Where Did All the LPs Go?

Physicians must be competent to perform the skills of their respective specialties before completing residency training. Educators struggle to understand just how many procedures are required of a trainee to become competent. Is there a minimum number? Does it differ by procedure for each trainee? How many is ‘enough’? And what should educators do if there are too few procedures to go around???

Our accreditation systems are designed to ensure patient safety, as a societal responsibility. Residency program directors attest to their trainees’ competence before graduation — as a safeguard. I was a program director and I lost sleep worrying about this expectation of my role. Were my residents ready? What if my mistakes assessing them led to their mistakes with vulnerable patients?

The worry – how many procedures is enough? – was a tough one for me. Every trainee is different and they each require a unique set of training experiences to become competent. The BIG however: there are a limited number of cases for trainees to learn from in teaching hospitals.

There, I said it. There are only so many chest tubes, crics, and LPs to go around.

As medicine advances, there is a slow decrease in the number of necessary bedside and surgical procedures required to diagnosis and treat a variety of acute illnesses.

Thanks vaccines and CTAs, but where did all the LPs go?

The math is as follows: if X is the number of procedures required to train a class of residents per year, and Y is the total number of procedures available, your program is fine if Y > X.

But if X > Y… you need to think outside the box.

Medical education has fundamentally changed in the last several decades. There are more trainees. There *may* be more patients. And there are certainly more training programs and teaching hospitals, sponsored by health systems that were previously and decidedly non-teaching. This represents both a challenge and an opportunity for educators who need to be creative in their search for ‘enough’ procedures for their trainees.

My research collaborators and I have some potential solutions for teaching hospitals and program directors to consider, in our article, “More Learners, Finite Resources, and the Changing Landscape of Procedural Training at the Bedside” in Academic Medicine.

Co-Authors: Linda Regan, MD – Johns Hopkins University, Jeremy Branzetti, MD – New York University, Laura Hopson, MD – University of Michigan

May 26, 2019

Ethical Dilemmas, Simulated

My most-cited publication to date describes a research project that I conducted during my Faculty Development Fellowship at Stanford University in 2003, “Assessment of Resident Professionalism Using High-fidelity Simulation of Ethical Dilemmas”. Medical simulation centers are wonderful venues for teaching high-risk tasks in low-stakes environments: the perfect settings for teaching medical ethics.

In 2003, medical simulation was still a relatively new teaching tool and the options for training seemed endless. I was particularly interested in medical ethics at the time and thought to marry that interest with my medical education training.

The design of the study was simple enough: emergency medicine residents who were managing a simulated clinical case would encounter an unexpected ethical dilemma – not all that dissimilar from day-to-day clinical practice. We designed a “Professionalism Performance Assessment Tool” as a checklist of dichotomous options for management of the case. Trainees either followed ethical and professional standards during their management of the simulated case or they did not, yes or no. A critical action was included in each case.

The ethical dilemmas selected in this 2003 research study are still important topics for trainees to learn about today. Five cases were used to test concepts in key domains: Patient Confidentiality, Informed Consent, Withdrawal of Life-sustaining Treatment, Practicing Procedures on the Recently Dead (Hint: Don’t do this!), and Do-Not-Resuscitate Orders.

I’ll always reflect fondly on this project because it was the first medical education research study that I designed and executed as the principal investigator. Thanks once more to my project mentors at the time, Drs. Rebecca Smith-Coggins and Phillip Harter. (Dr. Harter still co-directs Stanford’s Medical Education Scholarship Fellowship today!)

Read more about the study design, case development, and study outcomes in our article in Academic Emergency Medicine.

Co-Authors: Rebecca Smith-Coggins, MD – Stanford University, Phillip Harter, MD – Stanford University, Robert C. Soltysik, MS – Veterans Affairs - Chicago Health Care System, Paul R. Yarnold, PhD - Northwestern University

May 15, 2019

#StanfordAloha and CME

The 20th Stanford Symposium on Emergency Medicine kicks off on April 15, 2019 on Maui, Hawaii. Our faculty members and administrative staff worked very hard over the last several months to prepare for another successful CME conference. But how do we guarantee value in a crowded CME marketplace? And what is the Experience from the Audience?

The 19th Stanford Symposium on Emergency Medicine at the Grand Hyatt on Kauai, Hawaii.

The 19th Stanford Symposium on Emergency Medicine at the Grand Hyatt on Kauai, Hawaii.

The Accreditation Council for Continuing Medical Education (ACCME, United States) defines ‘continuing medical education’ (CME) as “educational activities that assist physicians in carrying out their professional responsibilities more effectively and efficiently “. The definition is purposely broad, to allow for creativity and innovation in an education space generally dominated by oddly-written learning objectives and Death by PowerPoint.

CME is a $2.5 billion dollar industry in the United States for the over 1,800 CME providers and their partner institutions. In 2016, a total 27 million physicians spent over 1 million hours participating in 159,000 CME educational programs. That’s a crowded marketplace.

Last year, at the 19th #StanfordAloha on Kauai, I reflected on this industry from my seat in the middle of the audience. What are the key measures of a successful, modern CME conference? For physicians who pay top dollar — and leave their clinical practices behind for a week — ROI goes way beyond the attainment of learning objectives.

I posed the question, “What makes for a wonderful CME conference experience?”, to #StanfordAloha faculty, conference attendees, and the President and CEO of the ACCME himself, Dr. Graham McMahon.

Click below to read their answers in, “The Experience of the Audience: Must-Have Design Elements for a CME Conference”, published online last year by International Clinician Educators Blog.

The 20th Stanford Symposium on Emergency Medicine is sponsored by the Stanford University Department of Emergency Medicine and runs April 15-19, 2019 on Maui, Hawaii.

April 15, 2019.