The New Year offers us a fresh opportunity to take stock, learn from our mistakes, and set an even brighter path for emergency medicine
1. Mark Your Words
Words mean more than we think. This year, let’s be more careful in how we use our twists of the tongue. Let’s start with “unnecessary testing.” Everyone is throwing the phrase around, but what does it actually mean? Care that is avoidable? Futile? Redundant? Exorbitant? Wanton? Given the variety of environments, geography, resources, patient expectations, comfort with uncertainty and pressures under which we practice, I’m afraid this phrase is simply not accurate. I’d like to propose that we think about this topic more in terms of “practice variation,” a phrase which helps us better visualize the bell shaped curve of practice. In many ways medical practice lives in a bell-shaped world, not the binary world of necessary vs. unnecessary. Most of us fall in the middle of the curve, while those on the left are early innovators and those on the right are late adopters. Rather than talk about a perfect standard of care, therefore, we need to discuss “ranges of contemporary clinical practice”.
2. Sharing Isn’t Always Caring
Every day I hear something from my residents about ‘shared decision-making’. We need to clarify the meaning of this phrase. After all, does a patient really understand medical decision-making when discussing diagnosis and treatment of simple or complex conditions? Patient values and expectations and professional knowledge, experience and judgment all come to bear on ‘shared-decision making’. There is no evidence to suggest that we have robust tools yet for effectively communicating risk-benefits to our patients . This year we should encourage EM research in this area.
3. Understand that Longer Isn’t Always Better
Have you checked the 2015 AHA and ILCOR/ERC guidelines? The AHA executive summary consists of 52 pages, and the ERC, 80 pages. Perhaps the length of the ‘summaries’ is one reason why it is so difficult to keep physicians updated and change practice. An executive summary is supposed to BRIEFLY summarize facts so readers can rapidly assimilate, and use, the information. Let’s see if we can change guideline editorial practice. Let’s write these editors and urge them to put key recommendations in short, direct, clear prose so that we can enact them more quickly.
4. From Books to Blogs, Be a Better a Student
Emergency medicine is a dynamic specialty. As a matter of fact, it is the most dynamic specialty. Not only do we regularly change practice to incorporate EM-specific guidelines, diagnostics, and treatments, we have to understand developments in other specialties that affect emergency care. Fortunately, we’ve entered a new age of medical education. Books, our old standbys, still have their role. They provide spatial landmarks that allow cross-reading in different chapters. You can loan your book to others, and xerox pages. You can re-read complex material, take notes in the margin, and incorporate information so it becomes part of your mental framework.
Of course, books can’t handle late- breaking developments, they’re heavy, and you can’t read while you’re driving. The real future of textbooks is the print/digital hybrid, which allows searching, cross-linking, videos, interactive learning and online note-taking.
Blogs and Podcasts are great tools for contemporary learning. They are better for ‘listeners’ rather than ‘readers’. They are perfect for quick facts, individual opinions, and hot information. They can make learning more fun, because the good podcasters are entertaining. However, blogs and podcasts may not provide careful analysis of data, and opinions are easy to accept without much thought because they fit the immediate gratification characteristics of emergency medicine.
And there are a myriad other ways we keep up with new information: journals, newsletters, LLSA and ConCert, journal clubs, clinical apps, journal aggregators, conferences, discussions with consultants, and cross-learning from interns and residents, especially from off-service rotations. Whatever our preferred learning method, just make sure it is providing a platform for review, analysis and critique of the both the old and the new information.
5. Learn from Global Colleagues
In 2014 I attended both the International Conference on Emergency Medicine (ICEM) in Hong Kong and its follow-up conference in Shenzen, China. Both were incredibly eye-opening. If you want to truly broaden your knowledge base – and meet inspiring people – look beyond our borders. Attend a global EM meeting . . . and don’t skip the lectures! Last October I attended the European Society of Emergency Medicine (EuSEM) annual meeting in Torino, Italy, and got to hear Barbara Backus describe the story behind the HEART score in front of an audience spilling out to the hallways. Backus, who completed cardiology before getting hooked on emergency medicine, did the HEART research on her own time, without funds, while covering the CCU—on nights. Not to mention that she had a few children along the way. Truly an inspiration. Keep your eyes on Europe. I am told France will approve the specialty in 2017, and then hopefully Germany will be next, followed by Spain (hopefully). But in the meantime, we have a lot to learn from European emergency medicine, which is already championing excellent EM research and helping us to improve our practice worldwide.
- Kuppermann M, and Sawaya GF ‘Shared Decision-Making. Easy to Evoke, Challenging to Implement’ JAMA InternMed 2015; 175(2):167-168