You don't need to be signed in to read BMJ Blogs, but you can register here to receive updates about other BMJ products and services via our site.

The ‘Deliberate Practice Mindset’

27 Jan, 17 | by rlloyd

Performance improvement is an interest of mine. I have previously blogged and podcasted about the strategies I employed to lift my game (from rock-bottom) when working in an extreme environment – a South African township ED.

I first became aware of ‘deliberate practice’ after reading an excellent St. Emlyn’s post last year. I had never encountered the concept before, but it resonated with me because it resembles certain aspects of how I’ve approached self-improvement in a professional setting, particularly when desperate to prove myself in South Africa.

The psychologist who originally described deliberate practice, Dr. Anders Ericsson, has recently published a book – Peak. It explores the ‘science of expertise’, for which he is the world’s leading expert – the expert on experts.

I thought I’d discuss a few of my take-home points from the book.

The ‘gift’ fallacy

“I am not talented, I am obsessed” – Conor McGregor, UFC lightweight champion

Too often, wider society’s assumption is that elite performers are naturally ‘gifted’. They have been magically blessed with superhuman ability. According to Ericsson, this is false.

No-one is born with an innate ability to perform at expert level, in any domain. All exceptional performers, regardless of field, have had to push themselves through a very intense practice regime to get to where they are. They have learnt how to be brilliant.

Ericsson repeatedly makes the point that in his 30+ years of studying an extraordinarily wide range of expert performers, from grandmaster chess players to professional tennis players to concert violinists, he is yet to encounter a genuine ‘prodigy’ – somebody born with prerequisite skills for expert performance.

MozartEricsson’s favourite example of the ‘God-given talent’ fallacy is legendary composer Wolfgang Amadeus Mozart. From an astonishingly young age, Mozart wowed audiences in concert halls across Europe with his apparent mastery of multiple musical instruments, and was labelled a child prodigy. Not so much, it turns out. The history books reveal that Wolfgang could barely walk before commencing a comprehensive training regime designed by his father, a pioneer in musical training. Furthermore, Ericsson claims that if he were around today he would barely stand out from the crowd. In fact, it’s been demonstrated that Suzoki Method-trained child musicians are often able to perform to a higher level than Mozart was ever capable of achieving.

A key component of Mozart’s prodigious skillset was thought to be his possession of perfect pitch – the ability to accurately name a musical note upon hearing it in isolation. The assumption was that it spontaneously emerged from birth and was un-teachable. It has since been proven that anyone can be trained in perfect pitch, particularly if they’ve received appropriate training between the ages of 3 and 5 years. Intriguingly, it is now acknowledged to be fairly common for children born in countries where tonal languages (e.g. Mandarin) are spoken to possess perfect pitch if musically trained. No magic involved.

The only exception to the rule that natural talent is bogus is when it comes to height and body size. Specific phenotypes are essential for certain sports – you need to be tall to slam dunk a basketball, and being short confers a big advantage for competitive artistic gymnastics. No specialised training regime will lengthen or shorten your bones.

We’re all endowed with the same ‘gift’ – the ability to adapt and improve if we train ourselves correctly (i.e. effective practice). Excitingly, Ericsson’s key message in Peak is that a common set of general principles lie at the heart of effective practice for any human endeavour… all walks of medicine included.

All practice is not equal – avoid naive practice (and forget the 10, 000 hour ‘rule’)

The most common approach to improving performance is ‘naive practice’.

This is where one spends a significant amount of time engaging in the activity, with the hope that stockpiling experience alone will improve performance, and move them closer to the realm of expertise.

“All I need to do is see 15 Majors patients per shift for the next 10 years and I’ll become a world-beating Emergency Physician” – hapless emergency medicine trainee destined for mediocrity

This is aligned with the 10, 000 hours ‘rule’ as per Malcolm Gladwell in his book Outliers. The proposed theory is that 10, 000 hours of generic practice yields expertise, with emphasis on time spent practicing as opposed to the nature of the practice itself. No specific component of the activity is isolated and focused on (e.g. putting in golf, or needle manipulation in central venous access), one just keeps doing the task over and over again. Outliers has been an immensely popular publication, and the 10, 000 rule a widely-disseminated concept. It sounds cool, and it satisfies the basic human desire for cause and effect.

In reality, this theory is fundamentally flawed. In order to change behaviour (i.e. improve performance), you need to engage in effective training. Ericsson calls this ‘purposeful practice’.

Interestingly, it is Ericsson’s original work, examining concert violinists in training, that inspired Outliers, and he levels a reasonable amount of hostility towards Gladwell in Peak, with accusations of corrupting lessons from the research. The best violinists out of the trainee group had all spent approximately 10, 000 hours by the age of 20 in solitary practice, as compared to the more inferior (but still relatively elite) trainees who had a few less thousand hours on the clock. It was this finding which prompted Gladwell to jump to the conclusion that 10, 000 hours was the magic number, yet the few that went on to win international music competitions did so at 30+, when they had put in 20,000 to 25,000 hours of practice.

“The greats weren’t great because at birth they could paint, the greats were great because they paint a lot” – Macklemore, rapper

It might be mired in controversy, but the 10, 000 hour rule does serve one crucial purpose – it reminds us that a massive volume of practice is required to achieve peak performance. No elite performer in any field has not dedicated a significant slice of their life towards achieving their goal. The path to greatness is not easy.

Purposeful Practice (core of Ericsson’s deliberate practice)

Exactly what it says on tin – this is practicing with a purpose. The mission is to improve, and you are practicing for that sole reason. Every time you practice, you are asking the question: “How can I do this better?”

A specific component of the skill is isolated (a component that one is poor at/can’t do) and then targeted for improvement via training activities. There are four principles of purposeful practice:

1.     You need to establish a (reachable) specific goal. Vague overall performance targets like ‘succeed’ or ‘get better’ won’t cut it.

2.     You must be maximally focused on improvement during practice. It must be intense, uninterrupted and repetitive (‘drilling’). Not particularly pleasant, but highly rewarding.

3.     You must receive immediate feedback on your performance. Without it, you can’t figure out what you need to modify or how close you are to achieving your specific goal.

4.     You must get out of your comfort zone, constantly attempting things that are just out of reach.

Take chest drain insertion for example. You isolate one part of the procedure that you know needs improvement – e.g. surgical hand-ties (to suture the chest drain to the skin):

Goal: Be fast and efficient at single-handed surgical hand-ties by the end of the training session.

Focus: Watch a training video explaining how best to perform the tie a few times; then practice tying knots round a kitchen utensil using the taught technique multiple times.

Feedback: Compare your performance to that on the training video, or ideally get personalised feedback from a supervisor.

Exit comfort zone: Experiment by performing the technique under time pressure or give yourself less suture thread to work with.

A hallmark of purposeful practice is that performance level during training tasks is not initially at the desired level – there is a gap. By the end of a phase of training, there needs to be something measurable that you’ve improved.

Embracing these principles in training squeezes the trigger of the greatest weapon in the arsenal of the human brain – adaptability. Every training session should be viewed as a challenge to refine and improve.

Deliberate Practice

“The most effective (improvement) method of all: deliberate practice. It is the gold standard, the ideal to which anyone learning a skill should aspire.” – Anders Ericsson

Deliberate practice encompasses the principles of purposeful practice, with a couple of additional elements:

1.     The field must be well established, and elite performers easily identified.

2.     A coach or teacher guides training.

A good coach provides constant individualised feedback and designs training activities that target specific areas. They hold the ‘roadmap’ that guides the student through an evolving training regime that hones skills in a specific order. Certain skills can only be taught and practiced once others have been mastered.  This calculated and heavily supervised approach to training always leads to elite performance when the student is motivated. It is tried and tested.

A useful analogy is to think of purposeful practice as trekking through the desert to a specific destination that is out of sight. You know the general direction you need to go, but in order to reach the destination you must walk in a completely straight line – notoriously difficult in the desert. A good strategy would be to use landmarks up ahead such as trees and sand dunes to aim at, so as to avoid walking round in circles. You are progressing with a purpose, but there is minimal guidance.

In this context, deliberate practice can be thought of as that same journey, but instead there is a path marking the route you need to walk, with signposting along the way, and even a camel guide to get you back on track if you veer off the route.

Mental representations

Engaging in purposeful/deliberate practice modifies the structure of our brains. Specific neural circuitry, which fires action potentials when training a skill, get reinforced and increasingly complex. This serves to strengthen the ‘mental representations’ one has of the skill in question.

The human brain is a blank canvas, and learning a new skill is like painting a picture on that canvas – the picture being a mental representation of that skill. With effective training, and as one improves at performing the skill, a discernible image starts to take shape. As the years of effective practice roll on, the picture becomes increasingly detailed and animated, and eventually it correlates with performing the skill at an expert level.

The expert performer, via their mental representations, is acutely aware of how best to perform. By comparing what they are doing in the moment with the perfect picture in their head, they can modify their performance appropriately – self-policing. The quality and quantity of mental representations is what sets expert performers apart from everyone else.

“In pretty much every area, a hallmark of expert performance is the ability to see patterns in a collection of things that would seem random or confusing to people with less developed mental representations. In other words, experts see the forest when everyone else sees only trees” – Anders Ericsson

The perfect example of elite performance correlating with highly sophisticated mental representations is George Koltanowski, a chess Grandmaster who set the world record for simultaneous games of blindfolded chess – 34 games (he won 24 and lost 10)!  His mental image was so strong that he could animate each game in his mind without looking at a single chess piece. It turns out simultaneous-game blindfold chess has been a pursuit of Grandmasters for centuries.

Furthermore, in studies of elite footballers and basketball players, it has been shown that when visual stimulus is suddenly removed, they can accurately pinpoint the position of all their teammates and opposition, and even predict how the game evolves in the seconds that follow. Again, this is facilitated by their mental representations – highly detailed images that come to life in the brain of the performer.

Fascinatingly, if you asked a grandmaster to recall the positions of randomly placed chess pieces on a chess board, or asked a footballer to recall the positions of 22 randomly placed men on a football pitch (i.e. not in position as a result of a game), they would fail because their mental representations are specific for the respective activities. If the arrangement of pieces or players is random, it ceases to be meaningful, in much the same way a set of jumbled up words is meaningless in comparison to a sentence.

The ‘deliberate practice mindset’

To truly reap the benefits of purposeful/deliberate practice, one must reject three prevailing myths:

1.     Your abilities are limited by genetics.

2.     If you do something for long enough you’ll get better.

3.     All it takes to improve is to increase your effort levels.

Once this is done, you are set free; the world is your oyster. However, the road to expertise is long and gruelling, and patience is crucial. The four underlying principles of purposeful practice must be kept in mind at all times, and failure should always be viewed as a precious opportunity to reflect and refine one’s mental representations.

If no coach or teacher is available (i.e. deliberate practice not strictly possible), identify somebody who is at a level that you want to reach (i.e. a mentor), try and understand how they got there, and proceed to purposefully practice.

Intense periods of focus, constant repetitions, and hovering at the edge of one’s comfort zone in training will get pretty miserable and frustrating at times. However, it should be appreciated that when quantifiable improvements start to occur, striving for further gains will become more enjoyable… even exciting.

Remember that a crucial aspect of deliberate practice is that it focuses solely on performance (i.e. how to do it) – it is a skill-based practice, and this must be embraced. By effectively practicing components of the skill and building stronger mental representations, knowledge will build naturally alongside. New concepts will seem less abstract as they are absorbed whilst applying skills (NB: This is in contrast to the traditional approach to medical training which has placed more emphasis on knowledge acquisition than skill development, largely because it is more convenient and less labour-intensive to teach).

In medicine?

An unfortunate reality of most medical specialties is that once a practitioner is fully qualified (i.e. a consultant or attending physician) there are few opportunities for immediate feedback on his/her clinical practice. There are no longer regular mandatory appraisals, and too often, little feedback from the patients themselves (e.g. a radiologist might not be made aware of the outcome of a patient where a cancer was missed on CT scan).

Furthermore, as seniors are no longer being actively trained, it is very unusual for them to be pushed out of their comfort zones, and they will usually deem their own performance level to be ‘acceptable’. You might say that they are particularly guilty of naive practice. This is a recipe for stagnation, and an overall decline in performance. An interesting passage in the book is where Ericsson discusses research into senior radiologists looking at mammograms, and experienced GPs listening to heart murmurs. It turns out their diagnostic accuracy is no better (and in some cases worse) than their junior colleagues, who will have received more recent active education.

As an emergency medicine trainee, much of my daily work will embrace the principles of deliberate practice, but it is variable, and often depends on the boss I happen to be on shift with. Taking ownership is key. It’s up to me to be cognisant of what elements of practice will make me a better doctor, and anchor my training appropriately. Awareness of these principles has also given me a greater appreciation of the utility of simulation training – ‘off-the-job-training’ which focuses on closely supervised skill development rather than knowledge acquisition.

It will be far more of a paradigm shift for senior doctors (i.e. finished all training) to adopt deliberate practice, but the implications for patient outcomes, and indeed medicine’s overall trajectory, will be enormously positive if they do.

I highly recommend Peak to anyone interested in improving at what they do. Doctors, of all grades, should be aware of, and striving to incorporate, the lessons from Anders Ericsson’s masterpiece.

Robert Lloyd
@PonderingEM

*This blog first appeared on the Pondering EM blog

What do Emergency Medicine and Donald J. Trump have in common?

7 Dec, 16 | by rlloyd

trump-01

Illustration by A3 Studios

*Caution: Emotionally-charged post, pinch of salt required… personal feelings only and not the editorial view of the EMJ/BMJ.

On the morning of the 9th November 2016, I woke up to the earth-shattering news that Donald Trump had been elected President Elect of the United States. It’s a moment I’ll never forget.

Rain pounded menacingly against my bedroom window, all my social media outlets exploded with sentiment of anger and sadness, and my American fiancé lay next to me in floods of tears.

I, like many (urm… all) of my friends and family, and seemingly the majority of the #FOAMed community, am horrified by the Trump phenomenon. His hateful, divisive rhetoric is unlike anything I’ve previously encountered in a public figure, let alone the new leader of the free world. Appropriately, and frighteningly, he has drawn comparisons with some of modern history’s ugliest dictators, such as Hitler and Mussolini. Mind-bendingly hideous stuff.

Throughout his campaign, Trump would verbally decapitate anyone who dared to undermine him. Cutting personal insults and sinister threats (‘I’ll throw her in jail when I’m in the White House!’) were par for the course, and reflective of an insecure man with astonishingly thin skin. Of course most of the time it was his rival Hillary Clinton in the firing line, but even fellow Republicans took some damage if they decided to be critical.

If his foul-mouthed tirades were a shrewd strategic move for diverting attention from his lack of political acumen and poor grasp of the Presidential job description, then arguably, the man’s a genius. Decipherable policy specifics were sparse, but unashamed fascism seemed to be a common theme, exemplified by absurd proposals to build a wall on the US-Mexico border and ban all Muslims from entering the US.

I’ve lost count of how many times I felt convinced of his self-destruction. Whether it was accusing all Mexican immigrants of being ‘rapists’, jokingly inviting a Clinton assassination attempt, or the release of a video where he openly boasted of sexual assault, he somehow kept on surviving. And then he won the keys to the White House. Ugh.

I am no journalist. Nor am I a political analyst. I’m a blogtastic British junior doctor training to be an Emergency Physician, and therefore pretty far removed from the whole debacle (*wipes sweat off brow*). Having said that, witnessing Trump’s ascendancy has triggered an important work-related reflection that I feel the urge to share.

Where is our basic human decency?

The Trump campaign suffered from a disease which stripped it of basic human decency. Depressingly, this reminded me of the alarming regularity that I witness unnecessary rudeness and outright bullying in the ED environment. Unpleasant, heated exchanges are a daily occurrence (certainly where I work anyway). Where does the hostility come from?

We’re bloody busy

The influence of workload cannot be emphasised enough. The ED is inevitably the busiest department in every reasonably-sized hospital, and it remains so 24 hour-a-day, 7 days-a-week (despite what our Health Secretary might have the tabloid newspapers believe).

When you consider that in 2015-16 there were 22.9 million visits to the 136 existing EDs in the UK, I think it’s fair to say overburdened is an understatement (by developed world standards of course) (1). Stress levels can reach fever pitch at the sight of a an overflowing waiting room, a seemingly never-ending list of ‘unclicked-on’ patients on a computer screen, or a growing congregation of paramedics indicating that pregnant ambulances are queuing up.

All of these are inevitable features of working in a UK ED, and with the added pressure to have patients ‘sorted’ in under four hours (i.e. discharged or warded), it’s understandable that some might become irritable and combative. It doesn’t matter if you are a native ED doctor, nurse or visiting specialist, the feeling is contagious; it’s a pressure-cooker workplace, and too often I see people releasing their personal pressure-valves by taking out frustrations on colleagues.

Of course, all of the emotional demands of working in such an over-stretched environment are heightened when dealing with particularly sick and unpredictable patients. As such, the resuscitation room tends to be the arena where I am most stunned by the way colleagues address each other.

False inferiority complex

There is no department where tribalism is more evident than the ED. It’s a bubbling cauldron of inter-specialty and multidisciplinary interaction.

As emergency medicine practitioners, we’re arguably the only nominal generalists in the hospital setting. This means that in the eyes of some of our specialty colleagues, we’re ‘second best’ at managing many of the pathologies we see. We can commence management of acute coronary syndrome, but we’re not cardiologists; we can intubate, but we’re not anaesthetists; we can even crack chests, but we’re not cardiothoracic surgeons.

This, of course, is a total fallacy. Emergency physicians might seem like generalists at surface-level, but the reality is that they ‘specialise’ in appropriately differentiating the undifferentiated. Where neighbouring specialties anchor towards diagnosing familiar pathologies (e.g. the cardiologist quickly labelling a patient’s chest pain as myocardial ischaemia), emergency physicians won’t jump to premature and potentially dangerous false conclusions, and remain open to multiple possibilities until firm evidence presents itself. In the initial phase of managing patients fresh from the community, across the spectrum of acuity, the emergency physician possesses the safest, and most expert pair of hands.

Unfortunately this isn’t always recognised by our specialty colleagues, who can overlook the inherent challenges of the emergency medicine landscape, and occasionally be quick to patronise, condescend, and even ridicule when being referred to, particularly when by a junior person.

In the more vulnerable amongst us ED folk, this can breed a false inferiority complex and erode confidence. Seniors are more likely to react with verbal pugilism if they feel disrespected.

Conflict is further cultivated by the unfortunate reality that much of our job involves giving someone else more work to do, which naturally fosters resentment on their part.

Of course, the outcome of inter-specialty collisions in the ED don’t always end in tears, and I appreciate that I might be painting a overly grim picture. However, in my experience the referral process can turn ugly very quickly, particularly when other stressors are in play (e.g. being particularly busy).

Blame culture

Doctors aren’t supposed to make mistakes. However, it’s undeniable that healthcare (especially the ED) is highly error-prone. It’s an unpredictable, dynamic environment with an extraordinary amount of moving parts.

The hallmark of a good system is a strong culture of learning from failure. The ultimate example is the peerless aviation industry, whose safety model has become the stuff of legend – they jump up and down with excitement when a plane crashes because it represents an opportunity for precious learning (2).

In stark contrast, it’s no secret that the healthcare industry hasn’t exactly covered itself in glory when it comes to promoting patient safety. From the Mid-Staffordshire Enquiry to the Harold Shipman scandal, our history is littered with examples of system failures that should have been thwarted earlier through a healthier culture of incident reporting and institutional change management.

I’m not saying we’ve had no success stories, I’m merely suggesting that there’s an awful lot of room for improvement. There’s the tragic case of Elaine Bromiley, whose death in the anaesthetic room prior to a routine sinus operation prompted an independent investigation which led to a global revolution in patient safety measures around airway management (3). It’s worth noting that the investigation was driven by Elaine’s inspirational husband Martin – a commercial airline pilot.

There are plenty of historical and structural reasons for our suboptimal safety culture, but arguably the most important factor is that society puts doctors on a pedestal, and assumes invincibility. Error is heavily stigmatised in our workplace because the public expects perfection. So when the inevitable mistakes do occur and we fear being implicated, a strategy for deflecting attention is to turn on each other. Even when there is no risk of being implicated, we still can’t resist the urge to point the finger of blame (or gossip about the incident behind the back of the guilty party) because somehow it soothes open wounds from previous public humiliations.

When it comes to mistakes, our institutional focus is on who did it, and not what can be learnt from it. Opportunities for progression usually descend into fruitless professional witch-hunts. And this culture is ingrained in us all from medical school.

The ‘patients lives are on the line’ card

Trump exonerated himself from his revolting campaign narrative by playing the ‘political correctness’ card. He fooled the electorate, and branches of the media, into thinking his verbal excrement was acceptable (even attractive) because he wasn’t a career politician and therefore didn’t ‘play by the rules’. No other presidential candidate in US history would have got away with some of the things he’s said, but he was ‘sticking it to the establishment’, so it was OK.

In a similar vein, I believe that it’s become acceptable for collegiality and decency to be left at the door of the ED because the ‘patients lives are on the line’ card gets played. The stakes are far too high for us to care about the way we treat each other.

This attitude is helped along by our very rigid, arguably militaristic hierarchical structure.

There is no doubt that a hierarchy is crucial for ultimate decision-making accountability, but it gets abused too often in my opinion. Of course some are more guilty than others, but if a senior person is feeling particularly under pressure (or, dare I say it, out of their depth), it’s all too easy for them to take out their frustrations on a defenceless junior staff member – riding the authority gradient. And it’s totally acceptable to do so, because it’s a patient’s life at stake of course.

I’m not just talking about consultants and senior nurses, it spans the entire spectrum of ED staff. I’ve witnessed a rookie doctor rotating through the ED viciously bark at student nurses for taking ‘too long!’ to attach the monitoring to a perfectly stable patient in majors – unacceptable, and an abuse of authority even at the most junior level.

Misplaced self-importance anaesthetises basic manners. We weaponise the inherent moral high ground of doctoring in much the same way that Trump weaponised being ‘un-PC’. We’re getting away with behaviour that we shouldn’t.

The irony of playing this ‘card’ (so to speak) is that our patients ultimately suffer because our multidisciplinary teammates are less willing to go the extra mile for someone they don’t like. Truly toxic stuff. Are we that self-righteous? Are we that arrogant?

Why are we not holding ourselves to a higher standard?

I am not proclaiming to be mightier than thou. I have fallen foul of high stress, surfed the authority gradient and hidden behind the fallacy that I’m making regular life and death decisions as much as the next junior emergency medicine trainee. I can recall multiple times where I’ve been unacceptably rude to colleagues, and even remember an occasion where I made a nurse cry and run out of resus. I was remorseful about those moments, but only transiently. There was always something ‘terribly important’ I could distract myself with, ridding me of the shame I felt for being a b*****d to a colleague for no valid reason.

However, those I verbally abused will not have recovered so quickly, and are now more likely to treat their future juniors as I did them on those occasions. This is the vicious cycle of bullying that I’m sure every doctor reading this post will relate to on some level, whether they can admit to it or not.

Why are we not holding ourselves to a higher standard? As front row spectators to the fragility and preciousness of human existence, surely we of all people should have more respect for each other.

We musn’t be fooled into thinking that just because we have different skillsets or seniority that we aren’t singing from the same hymn sheet. No matter what it says on your hospital name badge, we all have the same job description: help make people better.

We deal in the currency of human life, which in my opinion is the greatest professional privilege that there is. No matter how bad our day seemingly is, or how much pressure we feel under, you can bet your bottom dollar that you need to look no further than the frightened, desperate person staring back at you from the trolley to find someone worse off. That dose of perspective is a gift, and it alone should do the job of warding off Trump-like demonstrations of contempt for our colleagues.

Of course, Americans voted for Trump in their droves (in much the same way that Brits voted for ghastly Brexit). Why? That’s not for me to say; I’ll leave that to the politicos. What I can say with some certainty is that a massive proportion of the Western world feels a potent combination of embarrassment, sorrow and anger that we’ve allowed such a harmful situation to escalate.

Is this not the very same cocktail of emotions that we feel after a hostile exchange in the ED? We must strive to be better at checking ourselves before forgetting our basic human decency and engaging in needless workplace warfare.

We’re better than this.

Do the right thing

As medical professionals, our knowledge-base and skillset give us almost supernatural status in the eyes of the public. Being a doctor is more than a job, it’s a title. But that’s not why they’ll allow us to slice into their bodies, poison them with medications, and have access to their most hidden secrets. They allow us these privileges because we’re supposed to be fundamentally good people who’ll always act in their best interests no matter what the cost. We, more so than anyone else in wider society, are deemed to be the custodians of doing the right thing.

That should be something we carry with us at all times in our workplace, regardless of who we are speaking to, or the nature of the scenario. There is no place for Trumpism in the ED.

Robert Lloyd
@PonderingEM

NB: I appreciate that the content of this post is emotionally-driven, opinion-based, and potentially controversial. Please feel free to commentate/agree/criticise in the comments, it would be great to generate some discussion around the topics brought up.

References

  1. Accident and Emergency Statistics: Demand, Performance and …
  2. Black Box Thinking. By Matthew Syed.
  3. What can we learn from fatal mistakes in surgery. By Kevin Fong, BBC News.

Many thanks A3 Studios for the amazing accompanying graphic.

The weekend effect. Part 1.

28 Oct, 16 | by scarley

the-weekend-effect

Chris Moulton VP of the Royal College of Emergency Medicine and Ellen Weber discuss the weekend effect. This is well worth a listen to get behind the headlines and politics of a controversial meme in healthcare.

What is it? Is there an effect and what can we do about it?

Click on this link to read more about the paper on Chris Gray’s blog.

 

vb

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.

vb

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

ECG Marksmanship: Posterior Wellen’s Syndrome

9 Sep, 16 | by rlloyd

posterior-wellens-syndrome-2

One of the most rewarding elements of emergency medicine is spotting a potentially catastrophic situation at an early stage, and proceeding to ‘nip it in the bud’ before things start getting hairy.

To coin a military analogy: a battalion might be perfectly capable of neutralising the enemy in close-quarters combat, but in an ideal world, a shrewdly placed sniper will take care of business ahead of time. No need for bayonets if you’ve got a man on the roof.

The emergency physician acts as the sniper when Wellen’s Syndrome is spotted on the 12-lead ECG. A pain-free, haemodynamically stable patient might be moments away from a ‘widow-maker’ infarct, but if the subtle precordial biphasic T-waves are picked up, the enemy lesion can be taken out from range via percutaneous coronary intervention (PCI), sparing the patient’s anterior myocardium. No drama.

What is Wellen’s Syndrome again?

It was first discovered in 1982 by Hein J. J. Wellen, and describes characteristic T-wave changes in the right precordial leads (V1-V3) that represent critical stenosis of the left anterior descending (LAD) artery.

Most cases (approximately 75%) of Wellen’s Syndrome have a ‘Type B’ pattern – deep and symmetrically inverted T-waves. This is an easy spot, and should ring alarm bells even at novice level.

wellens1_1

Wellen’s Type B (Image from ‘Life in the Fast Lane’)

A minority of cases (approximately 25%) will have ‘Type A’ pattern – biphasic T-waves. These are often more subtle, and easily overlooked, particularly if the patient is clinically well.

Wellen's Type A (Image from 'Life in the Fast Lane')

Wellen’s Type A (Image from ‘Life in the Fast Lane’)

The physiological basis for Wellen’s is spontaneous reperfusion of a previously occluded artery. Often patients will present to the ED following a bout of severe chest pain which has resolved. Classically, the ambulance ECG will demonstrate an impressive STEMI, which has disappeared once the patient has arrived in resus, pain-free. Despite being symptomatically better, these patients will have an active thrombus and are high risk for re-occlusion and STEMI. They need aggressive medical management, with a view to urgent angiogram/PCI.

Wellen’s waves are not exclusive to the anterior leads. They have been shown to correlate with spontaneous reperfusion in the left circumflex (LCx) and right coronary artery (RCA) when ECG changes are seen in the inferior and lateral lead distribution.

Interesting recent EMJ article – Driver et al, August 2016

Until recently, the literature has not described the ECG appearance of posterior MI (PMI) reperfusion.

An article published online first in the EMJ last month takes on this very challenge. Tellingly, one of the authors is Stephen Smith, author of ‘Dr. Smith’s ECG blog’ – one of the most prominent ECG #FOAMed resources available.

The classical acute PMI ECG demonstrates new ST depression in the right precordial leads – a mirror image of ST elevation in the hypothetical posterior leads (V7-V9). The posterior myocardium is supplied by either the LCx or RCA, depending on the patient’s anatomy.

The authors of this paper hypothesised that spontaneous reperfusion of the offending artery in acute PMI patients would result in Wellen’s waves (deep T-wave inversion) in the posterior leads, which would correlate with an increase in positive T-wave amplitude in the right precordial leads – again, the mirror image concept.

It was a retrospective observational analysis of 72 patients with LCx or RCA occlusions who underwent PCI – mimicking spontaneous reperfusion. Forty eight patients met criteria for PMI – ‘presence of right precordial ST depression, maximal in leads V2 and/or V3, not explained by QRS abnormalities’. Twenty four patients did not meet criteria – i.e. they had occluded their LCx/RCA, but the posterior myocardium was not infarcted.

Post reperfusion:

  • PMI patients had a greater increase in V2 and V3 T-wave amplitude when compared to non-PMI patients (p=0.0005 and 0.03 respectively).
  • PMI patients had greater maximal T-wave amplitude in lead V2 (p=0.04) when compared to non-PMI patients.

The authors believe they have described an ECG finding for PMI reperfusion that is ‘analogous’ to typical Wellen’s waves. ‘Posterior Wellen’s Syndrome’ is born.

Of course there are the inherent limitations of a single-centre study with a small patient population, but nonetheless the paper is compelling reading. It’ll make you a more accomplished ECG marksman, taking better aim from the roof of your department.

For me, the take-home point is to always carefully consider treating and admitting a patient with resolved ischaemic-sounding chest pain and unusually big right precordial T-waves (however subtle) – particularly if they have risk factors for coronary artery disease. At the very least previous ECGs should be hunted down and interrogated.

As always, would love to hear others thoughts on the paper.

Robert
@PonderingEM

The Paper

Driver BE, Shroff GR, Smith S. Posterior reperfusion T-waves: Wellens’ syndrome of the posterior wall. Emerg Med J. 2016 Jul 29.

Additional resources used

Should More Emergency Physicians be ‘Piloting British Airways’? The Musings of a Trainee: EMJ

22 Aug, 16 | by rlloyd

musings

Emergency physicians (EPs) routinely manage the sick, undifferentiated patients in whom life-saving interventions need to be executed rapidly. Our Royal College defines emergency medicine as ‘the specialty in which time is critical.’

In severe illness or injury, ‘A’ comes first. Securing a definitive airway is the gateway to the rest of critical care; without one, our sickest patients will usually be carried out of the resuscitation room in body bag. For this reason, emergency airway management must lie within the skillset of the emergency physician.

Rapid sequence induction (RSI) and tracheal intubation are, appropriately, considered core skills for EM trainees in the UK. The second year of ‘Acute Common Care Stem’ (ACCS) core training – the route to advanced EM training – consists of six-month rotations through anaesthesia and intensive care, allowing for ample exposure to critical illness, and development of advanced airway skills.

Despite this, frustratingly, EM-led RSI is a contentious issue in the UK. In 2010, Benger and Hopkinson published a survey in the EMJ that examined the practice of ED RSI across the UK over a 2-week period (1). It revealed that anaesthetists carried out the procedure a whopping 80% of the time (actual percentage likely to be even higher as only particularly ‘airway-keen’ EDs contributed). This starkly contrasts with Australasia and the US, where EM-led RSI is standard of care, with anaesthesia backup made available if difficulty is predicted.

Silo-culture and tribalism remain prominent in UK EDs in 2016, with anaesthetists usually assuming full ‘pilot duties’ when it comes to the airway. However, the landscape is changing, particularly in prominent teaching hospitals – in large part due to a new generation of EPs who’ve completed ACCS.

Additionally, there is some solid literature that suggests EM-led RSI is safe and effective, as long as practiced within a supportive system. Let’s have a look.

Stevenson et al, 2007 (2)

This EMJ publication is a single-centre prospective observational study which investigated the nature of ED RSI practice at a district general hospital in Scotland (Crosshouse Hospital, Kilmarnock) over 3 years. Data was collected via a questionnaire filled out by the intubating doctor immediately after the procedure. The authors were most interested in who was performing the procedure, and whether a specialty was implicated in airway-related complications (categories: desaturation, hypotension, aspiration, oesophageal intubation, cardiac arrest). In short, they wanted to know EPs were worthy of wielding laryngoscopes.

Over the 40-month period, 199 ED RSIs were performed. EPs carried out 44% of these – far higher numbers than contributing departments to Benger and Hopkinson’s survey (published 3 years later). Anaesthetists achieved superior laryngoscopic views and higher rates of first pass success (91% versus 82%) but promisingly, there was an identical overall success rate (97%), and almost identical complication rates.

The crucial detail from this paper is that the department had high instances of senior presence from both specialties during ED RSI. This suggests a supportive training environment, and a collaborative approach to emergency management. Ongoing inter-specialty synergy has probably further propagated safe EM-led RSI in this department in the years since the paper was published.

Kerslake et al, 2015 (3)

A more recent publication which supports EPs at the head-end is this paper from Resuscitation. Similarly, it is a single-centre prospective observational study, where 12 years of ‘ED Intubation Registry’ data was analysed.

Interestingly, this hospital (the Royal Infirmary of Edinburgh – a large, urban teaching hospital) has a protocol dictating that a senior anaesthetist is contacted to supervise all ‘drug-assisted intubations’ (invariably RSI). The anaesthetist only steps in if added expertise is required due to a predicted/encountered difficult case.

78% of 3738 tracheal intubations were performed by EPs – unprecedented numbers in the UK. EPs were found to achieve similar laryngoscopic views, but lower first pass success over the whole 13 year period. In order to reflect modern practice, the authors performed a subgroup analysis on intubations performed since 2007, which demonstrated improved EP performance – first pass success matched the anaesthetists (88% versus 87% respectively). This is probably a reflection of ACCS training being introduced relatively recently.

This paper demonstrates indisputably excellent numbers, and is further evidence that appropriately trained EPs, when part of a collaborative system, are fully competent airway practitioners. By formally protocolising dual specialty involvement with ED RSI, rapid progress has clearly been made at this institution.

National Audit Project 4, 2011 (4)

nap4

NAP4 was a very high profile publication from the Royal College of Anaesthetists which captured detailed reports of major complications from airway management across the UK over 1 year. Reports included cases from the ED and ICU as well as the anaesthetic environment. NAP4 has been widely discussed around the world because the lessons from it have been so valuable for all airway practitioners.

A headline finding from NAP4 was that out-of-theatre airway management is associated with a significantly higher complication rate than the anaesthetic room (at least one in four major airway complications occurred in the ED/ICU). Furthermore, these complications were far more likely to be fatal.

Close inspection of the paper revealed some eye-opening analysis with regards to events in the ED: Many complications were avoidable, and could be attributable to the visiting (often junior) anaesthetist being unfamiliar with the environment.

Analysis of the ED-based events included mention of:

  • Communication breakdown in the resus team.
  • Lack of team-based contingency planning (‘failing to plan for failure’).
  • Failing to locate/use appropriate equipment (e.g. waveform capnography).
  • Failure to follow usual protocol due to high stress levels and novel distractions.

In order to combat these examples of avoidable error in the ED, NAP4 recommend:

  • Development of excellent communications between specialities involved in emergency airway management – this encourages cross-specialty planning for commonly encountered airway problems.
  • Joint training of EM/anaesthetics/ICU staff. Ideally simulation and team training.
  • Regular audit of emergency airway management in resus.

Crosshouse Hospital and the Royal Infirmary of Edinburgh have demonstrated that adherence to NAP4s recommendations is more achievable with a collaborative approach to emergency airway management.

Opportunity for EM to take a leading role

Here in the UK, the reality is that most of us probably work in hospitals without protocolised co-operation and support from anaesthetics, and find ourselves frustrated by an institutional reluctance to us utilisating our skill-set.

If EPs/EM trainees can take a leading role in the pursuit of a closer relationship with the anaesthetics department, then perhaps the process of ushering in culture change can happen more rapidly, even in the traditionally less progressive hospitals.

The key is building better communication channels with the anaesthetics department. ACCS trainees have an important role, as they are perfectly placed to ‘start the conversation’ whilst working in theatres and ITU. Joint training initiatives can be lobbied for, and enthusiasm can be expressed.

Even if local policy dictates that anaesthetists are the only practitioners permitted to perform ED RSI, EM can still take the lead with auditing/surveying practice. This will foster improved communication and joint teaching (might stimulate creation of EM/critical care joint audit meeting).

Screen Shot 2016-08-15 at 01.58.09Surveying ED RSI practice via a questionnaire filled in by the intubator post-procedure is a project that I have initiated at my own hospital. The project was inspired by the papers mentioned in this post, and the Australia New Zealand Airway Registry, which I was exposed to whilst working in Melbourne. If emergency clinicians can identify opportunities for improving ‘anaesthetics practice’ in the ED then attitudes might start to change.

EM-led quality improvement projects involving airway management will almost certainly be welcomed by anaesthesia, being the leading specialty that they are for pioneering patient safety initiatives. For EM trainees keen to manage airways (like myself), demonstrating a persistent interest (i.e. beyond the 6-month anaesthesia rotation) should be considered as important as demonstrating competence, as it will be that interest which stimulates local, and UK-wide culture-change.

The appropriateness of an ED doctor at the head-end has been a circular (and boring) debate for years. Anaesthetists will always maintain a greater level of technical prowess when it comes to advanced airway management for obvious reasons. However, an EP who has demonstrated competence and ‘currency’ is perfectly qualified to manage the airway, and will have the advantage of more familiarity with the resus environment, and the luxury of initiating proceedings without delay. Bottom line? The ‘anaesthesia versus EM’ argument is moot – specialty is irrelevant when it comes to these patients, it is the skillset which matters. Anaesthetics? EM? ITU? We are all resuscitationists.

Final thoughts

It is worth remembering that EM is a specialty which struggles to retain trainees in the UK. An enormously attractive aspect of working in A&E is the critical care element, but all too often, our time in resus gets trumped by pressures to meet targets (‘the anaesthetist has arrived, go back to majors and pick up another patient’). The ability to manage the airway is symbolic of a true resuscitationist, and empowering trainees with that responsibility will galvanise those already in training, and attract more junior doctors to our great specialty. In the long run it will pay off.

Robert Lloyd
@PonderingEM

Worth Reading/Listening

‘RSI in the ED; should EM be taking the lead?’ – HEFTEMCast (podcast)

‘JC: ED RSI – you can do it’ – St. Emlyn’s (blog post)

‘John Hinds on Airway at RCEMBelfast’ – RCEM FOAMed Network (podcast)

‘NAP4 Major Airway Complications in Emergency Departments’ – Professor Jonathan Benger (lecture)

 

ADD-ON (23/08/16): An Important Tweet…

The day following publication of this post, a leading voice in the world of EM tweeted this:

On 1 December 2015, the Royal College of Anaesthetists and the Royal College of Emergency Medicine released a joint statement on emergency airway management (5). It echoes the recommendations made by the NAP4 report, and is very progressive with regards to the role of the emergency physician, and the importance of interdepartmental training. The statement dovetails beautifully with the points made in this blog, and is essential reading. Here is a snippet:

‘Opportunities for the maintenance of rapid sequence induction and tracheal intubation skills by emergency physicians should be provided within each acute hospital.’

Many thanks to both colleges for making their position clear on such an important issue in UK EM, and to Dr. Reid for bringing this to the attention of the author!

 

References

  1. Benger J, Hopkinson S. Rapid sequence induction of anaesthesia in UK emergency departments: a national census. Emerg Med J. 2011 Mar 1;28(3):217–20
  2. Stevenson AGM, Graham CA, Hall R, Korsah P, McGuffie AC. Tracheal intubation in the emergency department: the Scottish district hospital perspective. Emerg Med J. 2007 Jun 1;24(6):394–7 
  3. Tracheal intubation in an urban emergency department in Scotland: A prospective, observational study of 3738 intubations
  4. Cook TM, Woodall N, Harper J, Benger J; Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: intensive care and emergency departments. Br J Anaesth 2011;106:632-642.
  5. Emergency Airway Management: A joint position statement from the Royal College of Emergency Medicine and the Royal College of Anaesthetists

EMJ blog homepage

Emergency Medicine Journal blog

Analytical approach to the developments and changes in the field of Emergency Medicine Visit site



Creative Comms logo

Latest from Emergency Medicine Journal

Latest from EMJ