but relevant

So. Follow the link above to read the thesis (or at least read the abstract), follow Chris Walsh on his twitter account, and if you feel inclined I’m sure he would be delighted to hear your thoughts.

My final question is in regard to the proposed credentialing of #FOAMed activity into an online CPD portfolio.

The question is whether users will be able to record activity from non RCEM #FOAMed sites, or will it be limited and paywalled by the college. As a #FOAMed advocate I’m clearly keen to support learners to be able to record #FOAMed CPD from any blog or podcast.

That may not be a decision that Chris will personally make, but I’d love to know the answer (and hope it’s the right one).

The bottom line is that this is a great piece of work that takes our understanding of College based learning further and deeper than we have previously seen.

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S

 

How Junior Doctors Think: A Guide for Reflective Practice

19 Oct, 16 | by rlloyd

how-do-junior-doctors-thinkl_

In the UK, junior doctors will rotate through emergency medicine in their second year post-graduation (Foundation Year 2). They’re granted autonomy to make independent decisions and ‘own’ patients for the first time.

Elsewhere in the hospital, a junior’s role is largely secretarial, and generally within the confines of ‘normal working hours’. In the ED, the hours are brutal, the pace is relentless, and the sudden spike in responsibility ED is daunting. The learning curve is steep, but rewarding.

‘My first shift in the ED was the first time I felt like a real doctor.’

Perhaps the most unique element is the density of decision-making. Each shift serves up a broad menu of undifferentiated patients ‘fresh’ from the community, often requiring multiple investigations/interventions. When you consider the wider landscape of an ageing population, over-burdened health service, and the much maligned 4-hour target, it’s an undeniably tough job for rookies; a pressure-cooker workplace that’s fertile ground for misdiagnosis and clinical error.

Therefore, in the interests of patient safety (and junior doctors overall wellbeing) it’s important to understand the mechanisms by which junior doctors collect/process information, and make decisions. Otherwise known as ‘clinical reasoning’.

Published in the EMJ in June 2016, Adams et al have qualitatively investigated clinical reasoning in junior doctors rotating through the ED for the first time. Thirty-seven doctors were interviewed and took part in focus groups. Questions and discussion were based around retrospective recall of two cases (one straightforward and one difficult case).

The authors used ‘dual cognition theory’ (DCT) as a framework. DCT describes two distinctive cognitive approaches to decision-making: ‘Type 1’ thinking (T1) is automatic and intuitive; ‘Type 2’ (T2) is deliberate and analytical.

This system was, of course, pioneered by Daniel Kahnemen in his book ‘Thinking Fast and Slow’ (essential reading). Below is a video which provides a useful visual explanation.

Key findings from the paper:

  1. There are 3 phases of clinical reasoning in junior doctors – each is briefly explained below, but for more complete explanations please read the original paper.
  2. During all 3 phases, both thinking pathways (T1 and T2) were working in parallel.

*Please note: indented sentences in italics are my own interpretation of the research, not actual quotes from the data.

Phase 1: Case Framing

Initially, a decision needs to made whether to go into clerking mode (i.e. systematic enquiry) or ‘resuscitation’ mode (call for help, ABC approach etc).

The information processed to make this decision are clues from the patient demographics, triage note and ‘end-of-the-bed-o-gram’.

Phase 2: Evolving Reasoning

The next phase involves establishing a diagnosis. This happened in two ways:

1) Diagnosis instantly recognised (T1 predominant)

Usually from a single cue in the assessment.

‘This patient has right iliac fossa pain. It’s probably acute appendicitis.’

These reflex diagnoses are then interrogated for error via:

  • Screening for ‘red flag’ features
  • Diagnostic timeout’ to organise thoughts
    • Reflection whilst writing patient notes
    • Informal discussion/presentation to a colleague
  • Begin another task, allow opportunity for spontaneous thought (passive diagnostic timeout)

2) Diagnosis not recognised, further analysis commences (T2 predominant)

With no immediate diagnosis reached, ‘hypothetico-deductive reasoning’ is employed. This is where multiple possible hypotheses are generated, and then the history, physical examination, and investigations are used to test these hypotheses, with a view to eliminating them one-by-one.

The ‘SOCRATES’ mnemonic is a useful tool for challenging hypotheses in chest pain patients.

‘Site? Onset? Character? Radiation? Associated symptoms? Timing? Exacerbating/relieving factors? Severity?’

Ongoing observation is also employed to test diagnostic hypotheses, and to screen for an evolving clinical scenario.

‘The inflammatory markers are higher than I thought they’d be. This patient is likely to be septic. Let’s start IV antibiotics and refer to the medics.’

Phase 3: Ongoing Uncertainty

This was predictably common in an inexperienced cohort of doctors, and dealt with via:

  • Delaying discharge and continuing to observe
  • Simplifying the overall decision: ‘is this patient too unwell to go home?’
  • Sharing responsibility
    • With seniors
    • With peers via informal discussion
    • With patients via safety netting

Three points I’ve taken from the paper…

1) Inexperience can lead to ‘misframing’

T1 judgement was the dominant thinking pathway during ‘case framing’, particularly when it came to first impressions – a ‘gut-feeling’ assessment of acuity.

A lack of experience might prevent juniors from picking up on subtleties (e.g. sweating, mild agitation), or get falsely reassured by certain details (e.g. normal vital signs) that a senior doctor would not, and ‘misframe’ the patient’s level of acuity. Clearly, this has the potential to be detrimental to patient outcomes.

For this reason, focused reflection on this crucial phase of the assessment via case-based discussion with a senior colleague is critical. It will encourage juniors to gain some insight into how their own intuitive thoughts play a prominent role, and perhaps encourage them to interrogate those thoughts for biases.

‘Did you make any assumptions about this patient before seeing them?’

‘Were there any clues or triggers when you first saw them that changed how you felt about the case?’

‘Can you think of any other clues that might subtly point to the patient being more unwell than the triage note suggests?’

2) Diagnostic time-outs should be encouraged

It was established that junior doctors would utilise diagnostic time-outs whilst writing notes or via informally presenting to peers. This is an important part of the clinical reasoning process, particularly in complex patients. It can safeguard against premature ‘closure’ of a case (i.e. jumping to conclusions, and then sticking with them incorrectly) .

Again, this part of the process needs to be reflected on, so that it’s utility is appreciated.

‘It was when I was writing the notes about the 68 year-old male that I thought had renal colic, that the possibility of ruptured AAA came into my head. It’s a useful moment to think about the case.’

Diagnostic timeouts should be encouraged by higher ups, despite being potentially time-consuming, and particularly if the shop floor is manned heavily by junior doctors (a not-uncommon scenario). Despite the overburdened and target-driven climate of UK  emergency medicine, departments must avoid falling into the trap of pushing their staff to work faster. Patients are safer when junior doctors are given the chance to slow down and think.

3) Juniors should be given protected time for case follow-up

The transient nature of our patient encounters in the ED can lead to an ‘out of site, out of mind’ culture, where we fail to follow-up uncertain or particularly interesting cases. Again, this is re-enforced by the pressure to work quickly. This represents a glaring missed opportunity for learning, and the lack of diagnostic feedback potentially leads to the propagation of flawed clinical reasoning, particularly in inexperienced doctors.

Perhaps juniors should be given protected time to follow-up on cases they’ve seen (read discharge summaries/visit ward/call patient at home if discharged). They could then log this process, and formally reflect on notable cases with a supervisor.

This paper has highlighted that junior doctors have a tendency to make judgements on single cues, as opposed to pattern recognition, and can draw premature conclusions from insufficient clinical information. There is no doubt that regular feedback on real cases will serve as a powerful tool to improve clinical reasoning. It will gradually nudge them towards the realm of expertise.

Much like the encouragement of diagnostic timeouts, the key is likely to be departmental culture change. This will require brave consultants and senior nurses.

Final Thoughts

This paper should serve as a guide for junior doctors (and their supervisors) for more focused, effective reflective practice.

It’s not just about reflecting on the pathology encountered and decisions made, it’s also about the clinical reasoning process that led to those decisions. The journey is just as important as the destination. Junior doctors should be reflecting on how they think.

Additionally, departments should strive to create a healthy environment for regular reflective practice, and not to prioritise targets over the development of junior doctors clinical reasoning skills.

The Paper

Clinical reasoning of junior doctors in emergency medicine: a grounded theory study
E Adams, C GoyderC HeneghanL BrandR Ajjawi
Emerg Med J emermed-2015-205650
Published Online First: 23 June 2016 doi:10.1136/emermed-2015-205650

Many thanks to Dr. Emily Adams, the primary author, for her assistance in the creation of this blog post.

Robert Lloyd
@PonderingEM

Become an EMJ reviewer

18 Oct, 16 | by scarley

peer

The EMJ, like most journals relies on peer review to help the editorial team make decisions on submitted papers.You can have a look at the list of people who have reviewed for us here, and we are always looking for more.

Now peer review has had some tough times of late. Ex editors of major journals have described it as ‘A flawed process at the heart of journals’ and it is true that it is not a perfect process. However, it has also been argued, also by Richard Smith that it there is no obvious alternative and that is respected by the scientific community.

Personally I am a sceptic when it comes to peer review and am increasingly an advocate of a blend of pre and post publication review. I particularly like the idea of post publication review facilitated through social media and of course we encourage letters and comments through any of our social media outlets on papers published in the EMJ.

However, for now, peer review is here to stay prior to publication and that means we need the brightest and best people to help us make decisions for the EMJ. So, if you are good at critical appraisal, if you have expertise in an area of EM practice and/or research design and if you want to help the EMJ publish the best papers then get in touch.

Contact us here and send us your details. Help us make the world a better place.

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S

@EMManchester
Peer review: a flawed process at the heart of science and journals Richard SmithJ R Soc Med. 2006 Apr; 99(4): 178–182. doi:  10.1258/jrsm.99.4.178 PMCID: PMC1420798

BMJ Blogs on peer review

The other side of the ECG. EMJ

8 Aug, 16 | by scarley

Last week I was wandering through Amsterdam when I came across a tweet which stopped me in my tracks. A real game changer, a shock, a wake up call and a surprise. Rob Rogers (aka @EM_Educator) tweeted a really interesting ECG. Take a moment to have a look and consider the diagnosis.

Of course, you’ll have seen ECGs like this before, an inferior AMI with lateral and posterior involvement. It’s a biggy! You may well have thought…’I’m glad that this isn’t mine’. The thing is, for Rob that was not an option. This is Rob’s ECG from his hospital bed, tweeted about 24 hours after he attended. Take a moment to think about that. If you’re an emergency physician like me then you’ll have seen ECGs like this, you’ll have had those conversations with patients in the few minutes between diagnosis and thrombolysis, or the move to the cath lab. How different would it be if it was you?

Rob is just 45 years old, an emergency physician like you and me (I’m 48).

Rob is a medical education genius, he’s devoted many aspects of his career to helping others learn and to be better clinicians. He’s runs teaching courses, websites and conferences and I suppose that his tweeting of his ECG is another incredibly brave aspect of that. The altruism in sharing his story such that others can learn is amazing.

Now, his story has two good endings.

Here’s the first, a great result in the Cath Lab.

The second is his excellent podcast telling the story of his MI and how he has changed the way he looks at the world. Have a listen and think about his story, his journey, your journey and perhaps consider what it might be to be on the other side. Stop and think about your life, values and commitment to looking after yourself. This stuff matters.

At some point in the future it’s almost inevitable that we will all find ourselves in the hands of colleagues and friends. In education our ambition is to develop and train those who will look after our patients, but as ROb describes that might also mean looking after you or me. This is not a completely new concept to me as  I vividly remember one of my heroes (Chris Moulton) who taught me so much as a registrar telling me that investing in education is one of the best ways to improve the care that he might one day need. It was a little tongue in cheek, but there is some truth in this and when you listen to Rob talking about the excellent care he receved then all of that would be a consequence of someone (perhaps even Rob) investing in their training, skills and wisdom.

Education – pay it forward –  you might get it back in heaps later.

Rob has been incredibly brave to share his story, to give us all for thought, and for many of us to hear his wake up call.

To Rob from all of us in the Social Media, #FOAMed and Emergency Medicine world, the very best wishes and a speedy revovery.

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@EMManchester

This blog first appeared on St.Emlyn’s

Conference season

24 Jun, 16 | by scarley

Are conferences dead_

Having just returned from Dublin and the SMACC conference, and a few weeks earlier having travelled to the wonderful IFEM conference in Cape Town it’s time to reflect on the worth of the travel, expense and family disruption that ensues. Our work families too have to pull extra shifts and adapt to those of us lucky enough to get away for a few days away from the department.

In an era of web based technologies, podcasts, vodcasts and associated social media it’s questionable whether we need conferences at all. There are surely cheaper, less expensive and more convenient ways of communicating and in an era of social media it is ever easier to make those connections across the planet.

We should of course not forget the enormous environmental impact of many conferences, notably those large international conferences where 100s of tons of jet fuel are burned into the atmosphere to fuel knowledge dissemination that might so easily have been delivered online.

This is a theme we touched on in the EMJ in a paper looking at the future of conferences where the case for future more environmentally aware and better disseminated conferences was explored.

Innovation in the field of medical conferences.

So are conferences dead?

My experience last week and in South Africa would suggest not. Take the SMACC conference which has gained a bit of a reputation for blending social media, education and entertainment. The participants are almost all involved in online learning and so might be expected to shun the traditional travel to meet and great type affair.  Yet it is precisely this audience of online engaged clinicians who seek out the ability to meet, to network, to share, to laugh, cry and share together. This year the conference sold out in a matter of hours with competitions being held for the remaining tickets. The interest and anticipation to meet with like minded enthusiasts from across the globe was palpable and at times a little over the top and uncomfortable. The demographic was young, multicultural and multiprofessional. This is not typical behaviour for medical conferences, and perhaps is more akin to pop concert tickets. It’s a situation that makes some feel uncomfortable, but there is no doubt that it is engaging a worldwide population of learners.

A paradox perhaps, that the conference espousing an online socially connected world is one that sells out in hours and has a waiting list of those wanting to attend.

I’ve not quite got my head round this yet, but I think there may be at least two elements at work. Firstly there is a natural human desire to connect and conferences allow that, online interactions are good, but they are not the real thing and it’s great to meet in person, to explore ideas and to satisfy a human need to put faces to names. Secondly, although I find the online education world fascinating, there is only so much it can do. A live presentation of high quality is unsurpassed as a learning experience and you simply can’t do some things online.

Take the on stage discussion at SMACC on the future of medical journals as discussed by Richard Smith (ex BMJ editor). That was a great session that simply could not work as well in any other setting. A blend of science, politics, fun and entertainment with some really important discussion points and views.

Richard Smith: What will the post journal world look like?

So, the conference is far from dead, but it is changing. It’s role as a prime means of delivering information is perhaps waning, but as an opportunity to form and build social links, collaborations and understanding it is surely on the rise.

So I guess I’ll probably see you in an auditorium soon. If you do then say ‘hi’. After all, the people are just as important as the presentations. Collaborations, discussions and developments come from interaction, not from powerpoint.

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S

 

DOI: I’ve had supporting expenses to travel to many conferences, including SMACC last week. I am unbelievably lucky and priviliged to do so. I’ve actively supported a range of innovative conferences and believe that the old model of boring lectures given by boring speakers on boring subjects is a waste of time.

Social Media is Exploding – But is it Effective?

10 May, 15 | by rradecki

About a year ago, I posted about accelerating knowledge translation using Twitter, blogs, and other social media. In some respects, the embrace of social media was still in its infancy – originally, #FOAMed, powered by an independent group of individuals passionate about sharing knowledge and teaching Emergency Medicine. The Emergency Medicine Journal, driven in part by Prof. Carley’s efforts, was one of the first journals to add social media, discussion, and dissemination to their official scope and formally appoint Editors in this domain.

Now, to put it mildly, the scene has exploded.

Each of the major Emergency Medicine journals in the U.S. has at least one social media editor (Annals)(AEM), or an entire social media team. The major conferences, in Emergency Medicine and other specialties, have adopted hashtags (e.g., #ACEP14) and live tweeting by meeting participants as part of knowledge dissemination and promotion. Indeed, an upcoming conference in Chicago, USA, specifically addresses Social Media and Critical Care. Finally, even previously small, individual efforts at knowledge translation, like Academic Life in Emergency Medicine, have gathered momentum and become online clearinghouses of peer-reviewed editorial and educational content, along with their own online Journal Clubs.

The Council of Emergency Medicine Residency Directors (CORD) issued a long statement on the professional use of social media in by training programs, including a statement that “social media can be a powerful tool”. The American Congress of Obstetricians and Gynecologists recently issued guidelines on physicians’ use of social media. The United Kingdom Diabetes Professional Conference broadly covered social media use by endocrinologists to learn from and communicate with patients in a new context. Even other health professional disciplines, such as research nurses, have recognized the power of social media for unexpected viral promotion of clinical topics.

However, despite this enthusiasm, it remains a challenge to measure tangible benefits associated with social media use. Anecdotal stories of professional networking via social media abound – but, ultimately, patient-oriented outcomes as result of knowledge translation ought be the true measure of success. A recent study in Circulation randomized newly published articles to traditional knowledge translation or specific social media promotion – and there was no difference in online views between the two cohorts. The lesson, despite the authors’ conclusion, is not that social media is limited – but the content trumps the distribution method. If a social media stream consists of solely unfiltered noise, rather than useful signal, the entire effort will fail.

While increasing numbers of clinicians and patients are accessing information through alternative digital means, and the potential for education and accelerated knowledge translation through social media exists – individuals and organizations should recognize significant challenges remain. No amount of investment or effort into “social media” replaces useful content, and as more sources contribute to the pool of online information, the more difficult it will be to build a following or measure successful effects.

Emergency Medicine for medical students world wide!

17 Apr, 15 | by scarley

ISAEM HR LOGO

A guest blog from Larshan Perinpam (President of ISAEM) and Anh-Nhi Thi Huynh (Vice president of external affairs, ISAEM)

 

ISAEM is an organization established to take Emergency Medicine student Interest groups (EMIGs) extracurricular activities to a whole new level, not only locally or nationally but also worldwide.

ISAEM is the abbreviation of the International Student Association of Emergency Medicine. It is the first international Student organization of it’s kind within Emergency Medicine (EM) and was founded in Denmark in October 2013. ISAEM’s primary aim is to create International relations between EMIGs all over the world.

In the United States, EM was founded more than 40 years ago, and today it is a well-established specialty that occupies the Emergency Department (ED), which in most cases is the front door into the hospital. By having an individual specialty within EM you are able to provide a better and more optimized patient care. In many countries (Norway, Denmark, Brazil, etc.) EM does not exist as an individual specialty. In such countries EDs are occupied by the already established individual specialties (cardiology, general surgery, infectious diseases, primary physicians, orthopedic surgeons etc.) and many EDs does not have its own physician staff.

In order to develop a department the first step is to have its own staff, a staff that is continuous and present in the department on a daily basis. These are just some of the few challenges that are being faced in the EDs worldwide. Some countries already have an established specialty within EM, but it is still under development. Furthermore these countries are also facing recruitment problems due to the rough working conditions.

Larshan1 2

Larshan Perinpam

The members of ISAEM are local and national EMIGs around the world. ISAEM believes that the best possible way to recruit future staff into EM is through the EMIGs that are already established in many medical schools. We need to optimize the extra curricular activities in comparison to all other medical student interest groups, who have their interest within another established specialty.

In ISAEM we believe that by connecting every EMIG on a international level we will be able to; exchange ideas, find inspiration in activities created by different EMIGS, be able to further develop the local EMIGs and create a foundation for the next generation of physicians who wishes to pursue a careare in EM

Anh-Nhi Thi Huynh(1)

Anh-Nhi Thi Huynh

Since the establishment of ISAEM we have strived to promote ISAEM in the best way possible by attending international EM meetings (ACEP, EuSEM14, ESEM2014 etc.); finding the right collaboration partners (EMRA, DASEM, EuSEM, ESEM etc.) and focused on creating a stable and strong infrastructure of the organization. Recently ISAEM launched its latest initiative to further develop EM among medical students by creating the ISAEM National Ambassador program. The National Ambassadors will play the part as bridge-builders between the local EMIGS and ISAEM.

The practice of EM is extremely diverse and various internationally and ISAEM wishes to create opportunities in order to expand the experience and understanding for students with an interest in EM. Therefore ISAEM decided to develop an international ED Observership program in order to give medical students the opportunity to see how EM is practiced in different cultures and settings. This will also help to inspire the individual student to further develop Emergency Medicine in their home country.

Currently ISAEM is represented by five countries/members (Denmark, Netherland, Brazil, US and the Netherlands.) These already represent more than 2000 EM interested medical students. In the end of April 2015, ISAEM wish to enroll more EMIGs and by the end of 2015, ISAEM aim to represent more than 20.000 EM interested medical students worldwide! We want to create the biggest international student network within EM.

ISAEM is slowly developing and our current achievements is all because of our members, partners and the medical students who dedicate their free time in order to develop ISAEM. This work is what defines ISAEM and the future of ISAEM. In ISAEM we believe “alone we can go fast but together we will go far”.

 

If you find this interesting, please don’t hesitate to contact us:

Website: www.isaem.net, facebook: https://www.facebook.com/ISAEM13, twitter: https://twitter.com/ISAEM13 or email: Larshan@isaem.net

 

We are looking forward to further develop EM among medical students with you.

Is the Opioid Epidemic Just an American Problem?

3 Sep, 14 | by rradecki

Many problems among developed countries are unique to the United States. Gun violence is at levels comparable to locations of civil unrest around the world, and we are proud of our world leadership in obesity. Our dysfunctional healthcare incentives and payment system, despite many examples of innovative excellence, shows starkly different health status based on socioeconomic standing.

Opioid abuse and overdose is a rapidly increasing issue in the United States.  Even more damning is the obvious: all the opioids in circulation are at some point prescribed by physicians.  There are no fingers to be pointed except at ourselves.   Opioid abuse has given rise to increased heroin use and sporadic clusters of deaths, as unfortunate addicts find their typical supplies laced with fentanyl or acetyl-fentanyl, each far more potent concoctions.  Naloxone auto-injectors have recently gained notoriety – but, while these are life-saving in the appropriate circumstances, the devices cost several hundred dollars and address the symptoms of the epidemic, not the root causes.

The Academic Life in Emergency Medicine recently hosted an excellent Google Hangout discussing the challenges associated with opioid prescribing – balancing the alleviation of suffering with downstream diversion and other complications. Resident authors from the Harvard-Affiliated Emergency Medicine Residency were joined by clinical toxicologists from Toronto and Washington, D.C., to discuss appropriate analgesia in the Emergency Department. Surprisingly, many resident respondents felt this aspect of practice was highly neglected in their training.  The video discussion, the comments section, and the accompanying Twitter feed highlight questions and responses from all levels of training and expertise.

One of the other interesting question posed, however, was – how are prevalent are opioid prescribing and abuse issues outside the U.S.? Are you evaluated on patient satisfaction – and pressured to give opiates as a result? Are prescription databases widely available to screen patients at risk for abuse or diversion? How was your analgesic education handled?

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