1. science
2. medicine

HOW TO REACH THE UNREACHABLE: HANDOUT
WHAT ARE OUR CREDENTIALS TO GIVE THIS LECTURE?
o
o
o
Drew Nyce – program director for 5 yrs, clerkship director for 6 yrs
Sundip Patel – clerkship director for 4 yrs
Required clerkship since 2007
 Our program stats based on AAMC Medical Student Graduation Survey
Year
2007
2008
2009
2010
2011

Our Clerkship
National Avg
Our Clerkship
National Avg
Our Clerkship
National Avg
Our Clerkship
National Avg
Our Clerkship
National Avg
Poor
0.0
6.0
3.8
6.1
3.6
4.5
0.0
4.3
0.0
4.3
Fair
25.0
13.9
11.5
13.7
3.6
11.5
2.3
11.3
12.0
11.1
Good
50.0
36.7
26.9
35.0
32.1
33.1
34.9
32.4
12.0
32.1
Excellent
25.0
43.4
57.7
45.2
60.7
51.0
62.8
51.9
76.0
52.6
What do these stats mean?
 We did not do well in our first year as a 4th year mandatory rotation in
2007 when you compare the excellent category
 However, we have steadily improved over the past few years surpassing
the national average in the excellent category
 This is not to show off / brag, but to show that we have been able to
utilize certain techniques and teaching methods that have reached all
students rotating on the Emergency Medicine (EM) clerkship
throughout the year
WHY ARE YOU CURRENTLY (or will in the future) HAVE STUDENTS NOT INTERESTED IN EM ROTATING
ON YOUR CLERKSHP?
o
LCME requirement ED-17 states that all students be exposed to Emergency Medicine
 ED-17. “Educational opportunities must be available in a medical education
program in multidisciplinary content areas (e.g., emergency medicine,
geriatrics)”
 Database question – “Describe where in the curriculum the following
subject areas are covered and specify the amount of time devoted to
each area”
 Self Study question – “Comment on how well all content areas
required for accreditation are addressed in the curriculum. How
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confident is the educational program leadership that these topics are
appropriately addressed”
o Having students do H&Ps in the ED on their Medicine
rotation does not seem to meet this requirement
o Other clerkships (OB, Surgery) have minimal EM experience
and that experience does not provide students the ability to
see a patient as the first healthcare provider

o
Schools meet the ED-17 requirement by making EM a required rotation
 36% mandatory rotation in EM (14% selective) in 2007 (Wald Acad
Emerg Med 20071)
 65% clerkships have EM rotation only in 4th yr (Wald Acad Emerg Med
20071) where you are more likely to encounter students not interested
in EM
 So if you’re not a mandatory EM rotation now, you just may become
one soon to help meet this LCME requirement
EM clerkship can help the medical school meet many other LCME requirements
(McLaughlin Acad Emerg Med 20052) – Taking their article and using the most updated
LCME requirements from the website – www.lcme.org
 ED-2. An institution that offers a medical education program must have in place
a system with central oversight to ensure that the faculty define the types of
patients and clinical conditions that medical students must encounter, the
appropriate clinical setting for the educational experiences, and the expected
level of medical student responsibility
 Translation
o We see many different patients and disease processes in the ED
o Medical schools have a hard time finding these patient
encounters, especially initial presentations, in other clerkships
so they turn to EM
 Examples – Anaphylaxis, Cardiac arrest, Ruptured
ectopic
o More reason for medical schools to drive their students to the
EM clerkship, even ones not interested in EM as a career

ED-6. The curriculum of a medical education program must incorporate the
fundamental principles of medicine and its underlying scientific concepts;
allow medical students to acquire skills of critical judgment based on
evidence and experience; and develop medical students' ability to use
principles and skills wisely in solving problems of health and disease
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

Translation
o Evidenced Based Medicine (EBM) is required and no better way
to teach it than at the bedside in ED
o EM is a great way to show disease process, real patient, and
evidence all tied together in real time
o Med school recognizes this as well and will try to get students
exposed to EBM in the ED
All these LCME requirements show the following
 The EM clerkship can provide many solutions to the medical school
LCME requirements
 This will lead to more students being required to rotate in the ED which
means many of us will see students not going into EM rotating through
our EDs from Jan to June
WHY IS IT IMPORTANT TO REACH THOSE STUDENTS FROM JANUARY TO JUNE?
o
Need to answer to the Dean and your chairman
 Your clerkship stats on the rotation are analyzed VERY closely
 Organization of your rotation
 Patient care experience
 Educational experience
 Opinion on faculty & resident educators
 Professionalism
 Dreaded “Additional Comments”
o Medical school administrators love to focus on these random
comments about your clerkship
o One disgruntled student writing bad “additional comments” can
cause a lot of work for you
 All of these stats can be affected by dissatisfied students not going into EM
 It is imperative that you find a way to connect to those January to June
students, otherwise your overall stats will be skewed towards lower evaluations
o
Showcase your EM program
 Visiting students, home program students will view treatment of their
peers/friends not going into EM as a sign of a malignant program
 This bad treatment could cause you to lose out on a potential recruit
o
We’re educators, Damnit!!
 We in Emergency Medicine enjoy educating everyone
 Even those not going into EM
 We’ve never shown preferential treatment to students going into EM
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

o
We want to create an image of a rotation that enjoys educating everyone
This enhances our reputation
Potential to sway a really good student to EM
 Give the student a fair chance to decide if EM is the right career for them
 Would not want to turn off someone who could really contribute to our field
 While Jan to June is very late in the game, a student who initially was not going
into EM may decide to take the year off and then go through the EM match
KEY MOTIVATIONAL FACTORS FOR STUDENTS ROTATING FROM JANUARY TO JUNE
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
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Need to fulfill this required rotation (and that may be the only motivation a student may have)
Other students may recognize that they have a final chance to work on certain things before
they become interns
Some things that you need to remind all students about the EM rotation to motivate them
o Procedures
 Fulfill medical school requirements
 Get practice with procedures they will be doing very soon as interns
o Opportunity to see things, do things they may never do again
 Peds student seeing elderly patients
 Internal Medicine student seeing surgical abdomens
 Pathology student seeing living patients
o “What are you going to do in 6 months” argument a.k.a “You will soon be an intern”
 Practice H&Ps, committing to plans that the students will soon need to do as
interns
 Practice placing orders, calling consults, working on interpersonal skills
o Handling sick patients
 Learn how to handle the situation at 2 am when a nurse tells you “Mrs. Smith is
really short of breath and doesn’t look good….”
 Ability to run through ACLS protocols
How do we remind the students from January to June of all of this
o EM Clerkship Orientation Day
o Our orientation is different depending on the time of year
 July – Nov orientation (geared for EM bound students)
 Focus on LORs
 Additional EM experiences
 If deciding late to pursue EM, how to go about the process, visiting
rotations
 Jan – June orientation (geared for non-EM bound students)
 Focus on fulfilling procedures
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

Completing med school requirements
Obtaining skills that will help when they are an intern
METHODS TO REACH THE “UNREACHABLE” JAN TO JUNE STUDNETS
1. Simulation Experience
o Not many other clerkships provide it
o Those that do focus on small areas
 Anesthesia – intubations, difficult airway
 Critical Care – sepsis, shock pts
o Practice procedures (more on that later)
o Our simulations provide students the opportunity to practice things they never get to do
 ACLS protocols
 To run a code is something a student never gets to do
 In real life, they do compressions and that’s it
 Students always provide positive feedback/evaluations on this
 Broad approach to SICK pts
o Will help when they are interns on the floors in a code
o Can instill helpful algorithms in students
 Student really love running through ACLS protocols
o Yeung Canadian study (CJEM 2010; 12: 212-219)3
o 2 x 2hr ACLS lectures with 8 hr skills session
o Students ranked ACLS training with skill workshop over clinical
shifts, supervised shifts (teaching shifts)
o ACLS is a hands-on activity that they can apply clinically
o
Can tailor simulation experience to student’s interest
 For example
 Student going into derm – take septic shock case and tweak it to be a
toxic epidermal necrolysis (TEN) or staph scalded skin syndrome
 Show images of TEN during sim and then go into septic shock sim
 Student has buy-in to sim and you still cover main points in shock
simulation
 Other examples
 Optho – globe rupture into a trauma simulation
 Ortho – long bone fractures into a trauma simulation
 Radiology – pregnant trauma
o Can have them discuss radiation exposures
o Other imaging options in trauma and limitations (MRI,
ultrasound)
 Family Medicine
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o
o Simulation about end of life
o Breaking bad news
 Pathology
o Nothing you can do for them
o Send them to the anatomy lab
 More work on your part
 Doing the preparation to get images
 Tweak existing simulations
 However students have huge buy-in and great evals of the experience
Simulation has been shown to increase med student satisfaction
 Ten Eyck article4
 Randomized control study with crossover where one group starts with
simulation and the other group discussion and then switches midrotation
 Simulation while more stressful was more enjoyable, more stimulating,
and closer to actual clinical setting
 Small improvement in learning as well
2. Teaching shifts
o We have employed teaching shifts for over 7 years
o A dedicated faculty member teaches 2-3 students on a 6 hour shift
o Dedicated faculty member
 Does not hear any other cases
 Generally does not see any pts primarily
o Change in pace from regular shifts as more time spent on education
o Opportunities to directly observe students do H&Ps
o Can spend time going over concepts (acid/base, anion gaps, etc.)
o Problems
 Need buy-in from faculty worried about RVUs
 Expensive shifts for department to finance
o It has been proven to work (Cassidy-Smith5)
 Students were more satisfied with the quality of bedside teaching, preceptor
experience, and usefulness of the rotation
 Faculty noted improvement in their availability to listen to student
presentations, timeliness to initiate workups, and timeliness in pt disposition
 Residents noted improved availability of the other attendings working that day
and improved faculty bedside teaching of residents
3. Evidence Based Medicine (EBM)
o LCME requirement (ED-6) states we need to provide EBM to students
o Real time scenarios / patient cases provide better retention of knowledge
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o
o
o
So many different aspects of EBM to focus on
 Gold standards, sensitivity, specificity, negative predictive value, number
needed to treat, results applicable to your patient population
Tailor the EBM to their future interests
 For student going into Ortho – do open distal tuft fxs need OR washout?
 Pediatrics – fever workup in the ED of children 8 weeks old?
 Surgery – Does morphine prevent an accurate abdominal exam?
 Pathology – Will you ever raise your hand in a plane if they ask for a doctor?
Our ways to expose EBM to all students
 EBM stressed with students during patient care in the ED
 Wells Criteria for pulmonary embolism
 Ottawa ankle rules for ankle injuries
 Early Goal directed therapy for septic patients
 Centor criteria for sore throats
 On-line journal club
 Did not want to use up an hour of lecture time going over article no one
has read
 We post an article online for students to read “CT should replace a 3
view radiographs in the initial screening test in patients at high,
moderate, and low risk for blunt cervical spine injury: a prospective
comparison” (Bailitz J Trauma 2009; 66: 1605-1609)
 Questions about article are also posted online
o Design of study, sensitivity, specificity, likelihood ratio
o Strengths, weaknesses
o Applicability to our patient population
 We go over the articles and questions on day of test
 This requires students to read the article AND analyze it
 Student feedback has been very positive compared to traditional journal
club
4. Optional Enrichment experience
o All students have the option of meeting with an EM faculty member twice in 4 weeks
 Go over ECG module
 Clinical vignettes with ECGs
 Questions
 “Enrichment Case”
 Slow dissection of a case with students having to explain
o Pertinent positives and negatives in H&P
o Work-up and treatment plans
o Interpretation of labs and xrays
 Go over an interesting case selected by the student
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o
o
o
o
 10 min Evidence Based Medicine presentation
Gives students more in depth experience on EM (could help that student unsure about
EM)
One-on-one interactions with faculty always viewed well by students
Student particularly like ECG module
 Reinforces concepts learned
 Clears up confusion areas on ECGs
 Have ECG with clinical situation which provides more meaning to a student than
just looking at ECG and interpreting it
Problem
 Finding faculty who have the time to do this
 Pretty big investment in time and effort to set up the experience initially
(gathering ECGs, creating the enrichment case, supporting documents)
5. Ultrasound
o Literally no experience on other rotations
o Radiology rotation – they read ultrasounds, they don’t do them
o Perfect marriage of disease process, imaging, procedure, and patient contact
 ED provides wide variety of ultrasounds
 RUQ
 First trimester pregnancies
 Fast exams
 Peripheral IV placement
 Arthrocentesis
 Cooler stuff
o Central line placement
o Peritonsilar abscess drainage
o FBs in eye
o Could provide ultrasound experience
 Integrated into EM clerkship
 Pros
o Every student gets exposed to it
o Enhances the rotation
 Cons
o Time taken away from other aspects of the clerkship
o Hard enough in 4 weeks to get ultrasound competence, even
Harder if only using small portion of 4 weeks for ultrasound
 Solutions
o Separate ultrasound rotation
 More time to focus on ultrasound techniques, get
proficient
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

o
However students not going into EM won’t do it
Another course you need to run which entails a lot of
work
Concentrate on one aspect of ultrasound during the EM
rotation
 Pelvic ultrasound for first trimester pregnancies
 FAST exams in trauma
 Peripheral IV insertion
6. Mid-clerkship Feedback
o Students appreciate feedback and it is not given well, if at all, in other clerkships
o Can serve as a wake-up call to those students not interested
o More detailed the better
o Can give solutions to correct deficiencies a student may have
o Also can give reminders about requirements
 Patient encounters that still need to be seen
 End of rotation presentation
 Meeting with advisor
o Example of the feedback we give is in the back of this handout
 Focus on 3 areas
 Clinical work
 Have they seen required patient encounters
 Written patient notes
o Example of student comments after this mid-clerkship feedback
 “Thanks a lot for the thorough feedback. I will continue to read and work on my
data gathering skills”
 “Thank you for sending me my mid clerkship feedback. It is rare that I get that
detailed a report, and I greatly appreciate the chance to know what I need to
work on before the end of the clerkship”
 “I just want to let you know that this is the most thorough mid-clerkship
evaluation I have gotten to date”
7. Procedures
o Students are exposed to a wide variety of procedures on EM clerkship
 Just don’t get them in other clerkships
 Lumbar Puncture, suturing, arthrocentesis, joint reductions, splinting, ABGs
 Ability to be directly supervised by faculty
 From Jan to June, you will have residents give up procedures to students as they
have become comfortable with them
o Can fulfill any med school requirements
 Foleys, nasogastric tubes, IV lines, phlebotomy, etc
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o
o
Stress importance of knowing mastery of certain procedures to help out in intern yr
We can also run them through simulation to practice invasive procedures such as
intubation, central lines, etc.
DO’s AND DON’Ts OF DEALING WITH STUDENTS NOT GOING INTO EM
o
o
Do’s

Let them see cases in the field they are going into (on a limited basis)
(Example – student going into ortho picking up ankle sprains, dislocations)
 If prevent them from seeing cases they’re interested in, you may have an
unhappy student on your hands
 If you allow them to focus primarily on those cases
o Miss out on the true EM experience
o Not really an EM rotation
o Faculty will be resentful
 Need a mix
o Allow them to sometimes see those cases
o Make sure to stress value in seeing wide variety
 For student going into peds complaining about seeing 80 yo
pt, ask them what will they do when their grandmother gets
sick? Parent gets sick in their office?

Flexibility in scheduling
 Allow students to go to ortho conference, meet with advisor, etc.
 However students still need to make up shift, meet all requirements
 Make all schedules similar (same amount of nights, weekends, days on
lecture days)

Have the SAME expectations in seeing patients
 Don’t lower the bar for what is expected in clinical work
 If you lower the bar, students going into EM won’t be happy
 Short-changing the student who may think what they are doing is ok and
will then transfer that practice to actual patient care as interns
 Make the objectives clear and unyielding for ALL students
Don’ts
 Do NOT provide preferential treatment to students going into EM (with scheduling,
more attention, more opportunities to do procedures)
 Easiest way to anger non-EM student
 Easy way to get bad reviews on the clerkship
 Easy way to draw the dean’s ire on you
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

Do NOT cut down shift number Jan-July
 Your faculty will pressure you into doing this
 A non-EM student who rotated in July working 16 shifts will not be happy
about non-EM students rotating in Jan working 13 shifts
 Sends wrong message as well – that we don’t want to spend time with nonEM students
Do NOT allow faculty to ignore or let non-EM students slide
 Don’t allow faculty members to send students home early
 Don’t allow faculty members to have students stop seeing patients early or
shadow residents
 Your chairman should support you in preventing this
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Journal articles
1. Wald DA, Manthey DE, Kruus L, et al. The state of the clerkship: a survey of Emergency
Medicine clerkship directors. Acad Emerg Med. 2007; 14: 629-634.
2. McLaughlin SA, Hobgood C, Binder L, et al. Impact of the Liasion Committee of Medical
Education requirements for Emergency Medicine education at US Schools of Medicine. Acad
Emerg Med. 2005; 12: 1003-1009.
3. Yeung M, Beecker J, Marks M, et al. A new Emergency Medicine clerkship program: students’
perceptions of what works. Canadian Journal of Emergency Medicine. 2010; 12: 212-219.
4. Ten Eyck RP, Tews M, Ballester JM. Improved medical student satisfaction and test performance
with a simulation-based Emergency Medicine curriculum: a randomized controlled trial. Ann
Emerg Med. 2009; 54: 684-691.
5. Cassidy-Smith TN, Kilgannon JH, Nyce AL, et al. Impact of a teaching attending physician on
medical student, resident, and faculty perceptions and satisfaction. Canadian Journal of
Emergency Medicine. 2011; 13: 259-266.
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MID-CLERKSHIP FEEDBACK EXAMPLE
Mary,
these were some of the comments from the evaluation cards for you over the past 2 weeks.
Clinical Work Feedback
“Enthusiastic, hard working”
“Good histories, hard working, should read about differential diagnosis of back pain”
“Oral presentation are organized and succinct. Would like to see her be confident with
her differentials and treatment plans. Pleasure to work with”
“Hard working, wrote good notes”
“Does good job overall, should make sure to follow up on labs, xrays”
Mary, please continue to work hard and keep up the enthusiasm. Please continue to work on
ED appropriate differentials for the common complaints - chest pain, shortness of breath,
abdominal pain. Remember to "rule out" the bad ones like abdominal aneurysm in an
abdominal pain patient. Keep an eye out for any tests that were sent and do not just report the
results, but interpret them in context with the pt’s disease process. Try to read up on a few case
you saw in the ED concentrating on differentials and workup plans. One really good source is
www.cdemcurriculum.org which has an approach to disease processes along with education on
particular ones. By the way, it was commented that your patient notes are very good with
regards to detailing the history, physical exam, and assessment and plan. Please continue your
excellence in writing notes.
Continue to hand out the blue evaluation cards over the remaining weeks to the attendings and
senior residents. Remember, your grade is largely derived from these evaluation cards and it is
your responsibility to hand them out. Attendings and senior residents may hand in eval cards if
you forget, but they are not obliged to do so. If you run out of blue cards, make sure to ask Ms.
Nancy Loperfido for more.
Required Patient Encounter Feedback
It is also your responsibility to make sure that you see all seven of the required patient
encounters; chest pain, abdominal pain, shortness of breath, altered mental status, blunt
trauma/fall, back pain, and management of a wound/suturing. Having reviewed your online
patient logs, here are the following that you still need to see:
Altered mental status, blunt trauma / fall
Please make sure to see the required patient encounters. If the encounters are not seen, then
you will have to do the remediation process as outlined online. You have until midnight Sunday
following the end of the rotation to log all your patient encounters. Failure to do so will lead to
your final grade being lowered by one grade. I have no desire to do this so please make sure
you see and log all your required encounters.
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Patient Notes Feedback
I have also reviewed the notes you have written in EPIC. I am able to run a report to see notes
written by students. Here is some feedback on your notes (Due to HIPAA privacy laws, I will not
be providing the pt’s name or other identifying details):
Patient Note Feedback:
Back pain
- Very good description of her pain, what caused pain, exacerbating and relieving factors
- Really liked how you described what meds pt took and associated symptoms such as
paresthesias
- One suggestion is to give a small blurb on whether pt has had prior back pain episodes and
if this episode is similar to past ones
- I would also make sure to document if the pt has ever had any imaging such as an xray, CT
scan, or MRI.
- Excellent physical exam with concentration on neurovascular symptoms
- For back pain pts, it is good to document their gait. If they can’t walk due to pain, that
should be documented as well
- Good Differential Diagnosis and plan. You stated what you thought was the most likely
diagnosis, but also listed what else you considered and why you thought those were less
likely.
Let me know if you have any questions, comments, concerns, or want to meet to discuss these
comments further.
Dr. Patel
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