Category: 1 – Senior EM Clerkship Topic

The Importance of the Emergency Medicine Clerkship (2023)

THE IMPORTANCE OF THE EMERGENCY MEDICINE CLERKSHIP
~ iEM Education Project Team ~ Leave a comment

by Linda Katirji and Farhad Aziz

Authors
Listen

Introduction

The emergency medicine (EM) clerkship typically takes place during the fourth year of medical school. However, some medical schools may have an optional elective or a core rotation during the third year. Whether or not you plan to specialize in emergency medicine, the rotation is an important part of your medical education that will help you develop unique skills. The emergency room is a unique learning environment which is different than any other setting in the hospital. It provides clinical opportunities that are largely unavailable in other clerkships and rotations, and one of the few places you will encounter a completely undifferentiated patient. During residency, many specialties will also spend a significant amount of time in the Emergency Department (ED). This may be within a structured EM rotation, or while admitting or seeing patients for a certain medical or surgical service. Therefore, it is important to gain an understanding of the flow of the ED as well as the unique thought process that must be employed with emergency department patients. This chapter will discuss some of the unique aspects of the emergency department, some of the skills to acquire during the EM clerkship, as well as how to best be successful and take the most away from your rotation.

Unique Aspects of The Emergency Department Environment

The high volume and acuity of patients in the ED create a time pressure and forces physicians to employ a different style of practice than in most other settings. A steady stream of patients, some of whom may require immediate life-saving measures, means that many times there is little to no time to review history or any medical records prior to evaluating a patient. Most of the time you will need to assess a patient without knowing anything about their background.  Therefore, it is important to gain an understanding of what the most important pieces of information to gather are for each patient.  This can be difficult since most patients will arrive with completely undifferentiated complaints. Some common examples of these undifferentiated complaints are “chest pain” and “abdominal pain”, where the etiology can range from completely benign to immediately life-threatening, or “weakness”, where the differential diagnosis includes essentially the entire spectrum of medical pathology.

This undifferentiated patient is the standard in the ED. However, they can present in any medical setting. It is important to learn the thought process and develop a strategy for thinking through these types of patients whether you plan on a career in EM or not. Emergency physicians (EPs) must employ and master a completely different style of practice than most physicians. EPs must always think worst case scenarios for each chief complaint and must be knowledgeable and comfortable with associated the workup and treatment. A good example of this is chest pain. Even though many times the complaint of “chest pain” is found to be caused by a non-acutely life threatening etiology, EPs must immediately think of six fatal causes of chest pain: acute coronary syndromes, aortic dissection, pulmonary embolism, pericardial tamponade, pneumothorax, esophageal rupture. Additionally, ED doctors must use a different thought process in determining the disposition, or outcome, of the patient. The ED doctor essentially wants to avoid sending a patient home that is not safe to go home, where as a consultant, or admitting service, does not want to admit a patient who does not need be admitted. This may seem trivial, however this difference in thought process can occasionally create tension between the ED and admitting services.

Teaching in the ED is different than most other settings in the hospital as well. There is usually no time set aside for formal rounds, so most teaching is done actively at the bedside or at the time the student or resident presents the patient to the attending physician. Many times, attending physicians will pick out “teaching points” for each patient. Each physician will have a different teaching style. Your learning will generally be more active than passive, and likely more short and frequent rather than one long teaching sessions or lecture on rounds.

Lastly, the ED is a great place for medical students and first-year residents to learn to take responsibility for their patients. Students often time have an increased level of autonomy compared to other rotations. Many times, the student will be the first person to assess the patient, which is a very important role. It is important to learn to distinguish whether a patient is “sick” or “not sick”, and whether or not at first glance you think this patient could go home or needs to be admitted no matter what the diagnosis may be.

Unique Skills To Take Away From EM Clerkships

Emergency medicine is a wonderful rotation that exposes you to not only different patient populations but also a variety of pathology and diseases. This diverse collection of patients and pathology lends emergency medicine residents and students a unique opportunity to gain a mastery of different skills. These skills range from a knowledge of how to approach critically ill patients, gaining procedural skills, reading radiographs and CT scans, performing ultrasounds and much more.

Often you may be busy doing different tasks when you must drop everything to manage a critically ill patient. This is one of the exciting aspects of emergency medicine. These patients offer students a great opportunity to learn the principles of resuscitation, such as managing airways and circulatory collapse, identifying causes for the patient’s decompensation, and instituting the appropriate treatment. Whether you pursue a career in emergency medicine or choose to pursue a different specialty, critically ill patients will likely always be a part of your patient population. Understanding how to approach and stabilize these patients is an important part of being a physician.

Though learning the art of resuscitation is a vital part of the EM rotation, this is also an opportunity to gain competence in a variety of procedures. Whether you intend to pursue a career in pediatrics, internal medicine, orthopedics, general surgery or any other specialty, your rotation through the ED will expose you to a wide array of procedural skills ranging from intubating and placing central lines and arterial lines in the critically ill to performing lumbar punctures and fracture reductions in children. Autonomy is encouraged with procedures, and you will have the opportunity to improve your skills and techniques under the guidance of residents and attendings. EM is a very hands-on specialty. You should take advantage of medical student and resident didactics as an opportunity to learn.  These usually consist of lectures on different subjects but also may include ultrasound practice, procedure labs on mannikins or cadavers and simulation. This will give you an opportunity to practice and provide better patient care during your rotation.

In addition to becoming familiar with a wide array of procedures, your EM clerkship will also allow you to familiarize yourself with a variety of imaging modalities ordered in the ED. There is a tremendous amount of pathology found in the ED which lends itself to a range of imaging. Whether it be learning to perform bedside ultrasonography on a crashing patient or simply learning how to approach reading a chest x-ray or a CT scan of the abdomen on your own, your EM rotation will give you plenty of opportunities to become proficient in a skill you will need later in your career.

Though your EM clerkship gives you exposure to a tremendous amount of skills which will help you become a savvy doctor, no skill is more important than compassion and humility. Every day, you will meet patients on the worst day of their life. Many will have gone through traumatizing experiences, or have a life changing chronic condition, or be in a severe amount of physical or emotional pain. Realizing this and comforting patients and their families is paramount to your success as a physician. You will also encounter a variety of consulting physicians. Speaking with consulting physicians about a patient is an art form in itself that EM physicians must master. While most consultants will be polite and professional, its not uncommon in to meet push-back from a consultant. Occasionally, some may be out right rude. Having a general understanding that they all have knowledge that you can learn from will set you up for a successful career in medicine.

How To Be Successful on Your EM Clerkship

Many of the of the same qualities that allow you to be successful in other rotations will help you to be successful in the ED.  It is important to be hardworking, proactive, and knowledgeable. Keep a close eye on your patients, re-evaluate them frequently, and make sure to follow up on any results, including labs, imaging, and any recommendations by consultants. The unique aspects of the ED and EM clerkship discussed previously mean the first few shifts may be stressful and seem chaotic and hectic. For every student and resident that rotates through the ED there is a significant learning curve – with each shift you spend in the ED, things will feel less and less daunting. It’s important during this time that you know your limitations and what you are comfortable and not comfortable with. Many times you will be the first person to assess the patient. You should have a low threshold for alerting an upper-level resident or attending if the patient appears to be sick, or if they present with a complaint you are uncomfortable with. At the same time, you should be confident in what you do know and take the opportunity to learn how to diagnose, treat, and manage your patient.

The best way to build confidence during your EM rotation is to gain experience and knowledge. Try to be proactive in learning new procedures or treatments with attending or resident assistance. Additionally, it’s very important to keep up with reading and studying. In the emergency room, you may see medical pathology you’ve only read about and will be expected to know how to diagnose and treat these diseases properly. When you have the time, use the resources you have at your disposal and look things up before presenting to your resident or an attending, and have a plan to disposition (ie, admission or discharge) already made for the patient.

Good communication is essential for a physician in any specialty, and in the ED, it is an imperative skill to have.  You will be working with a large team of nurses, technicians, consulting doctors, social workers, and paramedics, just to name a few. When you see a patient, it is a good idea to speak with the nurse before you enter the room to gain a better understanding of the patient’s complaint, as well as gather any information that was relayed by EMS. By communicating the plan of care to the nurse and supporting staff, you will not only improve patient care and reduce mistakes but also forge relationships that will enrich your experience in the ED. In acute settings such as a patient code or rapidly decompensating patient, good communication with the entire team is critical. As a medical student or rotating resident, this is a great time to practice and improve your communication skills in these acute settings under the direction of residents and attendings.

Your EM rotation will be an exciting, unique experience during medical school and residency. Whether you plan to specialize in EM or not, you will learn many procedural skills, improve your own method of diagnosing and treating patients and be able to practice a different method of medical decision making.

Authors

Linda KATIRJI

Linda KATIRJI

University of Kentucky, Department of Emergency Medicine

Farhad AZIZ

Farhad AZIZ

The Ohio State University, Department of Emergency Medicine

Listen to the chapter

Cite This Article

Please replace “iEM Education Project Team” below with the author(s) surname and initials.

Cite this article as: iEM Education Project Team, "The Importance of the Emergency Medicine Clerkship (2023)," in International Emergency Medicine Education Project, April 17, 2023, https://iem-student.org/2023/04/17/the-importance-of-the-emergency-medicine-clerkship-2023/, date accessed: September 27, 2023

2018 version of this topic – https://iem-student.org/the-importance-of-the-emergency-medicine-clerkship/

References

  1. EMRA and CORD Student Advising Guide (https://www.emra.org/books/msadvisingguide/msag/)
  2. EMRA Medical Student Page (https://www.emra.org/students/)
  3. The Emergency Medicine Clerkship Primer (https://www.saem.org/docs/default-source/saem-documents/students/em-clerkship-primer_0_0.pdf)

Reviewed By

Arif Alper Cevik, MD, FEMAT, FIFEM

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, vice-chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.

Emergency Medicine: A Unique Specialty (2023)

~ iEM Education Project Team ~ Leave a comment

by Anthony Rodigin

Author
Listen

What is EM?

Emergency Medicine (EM) does not claim its own body part or a physiologic system. With Vascular Surgery or Endocrinology things are straightforward. But what do we have?

Most of our procedures are shared with other specialties. We use many of the same tools and instruments. Emergency physicians also value evidence-based practice. And like providers in other fields, we believe in disease prevention, palliation, empathy, the Hippocratic oath and the magic of human touch.

In some places, emergency medicine is confused with the mere lights and sirens of ambulances or with various types of outpost facilities providing as little as vaccinations and screenings. And even if unmistakable emergency departments (EDs) are present, it is not apparent to many ED patients that the doctors seeing them are not just any doctors from somewhere else in the hospital.

It is easy to say that emergency medicine deals with emergencies. True – we initiate life-saving interventions, commence stabilizing treatments and ultimately supervise the patient’s transition to definitive care. But who is best positioned to select out these emergencies in the first place? And in what other settings besides the ED should our skills be called upon and applied? Real essence of modern EM cannot be understood without thinking through these questions.

So once again, who are we and what is EM?

Evolution of EM

History

Both prehospital emergency care and ancestral emergency rooms predate the emergency medicine specialty itself. Out of the many wars and civilian side catastrophes came the realization that competent care was needed before and during transport to a hospital. At the same time, early emergency rooms, often small and inconveniently located in basements or on second floors, served as the natural intersection for walk-ins, ambulances and hospital wards in the early and mid-twentieth century.

The technological boom following the Second World War was in part responsible for the transition from outpatient to hospital-based medicine. More could be done and in a quicker time frame inside of a hospital, and the sickest of the sick now perhaps had a chance of survival. A natural demand for expanded and better-equipped casualty (aka accident- or emergency-) departments was created. At the same time, more patients presenting to EDs with non-traumatic complaints underscored the need to move beyond mere trauma and injury.

Still, as the earlier version of this chapter correctly stated, “Only a few decades ago, emergency departments…were staffed by physicians with a variety of training backgrounds. The vast majority of these physicians had little to no emergency medicine training at all. General surgeons, family physicians, neurologists, and even psychiatrists were among those that staffed emergency departments…throughout the world” [1].

In the 1960s and 1970s things began to change rapidly. As ambulance care and destination decisions improved, in some nations relying on physicians and in others on newly established paramedics, so did the understanding that a dedicated provider specializing in ED services was invaluable. In the United States, pioneer physicians who chose to work exclusively at EDs provided additional advantages to the lifestyles and efficiency of specialists. Freeing up the latter to concentrate on more complex specialty-driven tasks led to their higher reimbursements. Thus, both the absence of competing emergency care physicians in the prehospital domain and economic incentives created by EM for narrow specialties pushed EM development in the US somewhat ahead of other parts of the world. The vast and ubiquitous benefits of EM to the general public were to follow.

From the 1970s and on rapid growth of EM residencies took place, together with the founding and strengthening of EM national boards and EM national and international societies. Brian Zink’s famous “Anyone, Anything, Anytime” comprehensively describes the history of modern EM in the United States [2]. Another excellent resource is this documentary from the Emergency Medicine Residents’ Association (EMRA). Such a trajectory was closely matched by EM’s path in the United Kingdom, Canada, Australia and other culturally Western nations, steadily but surely spreading throughout most of the world.

With every decade that followed, the number of countries developing EM increased exponentially. Arguably, each nation’s own EM chronicles are best regarded and studied in tandem with texts like Ryan Corbett Bell’s “The Ambulance”, which ought to describe the contemporaneous evolution of not only prehospital medicine but of the overall emergency care landscape in each nation as the precise background for EM’s necessity, birth and its coming of age [3].

The Future

Emergency medicine and its place within the emergency care endeavor are not going anywhere, but the scope of EM will undoubtedly change.

We can anticipate with a high degree of probability that, somewhat paradoxically to its origins, EM will continue to expand its reach beyond the emergency department. Very possibly, post-residency training via fellowships will become the norm rather than the exception. Further integration with prehospital services and sharing of EM workplaces with non-physician EM specialists (e.g. Advanced Practice Providers) will persist. Natural and technologically driven disasters will maintain high demand for EM’s unique combination of versatility and focused expertise. 

The future may not bring ready solutions to all of the clinging problems. Lack of access to universally accepted standards of emergency care in rural, remote and low-income areas is one. EM’s ambivalently viewed safety net function arising from any healthcare system’s gaps and incapacities in non-EM arenas like primary care and preventative medicine is another example. In addition, proper relationship of EM with other conceptual definitions and terms such as Frontline Medicine, Emergency Medical Services (EMS), Acute Critical Care and Pediatric EM will have to be philosophically teased out further on a global scale.

Finally, an area of medicine that has matured to its most commonly used name of Global Health (GH) needs to be mentioned in this context. Current involvement of EM physicians in GH projects, while not uncommon, is not something universally anticipated. Today it still rests on enthusiasm of individual participants or institutions. The future may call for things to change drastically in the long run.

The prognoses mentioned are not exhaustive, but they should all be met with optimist and eagerness. It is beyond any doubt that unprecedented opportunities await future EM trainees not only through engagement in primary clinical work and research in the ED, but also in domains ranging from local policy making to transnational epidemiology, and vice versa.

The Present

Today it can be surmised with justification and pride that the battle for EM’s existence, its independence and its own standards matching or surpassing those of more traditional medical specialties has been largely won.

Distinctive and concrete advantages of EM include flexibility in work schedules and lifestyles and the balance of individual expertise with teamwork. Further, EM offers multiple areas for gaining additional proficiency – ranging from bedside ultrasound to basic research and from business practices to international health. Last but not least, EM features an unparalleled interconnected global community of people just like you. If in doubt, you should strive to attend an EM International Congress (ICEM) or a regional EM conference in your area. See for yourself!

Of course, visible and hidden currents remain in motion, bringing in tides of new trials. Efforts toward fair employment practices, workplace safety, non-malevolent legal climate, job security and sustainability, EM’s influence on healthcare policies – these are only a few of today’s pressing themes. Still, such challenges are neither unprecedented nor unique to EM, and are not anything to be afraid of for future EM clinicians.

Above all else, one should know that EM is an exciting, versatile and dynamic specialty to consider as one’s top choice for a career in medicine.

Why EM?

Who are EM docs?

Our field is not without its stereotypes.  A common one is that all EM physicians are adrenaline junkies and type A immediate gratification personalities. When we are not intubating in the ED, we are skydiving or playing extreme sports. In truth, there are as many characters, hobbies and interests in EM as there are in the world at large. The passion in EM that we all share is to be found it its mission. We believe in equal opportunities to receive competent emergency care world-wide and in EM’s unique approach to the undifferentiated patient.

What sets EM physicians apart?

In the next two chapters, you will discover more words of wisdom and advice about why EM is a great choice for a specialty, and how EM physicians think differently from other providers. Here, we will come back to the two questions mentioned at the beginning of this chapter.

The first had to do with the selection of those patients who truly do have urgent, emergent and even life-threatening conditions. Of course, some selection is self-selection, as it happens at the patient’s own home or wherever they happened to be.  At other times, primary care, walk-in or ambulance services may be involved and may even play a great part. All countries differ in how the tiers of access to emergency services are designed and staggered. Interestingly and controversially, the ethics of what and to what extent an emergency care system is allowed to miss also varies by locale depending in part on culture, in part on the level of public education and in part on historical precedent shaping expectations.

In general, however, EM does not rely on or trust other types of medical providers to do this selection for us. Our specialty was designed specifically to work with the population at large presenting with all health concerns, worries or issues. These truly can be anything coming from anyone at any time. Thus, at least a third of our jobs is to figure out who truly is at risk no matter what the actual diagnosis. This task relies on a completely different set of skills than dealing with someone you already know is critical. Afterwards, we have to perform the next crucial step and stabilize our sick patients. Like bread and butter, it is hard to imagine our field without both of these essential components of practice intertwined together. Of course, in reality, we do much more than caring only for the very ill, which is the last third. From bedside psychology and social advocacy to primary pediatrics, second opinions and after-hours dermatology – we do it all.

The other question was about applying ourselves beyond the ED. EM skills are not only for the hospital. Over the last few decades, it has become obvious that EM physicians function superbly in multiple other settings, from ground and helicopter EMS (including direction and planning) to disaster relief and event medicine. EM physicians make excellent wilderness docs, public and organizational consultants, surgical assistants on GH medical missions (sometimes functioning as the only “anesthesiologist”), proceduralists, tactical support physicians, academic researchers, critical care and ICU providers and much more. All of these cojoined fields provide and will continue to provide ample opportunities for worldwide EM practice for generations of EM aficionados to come.

So, would you like to join in on the fun?

Author

Anthony RODIGIN

Anthony RODIGIN

Anthony has practiced clinical EM in the San Francisco Bay Area since 2010 and has lived in California for nearly thirty years. A fourth-generation doc, he was awed as a kid by his great-grandmother’s ambulance stories spanning decades. EM’s versatility has been a personality match from the get-go.

Since residency, choices for EM projects have been guided mainly by fun and intellectual curiosity, trying to mimic a childhood hero Sherlock Holmes. Anthony does not play a horrible violin, but rather a lousy synth keyboard. He has been passionate about education since a university TA and has comparatively studied nations’ emergency care systems for twenty years instead of sleeping. He continues to work at a busy community ED, volunteers as an EMS medical advisor for the US National Park Service, and has experience with telemedicine, urgent care, academic shifts and admin leadership. He is also a couch househusband with a spouse, two kids and a real scaredy cat.

Listen to the chapter

Cite This Article

Please replace “iEM Education Project Team” below with the author(s) surname and initials.

Cite this article as: iEM Education Project Team, "Emergency Medicine: A Unique Specialty (2023)," in International Emergency Medicine Education Project, April 7, 2023, https://iem-student.org/2023/04/07/emergency-medicine-a-unique-specialty-2023/, date accessed: September 27, 2023

2018 version of this topic – https://iem-student.org/emergency-medicine-a-unique-specialty/

References

  1. Sanderson W., Cuevas D. and Rogers R. “Emergency Medicine: A Unique Specialty”. iEmergency Medicine for Medical Students and Interns. 1st edition, Version 1, 2018.
  2. Zink, Brian J. “Anyone, Anything, Anytime: A History of Emergency Medicine”, 2nd Edition Hardcover – January 1, 2018
  3. Bell, Ryan Corbett. “The Ambulance: A History”. Reprint edition, McFarland & Company, Inc., 2009

Reviewed By

Arif Alper Cevik, MD, FEMAT, FIFEM

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, vice-chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.

Thinking Like an Emergency Physician (2023)

~ iEM Education Project Team ~ Leave a comment

by Joe Lex

Author
Listen

Emergency Medicine is the most interesting 15 minutes of every other specialty.

Dan Sandberg, BEEM Conference, 2014

Everyone in medicine knows that Emergency Medicine is different, even if they can’t put the reason into words.  We know why.  We work in an environment that is different, in hours that are different, and with patients who are different more than any other medical specialty.  Our motto is “Anyone, anything, anytime.”  No other specialty of medicine makes that claim.

While other doctors dwell on “What does this patient have? – that is, “What’s the diagnosis?” – emergency physicians are instead thinking “What does this patient need right now?  In 5 minutes?  In two hours?”  

The concept of seeing undifferentiated patients with symptoms, not diagnoses, is alien to many of our medical colleagues. Yet we do it on a daily basis, many times during a shift.  The idea of juggling decisions for several sick people simultaneously is beyond the capabilities of almost everyone else in medicine.  They are used to working with one patient at a time in a linear fashion.

I retired a few years ago after more than 45 years in Emergency Medicine, dating back to my time as an Army medic in Vietnam.  Every time I introduced myself to a patient, I never knew in advance which direction things were going to head.  I never knew whether I could help the patient in 30 seconds or 30 minutes, if at all.  I felt like I should have given this disclaimer.

Hello stranger, I am Doctor Joe Lex.  I will spend as much time with you as it takes to determine whether you are trying to die on me, and whether I should admit you to the hospital so you can try to die on one of my colleagues.  

You and I have never met before today.  You must trust me with your life and secrets, and I must trust that the answers you give me are honest.  

After today, we may never see one another again.  It may turn out to be one of the worst days of your life.  For me, it is another workday.  I may forget you minutes after you leave the department, but you will probably remember me for many days or months, possibly even for the rest of your life.  I will ask you many, many questions.  I will do the best I can to ask the right questions in the right order so that I come to a correct decision.  I want you to tell me your story, and for me to understand that story, I may have to interrupt you to clarify your answers.

Each question I ask you is a conscious decision on my part.  In an average 8-hour shift I will make about 10,000 conscious and subconscious decisions – who should I see next, what question should I ask next, how much physical examination should I perform, is that really a murmur that I am hearing, what lab study should I order, what imaging study should I look at now, and is that really an infiltrate, which consultant will give me the least pushback about caring for you, is your nurse one whom I can trust with the mission of getting your pain under control, and will I remember to give you that work note when it is time for you to go home?  And so on…  So even if I screw up just 0.1% of these decisions, I will make about ten mistakes today.

I hope for both of our sakes you have a plain, obvious emergency with a high signal-to-noise ratio.  Gonorrhea, a dislocated kneecap, chest pain with an obvious STEMI pattern on EKG, shingles, a dental abscess, an eye foreign body … I can recognize and treat those things without even thinking.  If, on the other hand, your problem has a lot of background noise and vague signs and symptoms, I am more likely to be led down the wrong path and come to the wrong conclusion.  

I am glad to report that the human body is very resilient.  We as humans have evolved over millennia to survive, so even if I screw up, the odds are very, very good that you will be fine.  Voltaire told us back in the 18th century that “The art of medicine consists of amusing the patient while nature cures the disease.”  For the most part, this has not changed.  And Lewis Thomas wrote: “The great secret of doctors, learned by internists and learned early in marriage by internists’ wives, but still hidden from the public, is that most things get better by themselves.  Most things, in fact, are better by morning.” On the other hand, the path to dying is rather direct – failure of respirations, failure of the heart, failure of the brain, or failure of metabolism.

Remember, you don’t come to me with a diagnosis: you come to me with symptoms.  You may have any one of more than 10,000 diseases or conditions that we know about, and – truth be told – the odds of me getting the absolute correct diagnosis are small.  You may have an uncommon presentation of a common disease or a common presentation of an uncommon disease.  If you are early in your disease process, I may even miss such life-threatening conditions as heart attack or sepsis.  If you neglect to truthfully tell me your sexual history or your use of drugs and alcohol, I may not follow through with appropriate questions and might come to a totally incorrect conclusion about what you need or what you have.

You may be disappointed when you feel that you are not being seen by a “specialist.”  Many people believe that when they have their heart attack, they should be cared for by a cardiologist.  They think that the symptom of “chest pain” is their ticket to the heart specialist.  But what if the heart attack is not chest pain, but nausea and breathlessness?  And what if the chest pain is aortic dissection?  Or a pneumothorax?  Or a ruptured esophagus?  So, you are being treated by a specialist – one who can discern the life-threatening from the trivial, and the medical from the surgical.  We are the specialty trained to think like this.

We started our training in a state of unconscious incompetence – we were so poor at what we did that we did not even know how bad we were.  We were lucky if we could care for four patients in an 8-hour shift.  But we quickly learned and reached a level of conscious incompetence and multi-tasking – we knew that we were inadequate, but we felt ourselves getting better at our job on a day-to-day basis.  By the time we finished our training we had reached the next level: conscious competence.  We could deal with almost anything, but we still had to think hard about much of our decision making.  After a few more years of practice, we reached our pinnacle of unconscious competence

If you insist on asking “What do I have, Doctor Lex?” you may be disappointed when I tell you “I don’t know what you have, but I do know it is safe for you to go home.”  Sometimes I can do this without doing a single test.  I do know that if I give you a made-up diagnosis like “gastritis” or “walking pneumonia,” you will think the problem is solved.  Worse yet, other doctors will anchor on my false diagnosis, and you may never get the right answers.

Here’s some good news: we are probably both thinking of the worst-case scenario. You get a sudden headache and wonder “Do I have a brain tumor?”  You get some belly pain and worry “Is this cancer?”  The good news is that I am thinking exactly the same thing.  And if you do not hear me say the word “stroke” or “cancer,” then you will think I am an idiot for not reading your mind to determine that is what you are worried about.  I understand that no matter how trivial your complaint, you have a fear that something bad is happening.

While we are talking, I may be interrupted once or twice.  See, I get interrupted several times every hour – answering calls from consultants, responding to the prehospital personnel, clarifying orders for nurses and technicians.  Or I may get suddenly called away to care for someone far sicker than you.  I will try very hard to not let these interruptions derail me from doing what is best for you today.

I will use my knowledge and experience to reach the right decisions for you.  I know that I am biased, but knowledge of bias is not enough to change it.  I know the pathophysiology of pulmonary embolism in excruciating detail, but the literature suggests I may still miss this condition at least half the time it occurs.

And here’s the interesting thing: I will probably make these errors whether I just quickly determine what I think you have by pattern recognition or use analytical reason.  Emergency physicians are notorious for thinking quickly and making early decisions based on minimal information (Type 1 thinking).  Cognitive psychologists tell us that we can cut down on errors by using analytical reasoning (Type 2 thinking).  It turns out that both produce about the same amount of error, and the key is probably to learn both types of reasoning simultaneously.

After I see you, I will go to a computer and probably spend as much time generating your chart as I did while seeing you.  This is to document what I have found and how I have worked up your complaint, so the hospital and I can get paid.  The more carefully I document what you say and what I did, then the more money I can collect from your insurance carrier.  But that chart may be useless in helping other health care providers understand what happened today unless I deviate from the clicks and actually write what we talked about and explained my thought process.  In my eight-hour shift today I will click about 4000 times.

What’s that?  You say you don’t have insurance?  Well, that’s okay too.  The U.S. government and many other governments in the world have mandated that I have to see you anyway without asking you how you will pay.  No, they haven’t guaranteed me any money for doing this – in fact, I can be fined a hefty amount if I don’t do it.  A 2003 article estimated I give away more than $138,000 per year worth of free care because of this law.

But if you are having an emergency, you have come to the right place.  If you need a life-saving procedure such as endotracheal intubation or decompression needle thoracotomy, I’ll do it.  If you need emergency delivery of your baby or rapid control of your hemorrhage, I can do that too.  I can do your spinal tap, I can sew your laceration, I can reduce your shoulder dislocation, and I can insert your Foley catheter. I can float your temporary pacemaker, I can get that pesky foreign body out of your eye or ear or rectum, I can stop your seizure or your nosebleed, and I can talk you through your bad trip.

Emergency medicine really annoys a lot of the other specialists.  I think that it is primarily because we are there 24 hours a day, 7 days a week.  And we really expect our consultants to be there when we need them.  Yes, we are fully prepared to annoy a consultant if that is what you need.

I saw thousands of patients, each unique, in my near-50 years of experience.  But every time I thought about writing a book telling of my wondrous career, I quickly stopped short and told myself “You will just be adding more blather to what is already out there – what you have learned cannot easily be taught and will not be easily learned by others.  What you see as wisdom, others will see as platitudes.”

As author Norman Douglas once wrote: “What is all wisdom save a collection of platitudes.  Take fifty of our current proverbial sayings– they are so trite, so threadbare.  None the less they embody the concentrated experience of the race, and the man who orders his life according to their teachings cannot be far wrong.  Has any man ever attained to inner harmony by pondering the experience of others?  Not since the world began!  He must pass through fire.”

Have you ever heard of John Coltrane?  He was an astonishing musician who became one of the premiere creators of the 20th century.  He started as an imitator of older musicians but quickly changed into his own man.  He listened to and borrowed from Miles Davis and Thelonious Monk, Coleman Hawkins and Lester Young, African music and Indian music, Christianity and Hinduism and Buddhism.  And from these seemingly unrelated parts he created something unique, something no one had ever heard before.  Coltrane not only changed music, but he changed people’s expectations of what music could be.  In the same way, emergency medicine has taken ideas from surgery and pediatrics, critical care and obstetrics, endocrinology and psychiatry, and orthopedics, and we have created something unique.  And in doing so, we altered the world’s expectations of what medicine should be.

Now, how can I help you today?

Author

Joe LEX

Joe LEX

Joe Lex was involved in Emergency Medicine for more than 49 years – as a Vietnam combat medic, ER Tech, Certified Emergency Nurse, and Emergency Physician. For five years he was Education Chair for the American Academy of Emergency Medicine, which renamed their Educator of the Year Award the “Joe Lex Award.” After 14 years in the community, he joined the Emergency Medicine faculty at Temple University in Philadelphia. He is a “godfather” of free electronic open-access medical education and his website (www.FreeEmergencyTalks.net) taught thousands of people worldwide.

Since he retired in 2016 as a Professor of Emergency Medicine, he does a weekly radio show called “Dr. Joe’s Groove,” featuring 60-year-old news and jazz. He writes an occasional blog called “Notes from Nam” based on 170 letters he wrote home in 1968 and 1969. He is also an amateur cemetery historian and volunteer tour guide for Laurel Hill Cemetery in Philadelphia and West Laurel Hill Cemetery in Bala Cynwyd, in addition to researching and producing their monthly podcasts “All Bones Considered: Laurel Hill Stories” and “Biographical Bytes from Bala: West Laurel Hill Stories.”

Joe and his wife Andrea celebrate 50 years together in June. His publicity picture is quite old – add 15 years and 40 pounds.

Listen to the chapter

Cite this article

Please replace “iEM Education Project Team” below with the author(s) surname and initials.

Cite this article as: iEM Education Project Team, "Thinking Like an Emergency Physician (2023)," in International Emergency Medicine Education Project, March 20, 2023, https://iem-student.org/2023/03/20/thinking-like-an-emergency-physician-2023/, date accessed: September 27, 2023

2018 version of this topic – https://iem-student.org/thinking-like-an-emergency-physician/

Reviewed By

Arif Alper Cevik, MD, FEMAT, FIFEM

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, vice-chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.

Why is emergency medicine training important in medical schools?

Why is emergency medicine training important in medical schools?
~ iEM Education Project Team ~ Leave a comment

The ability to promptly and accurately diagnose and treat patients in critical condition is a crucial skill that students learn in emergency medicine programs. This exposure is especially important for doctors who practice in fast-paced environments like emergency rooms, urgent care clinics, and hospitals immediately after their graduation in some countries.

The ability to promptly recognize and stabilize critically sick patients is a key skill that is taught to prospective doctors as part of emergency medical training. This entails not only the ability to see the warning indications of illnesses like heart attacks, strokes, and septic shock, but also to initiate life-saving treatments like cardiopulmonary resuscitation (CPR) and the administration of antibiotics.

Medical students can learn to function well under pressure by participating in emergency medicine rotations. It’s very common for emergency departments to be noisy and hectic due to the high volume of people who are there for immediate attention. So, in order to offer the best treatment for their patients in situations where time and resources are limited, and many distractors in the environment, all doctors need to be able to think fast and make choices on the fly.

Learning to work with other medical professionals is also a crucial part of emergency medicine education. Patients in emergency departments are usually cared for by a multidisciplinary group consisting of doctors, nurses, and other medical experts. Medical students learn how to interact and coordinate with these other clinicians as part of their emergency medicine training.

In addition, emergency medicine education is crucial because it prepares future doctors to treat patients with a wide variety of acute and chronic disorders. Every doctor should be able to treat patients of different ages, ethnicities, and economic statuses, and they should do so in a way that is respectful of their cultural origins. Therefore, emergency departments create great opportunities with its unique learning environment for medical students.

Last but not least, emergency medicine education is critical since it helps students get a feel for the field. Physicians who have completed emergency medicine training are better equipped to deal with the high-stakes, high-stress scenarios they will experience in practice, as emergency medicine is one of the most rigorous and demanding specialties in medicine. All medical students, including those who want to specialize elsewhere, should acquire emergency medicine skills, familiarize themselves with how the emergency health care system operates, and be prepared to work in this field if necessary.

IFEM, or the International Federation for Emergency Medicine (ifem.cc), is an organization that supports the advancement of emergency medicine globally. One way that IFEM supports emergency medicine training in medical schools is by providing resources and guidelines for curriculum development. IFEM has created a set of guidelines for emergency medicine training, which can serve as a framework for medical schools to develop their own curricula. Additionally, IFEM offers training opportunities and conferences for medical educators to learn from each other and share best practices.

To improve emergency medicine training in their own countries, other nations can look to IFEM’s guidelines as a starting point for developing their own curricula. They can also seek out partnerships with IFEM and other organizations, to share knowledge and resources. Providing opportunities for medical students to gain hands-on experience in emergency medicine, such as through clinical rotations or simulation training, can definitely be effective in preparing them for the challenges they may face in the future clinical practice. Finally, investing in the development of emergency medicine residency programs can help to ensure that there is a pipeline of well-trained emergency physicians to serve the needs of the community.

In conclusion, emergency medicine training is a crucial part of a medical education because it prepares students for the realities of practice by teaching them how to quickly and accurately assess and treat critically ill patients, how to work effectively in high-stress environments, how to collaborate with other healthcare providers, how to care for patients from a wide variety of backgrounds and with a wide variety of medical conditions. Without this exposure, medical students would be less equipped to deal with complicated and challenging circumstances in clinical practice. Therefore, we highly recommend medical schools consider opening emergency medicine rotations or increasing the time of exposure to emergency medicine education.

Further Reading

  • Rybarczyk MM, Ludmer N, Broccoli MC, Kivlehan SM, Niescierenko M, Bisanzo M, Checkett KA, Rouhani SA, Tenner AG, Geduld H, Reynolds T. Emergency Medicine Training Programs in Low- and Middle-Income Countries: A Systematic Review. Ann Glob Health. 2020 Jun 16;86(1):60. doi: 10.5334/aogh.2681. PMID: 32587810; PMCID: PMC7304456.
  • International EM Core Curriculum and Education Committee for the International Federation for Emergency Medicine. International Federation for Emergency Medicine model curriculum for emergency medicine specialists. CJEM. 2011 Mar;13(2):109-21. PMID: 21435317.
  • Arnold JL, Holliman CJ. Lessons learned from international emergency medicine development. Emerg Med Clin North Am. 2005 Feb;23(1):133-47. doi: 10.1016/j.emc.2004.10.001. PMID: 15663978.
  • Beyene T, Tupesis JP, Azazh A. Attitude of interns towards implementation and contribution of undergraduate Emergency Medicine training: Experience of an Ethiopian Medical School. Afr J Emerg Med. 2017 Sep;7(3):108-112. doi: 10.1016/j.afjem.2017.04.008. Epub 2017 Apr 20. Erratum in: Afr J Emerg Med. 2017 Dec;7(4):189. PMID: 30456120; PMCID: PMC6234139.
  • Beckers SK, Timmermann A, Müller MP, Angstwurm M, Walcher F. Undergraduate medical education in emergency medical care: a nationwide survey at German medical schools. BMC Emerg Med. 2009 May 12;9:7. doi: 10.1186/1471-227X-9-7. PMID: 19435518; PMCID: PMC2689168.
  • Wald DA, Lin M, Manthey DE, Rogers RL, Zun LS, Christopher T. Emergency medicine in the medical school curriculum. Acad Emerg Med. 2010 Oct;17 Suppl 2:S26-30. doi: 10.1111/j.1553-2712.2010.00896.x. PMID: 21199080.

Related iEM Articles

Arif Alper Cevik, MD, FEMAT, FIFEM

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, vice-chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.

Cite this article as: iEM Education Project Team, "Why is emergency medicine training important in medical schools?," in International Emergency Medicine Education Project, February 24, 2023, https://iem-student.org/2023/02/24/why-is-emergency-medicine-training-important-in-medical-schools/, date accessed: September 27, 2023

Key recommendations for medical students interested in pursuing a career in emergency medicine

Key recommendations for medical students interested in pursuing a career in emergency medicine.
~ iEM Education Project Team ~ Leave a comment

Emergency Medicine is a popular speciality among students, and residency programs are receiving an increased amount of applications year by year. However, high competition to get into the residency programs requires successful preparation for the speciality training. In addition, choosing this speciality as a future professional career may fit some individuals while it can not be suitable for others. 

Here are some recommendations to be prepared and understand whether emergency medicine is a good fit for you.

  1. Get involved in emergency medicine early: Try to find ways to get involved during medical school, such as volunteering at an emergency department or shadowing an emergency medicine physician. This will give you a better understanding of the field and help you determine if it is a good fit for you.
  2. Seek out opportunities to develop clinical skills: Emergency medicine is a highly clinical field, and you will need to be comfortable managing patients with a wide range of medical conditions. Participating in clinical rotations and other hands-on learning experiences can help you build your clinical skills and prepare you for a career in emergency medicine.
  3. Network with emergency medicine professionals: Building relationships with emergency medicine physicians and other healthcare professionals can help you learn about different career paths in the field and gain valuable insight into the daily challenges and rewards of working in emergency medicine.
  4. Stay up-to-date on the latest developments: Emergency medicine is a rapidly evolving field, and it is important to stay informed about the latest developments in patient care and medical technology. Attending conferences and workshops, reading professional journals, and participating in online communities can help you stay current.
  5. Consider a residency program: Many emergency medicine physicians complete a residency program in the field, which provides in-depth training and hands-on experience in emergency medicine. Consider applying to a residency program if you are serious about pursuing a career in emergency medicine.
  6. Focus on developing your interpersonal skills: Effective communication and interpersonal skills are essential for success in emergency medicine, as you will be working with patients, families, and other healthcare professionals in high-pressure situations. Make an effort to develop your interpersonal skills, and seek feedback from others on how you can improve.
  7. Stay passionate: Emergency medicine can be challenging, but it can also be incredibly rewarding. Make sure to stay passionate about your chosen field and continue to seek out opportunities for growth and learning.

Emergency medicine is a challenging but rewarding field that requires a strong foundation in clinical skills, a commitment to staying current with the latest developments, and excellent interpersonal skills. If you are passionate about helping patients in high-pressure situations and are willing to work hard to develop your skills, a career in emergency medicine may be a great fit for you.

Further Reading

  • Huang RD, Lutfy-Clayton L, Franzen D, Pelletier-Bui A, Gordon DC, Jarou Z, Cranford J, Hopson LR. More Is More: Drivers of the Increase in Emergency Medicine Residency Applications. West J Emerg Med. 2020 Dec 10;22(1):77-85. doi: 10.5811/westjem.2020.10.48210. PMID: 33439811; PMCID: PMC7806335.
  • Blackshaw AM, Watson SC, Bush JS. The Cost and Burden of the Residency Match in Emergency Medicine. West J Emerg Med. 2017 Jan;18(1):169-173. doi: 10.5811/westjem.2016.10.31277. Epub 2016 Dec 19. PMID: 28116032; PMCID: PMC5226755.
  • Pianosi K, Stewart SA, Hurley K. Medical Students’ Perceptions of Emergency Medicine Careers. Cureus. 2017 Aug 24;9(8):e1608. doi: 10.7759/cureus.1608. PMID: 29075586; PMCID: PMC5655118.
  • Alkhaneen H, Alhusain F, Alshahri K, Al Jerian N. Factors influencing medical students’ choice of emergency medicine as a career specialty-a descriptive study of Saudi medical students [published correction appears in Int J Emerg Med. 2018 Dec 17;11(1):56]. Int J Emerg Med. 2018;11(1):14. Published 2018 Mar 7. doi:10.1186/s12245-018-0174-y
  • Boyd JS, Clyne B, Reinert SE, Zink BJ. Emergency medicine career choice: a profile of factors and influences from the Association of American Medical Colleges (AAMC) graduation questionnaires. Acad Emerg Med. 2009;16(6):544-549. doi:10.1111/j.1553-2712.2009.00385.x

Related iEM Articles

Arif Alper Cevik, MD, FEMAT, FIFEM

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, vice-chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.

Cite this article as: iEM Education Project Team, "Key recommendations for medical students interested in pursuing a career in emergency medicine," in International Emergency Medicine Education Project, February 15, 2023, https://iem-student.org/2023/02/15/key-recommendations-for-medical-students-interested-in-pursuing-a-career-in-emergency-medicine/, date accessed: September 27, 2023

Why do medical students favour emergency medicine experience?

Why do medical students favour emergency medicine experience?
~ iEM Education Project Team ~ Leave a comment

Emergency Medicine is a challenging and fast-paced speciality that is often considered one of the most popular clerkships among medical students. The appeal of emergency medicine stems from its dynamic nature, which requires medical students to be versatile, adaptable and able to make quick decisions.

One of the primary reasons that medical students like emergency medicine is the opportunity to learn the care for a wide range of patients. In the emergency department, medical students are exposed to a diverse patient population that includes individuals with acute illnesses and injuries, as well as those with chronic conditions that have taken a turn for the worse. This exposure to a wide range of patients allows medical students to develop a broad knowledge base and gain a deeper understanding of the complexities of medical care.

Another factor that attracts medical students to emergency medicine is the fast-paced environment. The emergency department is often the first point of contact for patients experiencing an acute illness or injury, and medical students must be able to assess, diagnose, and treat patients quickly. In addition, this challenging and fast-paced environment helps medical students to develop strong critical thinking and decision-making skills, which are essential for success in any medical speciality.

In addition to the opportunities for hands-on patient care, emergency medicine also provides medical students with the opportunity to work closely with other healthcare professionals. In the emergency department, medical students interact with nurses, paramedics, radiologists, and other specialists and learn to provide comprehensive care to patients. This interdisciplinary approach to care allows medical students to gain a deeper understanding of the role of each healthcare professional and to develop strong collaborative skills.

Emergency medicine is also a highly rewarding speciality for medical students, as it provides the opportunity to make a significant impact on a patient’s health in a short amount of time. Whether being in a team stabilizing a critically ill patient, providing pain relief, or simply offering emotional support, medical students in the emergency department have the opportunity to make a real difference in the lives of patients.

Finally, the training and education opportunities available in emergency medicine are another reason why medical students often favour this clerkship. Emergency medicine residency programs, with a robust training structure, are designed to provide medical students with extensive exposure to the most challenging cases and to provide a strong foundation in critical thinking and decision-making skills. Additionally, emergency medicine residency programs often offer a variety of elective rotations, which allow medical students to tailor their training to their specific interests and career goals.

In conclusion, emergency medicine is a popular clerkship among medical students for many reasons. From the fast-paced and challenging environment to the opportunities for hands-on patient care and interdisciplinary collaboration to the training and education opportunities available, emergency medicine provides medical students with a well-rounded and rewarding clerkship experience. Whether they go on to specialize in emergency medicine or another medical speciality, the skills, knowledge and experience gained in the emergency department will serve medical students well throughout their careers.

Further Reading

  • Pianosi K, Stewart SA, Hurley K. Medical Students’ Perceptions of Emergency Medicine Careers. Cureus. 2017 Aug 24;9(8):e1608. doi: 10.7759/cureus.1608. PMID: 29075586; PMCID: PMC5655118.
  • Langlo NM, Orvik AB, Dale J, Uleberg O, Bjørnsen LP. The acute sick and injured patients: an overview of the emergency department patient population at a Norwegian University Hospital Emergency Department. Eur J Emerg Med. 2014 Jun;21(3):175-80. doi: 10.1097/MEJ.0b013e3283629c18. PMID: 23680865.
  • Ray JC, Hopson LR, Peterson W, Santen SA, Khandelwal S, Gallahue FE, White M, Burkhardt JC. Choosing emergency medicine: Influences on medical students’ choice of emergency medicine. PLoS One. 2018 May 9;13(5):e0196639. doi: 10.1371/journal.pone.0196639. PMID: 29742116; PMCID: PMC5942813.
  • Benner P, Hughes RG, Sutphen M. Clinical Reasoning, Decisionmaking, and Action: Thinking Critically and Clinically. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 6. Available from: https://www.ncbi.nlm.nih.gov/books/NBK2643/

Related iEM Articles

Arif Alper Cevik, MD, FEMAT, FIFEM

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, vice-chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.

Cite this article as: iEM Education Project Team, "Why do medical students favour emergency medicine experience?," in International Emergency Medicine Education Project, February 8, 2023, https://iem-student.org/2023/02/08/why-do-medical-students-favour-emergency-medicine-experience/, date accessed: September 27, 2023

Two Roads, One Path: Academic vs. Non-Academic EM – Part 1

academic emergency medicine vs non-academic emergency medicine
~ Anthony Rodigin, USA ~ Leave a comment

Are academic and non-academic emergency medicine (EM) really two completely different worlds?

With this post I want to start a short series on this topic, hopefully with a little twist in the approach.

Why even question?

How and why do you question a distinction that is on the one hand very apparent and real, and on the other is very customary and traditional and may be true for all medical specialties?

Part of the answer is that in order to plan a fulfilling life in EM (not everyone believes in a “career”), it is best to understand the entire landscape – not only regionally and nationally, but also globally. To this end, perhaps more innovation, ingenuity and out-of-the-box thinking is needed to benefit future EM trainees than what habitual teachings on the subject offer.

Are we really committed for life to whatever we pick out of residency?  Is the decision regarding a fellowship for a senior registrar a now-or-never decision? Is there such an age as “too late” for academics and vice versa? Is the connection between academic and non-academic EM a one-way street? Is it true that once in EM you cannot do anything else because “you don’t know how to do anything else”, according to some?

Today we will begin by looking at a few labels and presuppositions that may be cemented in the collective EM subconscious. It is my intuitive suspicion that only by uncorking, uncovering or by altogether removing some of these, will we be able to get to the real deal underneath.

As they say, the devil is in the details.

Discussion One:  Smoke and Mirrors

Where will you work at and who will you work for?

First, academic vs. non-academic EM identity can to a large extent be affected by how your nation’s overall healthcare system is set up.

In countries with predominantly socialized medicine, “community practice” – very possibly a US-driven term – may simply indicate not being employed at one of the largest tertiary urban centers available, which carry all the prestige and concentrate all of research efforts. In such nations a classically proposed counterpart to academic medicine, a business-driven private EM enterprise, may be lacking completely.

If everyone works for the government, be it local or federal, then becoming “academic”, equally or more so than due to one’s personal talents and inclinations, may be the outcome of having urbanization, luck, connections or some other ability to find a bigger place to work. At one point or another one simply wins the lucky lottery ticket to move and “move up”. In essence, the EM physician is a large capital city’s teaching hospital worker first, and an academician largely by default. Such career aiming of course succumbs to the philosophy that urban and central is always better than rural and peripheral.

Second, let’s consider “community practice” as a kind of a weird term: if you are in academic EM, who else are you serving if not some community or communities? These may be communities of colleagues, trainees, organizations and researchers in addition to patients, but they are communities nonetheless.

Equally, if an EM physician is truly and solely in non-academic practice, does she really envision and lead her professional life without any engagement in research, publications, teaching, administration, local and international networking? What would the website “Life in non-academic EM” look like – a steady picture of a work mule without links or content?

Both terms academic and non-academic EM may be infused and muddied with other meanings like institutional- or government-affiliated practice, private practice, non-teaching, and so on.

In real life, both type of endeavors (if the distinction between academic and non-academic is genuine) can be conducted in very urban or in rather rural environments; and either practice type may be institutionally affiliated or tied to NGOs, governments or businesses. In the United States some recent criticism has sprung related to the so-called inbred residencies – EM training programs created and operated by large corporate entities.

More importantly for a future trainee: both types of EM practices may or may not involve exclusive night shifts, overtime, faraway travel, being underpaid, unfair seniority, feeling unappreciated and cogwheelish (new word for you), without a clear sense of direction or belonging.

Don’t get ridiculous with cliches.

Now to some cliches, most of which are from the trainees themselves.

One: the sigh “I love teaching, but I hate research” from those choosing non-academics.

Let me ask a provocative question: are all of the globally famous EM research superstars you and I know necessarily brilliant teachers? It appears that “I love research, but I hate teaching” never stopped anyone from an academic road. This, of course, is poor logic either way.

Teaching is a hard thing to do well, and there is a distinction between bedside and classroom teaching, but so is research! Just like the so-called charisma of say a journalist, perhaps some abilities one can be born with (in the words of Professor Snape, “possess the predisposition”). Yet, vast majority of skills can be and have to be acquired.

So instead of anguishing over your inborn leanings and phobias, think rather of what you would prefer to be doing, once you learn it, during any typical week of the next five or more years after residency. Now, how can you realistically translate that into life, given the types of attainable EM jobs out there in your current or anticipated environment?

Two: “get in, get out (of the ED), and enjoy the rest of your life!”

Often the EM backpack mentality, as bumper-stickered above, is sold as the prime appeal of non-academic work.

All true – academicians, when not at work, do not enjoy their lives to any significant extent. They spend most of their free time in dusky library dungeons and at other EM-bound noble activities, while those outside of academics enjoy hundreds of free hours sailing the high seas or YouTube.

As a very weak truism, non-academic EM may sometimes open up more free time for non-EM related activities of one’s life. But is wastage of time laying on a couch an activity, and are you susceptible?

On the contrary, it may be plausible that academicians may enjoy fewer and shorter shifts, more diverse practices, more immediate access to cutting edge innovations and articles, fuller specialist call panels and fewer unfinished charts to review and sign at home.

Three: “One should only do a fellowship if planning an academic career…in which case, you better get into one!”

No, you should probably do a fellowship primarily because you are very interested in what the fellowship is about. Everything else is an extra, albeit a welcome one – like perhaps natural entry into an academic institution or a network of contacts for expanded career options.

It is also completely legitimate to consider the burden and the years of your medical training so far. In some countries just getting to a recognized EM residency (which may be abroad!) has already cost you several years post medical graduation. In such cases, ambivalent feelings towards adding even more years via a fellowship to the perpetual student status are fully valid.

On the other hand, it may very well be that in the near future (if not already), all EM docs without a fellowship, whether entrepreneurial or in public service, academic or not, will become non-competitive for best jobs.

Is doing a fellowship straight off the bat after residency the only option? What if you are not interested in any during training, but become interested later?

To be fair, right after residency makes not only intuitive sense, but typically the system is set up that way, especially fellowship funding. Still, one has to be careful, as not all of fellowships are funded, nor are all fellowships accredited. Viewed in a constructive light, this creates not only constraints but also degrees of freedom for making choices.

True, if years pass, an entire family’s lifestyle dependent on attending level salary may not be very compatible with the salary of a fellow even with all the moonlighting in the world. But is the latter income difference profound in your country, or are the main barriers to a delayed fellowship of a different sort – e.g., government rules written in stone, the mass competition from the youngsters or some unspoken negative culture towards old-timers in their forties among fellowship directors?

Overall, nothing is insurmountable if given enough will, persistence and preparation. Otherwise, there would have been no people in their forties in my medical school class or residency.

Which professional currency would you rather deal in?

All mentioned above is not to be construed to say that some harsh realities do not exist.  One problem with cliches is that they are very zonal, while proclaiming to be universals.

The simple overhanging truth is that every field has its own currency, and both academic and non-academic EM are no exceptions.

For future EM trainees this is pertinent and applicable not only because of the obvious choices you will have to make after formal training, but also because of the need to gear and adjust your preferences while still in training.

Grant funding and publications are absolutely the ubiquitous currency in academics. Productivity, billing and people management (aka “leadership”) skills are the hardcore coinage in business-driven EM. Advancement and promotion within socialized medicine systems may call for yet another set of valuables altogether.

Still, thinking in terms of such hard constraints will tend to corner you in at least two ways.

First, it is not to be implied that ability to generate grants or publications never helps or is not useful in non-academics, or that no academician has to keep track of her billing and productivity metrics.

Second, if cornered, you will be liable to forget the correct reasons for choosing a certain path – the ones that spring from your deep interests and curiosities. These reasons miraculously happen to be the same ones to keep you out of burnout and disappointment years later, no matter what type of practice.

I am proposing a much simpler approach to the above dilemma. Choose currencies that will create the least disdain and subconscious resistance (manifested by nausea and wanting to do what your dog does after it gets wet), and then ones for which you think you already have more inborn propensity if not talent.

Finally, are you really ego-, career- and promotion-driven?  How would you define your own future success in EM?

Enough from me for now.

In future discussions and interviews we will try to elicit opinions of other EM physicians to shine different shades of light on the intriguing sub-topics this topic uncovers.

Stay tuned!

 

Intern Survival Guide – ER Edition

Intern Survival Guide - ER Edition
~ Sumaiya Hafiz, UAE ~ Leave a comment
In some parts of the world, Internships consist of rotating in different departments of a hospital over a period of one or two years depending on the location. In others, interns are first-year Emergency Medicine residents. Whichever country you practice in, an emergency rotation may be mandatory to get the most exposure, and often the most hands-on. Often, junior doctors (including myself)  find ourselves confused and lost as to what is expected of us, and how we can learn and work efficiently in a fast-paced environment such as the ER. It can be overwhelming as you may be expected to know and do a lot of things such as taking a short yet precise history, doing a quick but essential physical exam and performing practical procedures. I’ve gathered some tips from fellow interns and myself, from what we experienced, what we did right, what we could’ve done better and what we wish we knew before starting. These tips may have some points specific to your Emergency Medicine Rotation, but overall can be applied in any department you work in.
  • First things first – Always try to be on time. Try to reach your work a couple of minutes before your shift starts, so you have enough time to wear your PPE and feel comfortable before starting your shift.
  • Know your patients! Unlike other departments, ER does not always have rounds, and you do not know any of the patients beforehand, but it always helps to get a handover from the previous shift, and know if any of the patients have any results, treatment plans or discharges pending, to prevent chaos later on!
  • Always be around, inform your supervising doctor when you want to go for a break, and always volunteer to do more than what you’re asked for. The best way to learn is to make yourself known, ask the nurses to allow you to practice IV Cannulation, Intramuscular injections, anything and everything that goes around the department, remember the ER is the best place to learn.
  • Admit when you feel uncomfortable doing something, or if you’ve done a mistake. This makes you appear trustworthy and everyone respects someone who can own up to their mistake and keeps their patients first.
  • Breath sounds and pulses need to be checked in every patient!
  • Address pain before anything else, if their pain is in control, the patient will be able to answer your questions better.
  • Never think any work is below you, and this is one thing which I admired about ED physicians, you do not need someone to bring the Ultrasound machine to you, you do not need someone to plug in the machine, you do not need someone to place the blood pressure cuff if you can do it yourself. Time is essential, and if you’re the first person seeing the patient, do all that you can to make their care as efficient as possible.
  • Care for patients because you want to, and not for show. Often junior doctors get caught up in the fact that they are being evaluated and try to “look” like the best version of themselves. While it may be true, remember this is the year where you are shaping yourself for the future, and starting off by placing your patients first, doing things for their benefit will not only make it a habit, the right people will always notice and will know when you do things to provide patient-focused care, or when you do them to show that you are providing patient-focused care.
  • Teamwork will help you grow. Not everything in life has to be a competition, try to work with your colleagues, share knowledge, take chances on doing things, learn together, trying to win against everyone else only makes an easier task even more stressful and can endanger lives.
  • Learn the names of the people you work with! In the ER, you may across different people on each and every shift and it may be difficult to remember everyone’s names, but it’s always nice to try, and addressing people by their names instantly makes you more likable and pleasant to work with!
  • Keep track of your patients and make a logbook of all the cases you see and all the procedures you observe/assist in/perform. This not only helps in building your portfolio, but also in going back and reading about the vast variety of cases you must have seen.
  • Always ask yourself what could the differential diagnosis be? How would you treat the patient?
  • Ask questions! No question is worth not asking, clear your doubts. Remember to not ask too much just for the sake of looking interested, but never shy away from asking, you’d be surprised to see how many doctors would be willing to answer your queries.
  • Don’t make up facts and information. If you forgot to ask something in history, admit the mistake, and it’s never too late, you can almost always go back and ask. It’s quite normal to forget when you’re trying to gather a lot of information in a short span of time.
  • Check up on the patients from time to time. The first consultation till the time you hand them the discharge papers or refer them to a specialty shouldn’t be the only time you see the patient. Go in between whenever you get a chance, ask them if they feel better, if they need something. Sometimes just by having someone asking their health and mental wellbeing is just what they need.
  • Take breaks, drink water and know your limits. Do not overwork yourself. Stretching yourself till you break is not a sign of strength.
  • Sleep! Sleep well before every shift. Your sleep cycles will be affected, but sleeping when you can is the best advice you can get.
  • Read! Pick your favorite resource and hold onto it. A page of reading every day can go a long way. The IEM book can be a perfect resource that you can refer to even during your shifts! (https://iem-student.org/2019/04/17/download-now-iem-book-ibook-and-pdf/)
  • Practice as many practical skills as you can. The ER teaches you more than a book can, and instead of looking at pictures, you can actually learn on the job. Practice ultrasound techniques, suturing, ECG interpretation, see as many radiology images as you can, learn to distinguish between what’s normal and what’s not.
  • Last but most important, Enjoy! The ER rotation is usually amongst the best rotations an intern goes through, one where you actually feel like you are a doctor and have an impact on someone’s life! So make the best of it.
If you are a medical student starting your emergency medicine rotation, make sure to read this post for your emergency medicine clerkship, and be a step ahead! https://iem-student.org/2019/10/04/how-to-make-the-most-of-your-em-clerkship/  
Cite this article as: Sumaiya Hafiz, UAE, "Intern Survival Guide – ER Edition," in International Emergency Medicine Education Project, May 26, 2021, https://iem-student.org/2021/05/26/intern-survival-guide-er-edition/, date accessed: September 27, 2023

Recent Blog Posts By Sumaiya Hafiz

Knee Jerk, Shotgun and Kitchen Sink in Emergency Medicine

Knee Jerk, Shotgun and Kitchen Sink in Emergency Medicine
~ Anthony Rodigin, USA ~ Leave a comment

For a trainee in EM, it is useful to know about three types of cognitive practice that require caution.

While a knee jerk reaction may sometimes save time, a shotgun investigation may improve billing and a kitchen sink therapy may create the illusion of therapeutic rigor, arguably that’s all there is to it.

Anthony Rodigin Tweet

In reality, there is not much true value to any of these three missed approaches.

We will look at each one with a few examples and then briefly discuss below.

Knee Jerk

When I was rotating in the ED as an MS4, a visiting EM attending once told me that “adding a Type and Rh should become a knee jerk” for any patient with vaginal bleeding in early pregnancy. Whether or not taking the extra 30 seconds to scroll through the EMR for a previously documented Rh likely to be on file is a better strategy, this one is fairly simple.

Not all of our knee jerk reactions are equally simple or harmless.

I have seen adenosine being pushed before one could say “Mama” for anything from sinus tach to atrial flutter and A-fib with RVR: paramedics, physicians and even unsupervised nurses all being equally guilty. Why? Because a sustained heart rate above 180 is scary to some. And the reflex is to do something quickly because we don’t like to remain scared.

Nursing staff going straight for IV placement while forgetting not only the basic ABCs of resuscitation but even to disrobe the patient is another example. Starting any patient at 100% oxygen saturation who is short of breath on nasal cannula oxygen is yet another.

We like to do what we are trained to do well and/or what is easy. Our brains then compel us to prioritize doing it.

Anthony Rodigin Tweet

Once my ED team halted a verbal order for a whopping dose of colchicine blurted out to nursing by a careless consulting cardiology fellow – the patient had mentioned his ankle pain to the fellow in passing. The man was in acute renal failure and ended up with a septic ankle joint diagnosed later. Knee jerk is in part responsible for well-perpetuated ED mental formulas such as “gout = colchicine”, “fever = paracetamol”, “wheezing = albuterol” and “hypotension = 2 liter IV fluid bolus”.

The knee jerk is how we pick from our favorite antibiotics and how we generally prescribe, how we diagnose and order things on lobby and triage patients and how we even decide on CT scans and dispositions. Frequently, our hospitalist medicine colleagues will utilize the same reflex and unnecessarily or prematurely consult specialists.

On occasion, when the arrow released via a knee jerk reaction hits the bull’s eye, it feels and looks great. Knee jerk, unfortunately, is also how we assume, stereotype, over-simplify, ignore and ultimately miss.

Shotgun

This one does not have to be shot from the hip, though it certainly looks cooler that way. Often this is done thoughtfully, with a pseudo-scientific aroma to it.

I was on my MS3 internal medicine rotation when one day, the dreaded ED handed us an elderly female with a congratulatory thick paper chart, a bouquet of vague complaints and no clear diagnosis. When I asked my senior resident what we should do, the answer was a shoulder shrug and a confident “Lab ‘er up!”.

Shotgunning is not just about shooting out labs in the dark, however. It usually refers to a much wider “strategy” (actually, a lack thereof) of checking anyone for “anything” so as to not miss “something”.

Consider an ED evaluation of a headache involving some component of facial pain. Let’s order a migraine cocktail, CT and CTA of the head and neck, ESR to check for temporal arteritis; and when we find nothing, let’s do antibiotics in case of possible dental caries, otitis, mastoiditis or sinusitis. Sounds pretty thorough and terrific, doesn’t it? In fact, many patients would tend to think so. Clearly, after all that, we just could not miss something real badTM. We should remember that in EM you are worth every test that you order.

Hyperlaboratoremia and panscanosis are not the only clinical manifestations of the shotgun approach.

Anthony Rodigin Tweet

Though in all places, it is well-intended, there is a more buried shotgun in standardized chest pain workups, ED triage scales, pre-conceived clinical pathways and universal screenings than you may think.

Kitchen Sink

One might say that kitchen sink is the therapeutic twin of shotgun diagnostics, though one does not need to stem from the other.

The kitchen sink is how you and I treat most non-threatening and hence not easily identifiable ED rashes. As one of my professors once said: the rule of dermatology is that “if it is dry, use a wetting agent, if it is wet, use a drying agent, plus steroids and antibiotics for everyone”.

At its core, any kitchen sink approach violates two key pillars of modern medicine – evidence-based practice and personalized therapy.

Anthony Rodigin Tweet

Another example is the kitchen sink phase of resuscitation in a soon to be aborted CPR effort. While in the beginning, we do tend to follow certain parameters and algorithms, towards the end and well into the “futile” stage of CPR remedies like calcium, magnesium, bicarbonate, second and third anti-arrhythmic and so on all inevitably flow one after another regardless of the suspected cause of cardiac arrest or objective facts known.

While benign rashes are benign, and futile CPR is futile, most of the kitchen sink does not involve such obvious extremes. In fact, some of it is perfectly legitimized and even justified – have you ever thought of what “broad-spectrum antibiotics” in sepsis really implies?

Reasons For Need To Know

Why is knowing about the knee jerk, the shotgun and the kitchen sink ahead of time important?

First, the cognitive action patterns described are unavoidable and inescapable. It is precise because we will not be able to fully stop using all three on occasion, that we should know about them ahead of time.

Second, there is something positive and well-thought-out corresponding to the other side of each of the three behaviors:

Fundamentally, knee-jerk reactions rest on pattern recognition as the predominant cognitive pathway at work – something that physicians start to rely upon more and more as they mature. While risking the error of premature diagnostic closure (among others), pattern recognition does save time and resources. This mode is why, as some studies suggest, senior-most providers may be more effective in triage.

On the opposing side of the shotgun coin are the well-accepted mantras of keeping one’s differentials broad and of thinking outside the box. Such forced mental efforts help avoid anchoring among other cognitive errors.

Last, kitchen sink elements may indeed be acceptable in salvage type of situations or in uncharted waters, given multiple paucities in our scientific evidence and in our full understanding of physiologic processes. In such select cases, we humbly admit our limits and hope that something unknown may work at the last minute, while there is no further harm that can be done.

It would be a mistake, however, to confuse each of the positives described with the three patterns we started with when taken in their pure form.

Third, the limitations and harms encountered by not keeping the three tendencies in check are real and immediate:

  • Knee-jerk reactions do not yield beneficial results when the situation encountered is new and principally different from those experienced before, yet it has the external appearance of something familiar. Think of COVID.
  • Shotgun-galore practices subject multiple patients to unnecessary tests and to potentially harmful procedures and interventions that inevitably follow, further inflating the costs of healthcare.
  • Perpetuating myths and unmerited traditional practices, kitchen sink therapies also coach our patients into expecting both the unreasonable and the unnecessary for the next visit, undermining any accepted standard of care at its very core.

What Next?

A more in-depth discussion of all three phenomena presented would indeed be appropriate, including an investigation into any viable alternatives.

For now, I encourage all trainees to look further into the general and well-researched topic of cognitive errors in emergency medicine. 

We should also all strive to practice based on best available evidence and not to be coerced into questionable behaviors by external pressures such as performance metrics that may lurk as false substitutes for quality.

References and Further Reading

  • Frye KL, Adewale A, Martinez Martinez CJ, Mora Montero C. Cognitive Errors and Risks Associated with Provider Handoffs. Cureus. 2018;10(10):e3442. Published 2018 Oct 12. doi:10.7759/cureus.3442
  • Oliver G, Oliver G, Body R. BET 2: Poor evidence on whether teaching cognitive debiasing, or cognitive forcing strategies, lead to a reduction in errors attributable to cognition in emergency medicine students or doctors. Emerg Med J. 2017;34(8):553-554. doi:10.1136/emermed-2017-206976.2
  • Schnapp BH, Sun JE, Kim JL, Strayer RJ, Shah KH. Cognitive error in an academic emergency department. Diagnosis (Berl). 2018;5(3):135-142. doi:10.1515/dx-2018-0011
Cite this article as: Anthony Rodigin, USA, "Knee Jerk, Shotgun and Kitchen Sink in Emergency Medicine," in International Emergency Medicine Education Project, July 20, 2020, https://iem-student.org/2020/07/20/knee-jerk-shotgun-and-kitchen-sink-in-emergency-medicine/, date accessed: September 27, 2023

Triads in Medicine – Rapid Review for Medical Students

triads in medicine
~ Sumaiya Hafiz, UAE ~ Leave a comment

One of the most convenient ways of learning and remembering the main components of disease and identifying a medical condition on an exam are Triads, and medical students/interns/residents swear by them.

Be it a question during rounds, a multiple-choice exam question to be solved, or even in medical practice, the famous triads help physicians recall important characteristics and clinical features of a disease or treatment in an instant.

Since exam season is here, this could serve as a rapid review to recall the most common medical conditions.

While there are a vast number of triads/pentads available online, I have listed the most important (high-yy) ones that every student would be asked about at least once in the duration of their course.

1) Lethal Triad also known as The Trauma Triad of Death
Hypothermia + Coagulopathy + Metabolic Acidosis

2) Beck’s Triad of Cardiac Tamponade
Muffled heart sounds + Distended neck veins + Hypotension

3) Virchow’s Triad – Venous Thrombosis
Hypercoagulability + stasis + endothelial damage

4) Charcot’s Triad – Ascending Cholangitis
Fever with rigors + Right upper quadrant pain + Jaundice

5) Cushing’s Triad – Raised Intracranial Pressure
Bradycardia + Irregular respiration + Hypertension

6) Triad of Ruptured Abdominal Aortic Aneurysm
Severe Abdominal/Back Pain + Hypotension + Pulsatile Abdominal mass

7) Reactive Arthritis
Can’t See (Conjunctivitis) + Can’t Pee (Urethritis) + Can’t Climb a Tree (Arthritis)

8) Triad of Opioid Overdose
Pinpoint pupils + Respiratory Depression + CNS Depression

9) Hakims Triad – Normal Pressure Hydrocephalus
Gait Disturbance + Dementia + Urinary Incontinence

10) Horner’s Syndrome Triad
Ptosis + Miosis + Anydrosis

11) Mackler’s Triad – Oesophageal Perforation (Boerhaave Syndrome)
Vomiting + Lower Thoracic Pain + Subcutaneous Emphysema

12) Pheochromocytoma
Palpitations + Headache + Perspiration (Diaphoresis)

13) Leriche Syndrome
Buttock claudication + Impotence + Symmetrical Atrophy of bilateral lower extremities

14) Rigler’s Triad – Gallstone ileus
Gallstones + Pneumobilia + Small bowel obstruction

15) Whipple’s Triad – Insulinoma
Hypoglycemic attack + Low glucose + Resolving of the attack on glucose administration

16) Meniere’s Disease
Tinnitus + Vertigo + Hearing loss

17) Wernicke’s Encephalopathy- Thiamine Deficiency
Confusion + Ophthalmoplegia + Ataxia

18) Unhappy Triad – Knee Injury
Injury to Anterior Cruciate Ligament + Medial collateral ligament + Medial or Lateral Meniscus

19) Henoch Schonlein Purpura
Purpura + Abdominal pain + Joint pain

20) Meigs Syndrome
Benign ovarian tumor + pleural effusion + ascites

21) Felty’s Syndrome
Rheumatoid Arthritis + Splenomegaly + Neutropenia

22) Cauda Equina Syndrome
Low back pain + Bowel/Bladder Dysfunction + Saddle Anesthesia

23) Meningitis
Fever + Headache + Neck Stiffness

24) Wolf Parkinson White Syndrome
Delta Waves + Short PR Interval + Wide QRS Complex

25) Neurogenic Shock
Bradycardia + Hypotension + Hypothermia

Further Reading

Cite this article as: Sumaiya Hafiz, UAE, "Triads in Medicine – Rapid Review for Medical Students," in International Emergency Medicine Education Project, June 12, 2020, https://iem-student.org/2020/06/12/triads-in-medicine/, date accessed: September 27, 2023

Core EM Clerkship Topics

Core EM Clerkship Topics
~ iEM Education Project Team ~ Leave a comment

In the last ten years, there are few published undergraduate emergency medicine curriculum recommendations (Hobgood et al., 2009; Manthey et al., 2010; Penciner et al., 2013; Santen et al., 2014).

Current undergraduate curriculum trends recommend longitudinal and horizontal integration, and the topic lists related to emergency medicine are extensive for medical students.

In this post, we provide International Federation for Emergency Medicine and Society for Academic Emergency Medicine’s recommendations (Manthey et al., 2010; Hobgood et al., 2009).

The chosen topics can ideally be re-discussed in the clerkship during the senior years of medical school.

  • Abdominal pain
  • Altered mental status
  • Cardiac arrest and arrhythmias
  • Chest pain
  • GI bleeding
  • Headache
  • Multiple trauma
  • Poisoning
  • Respiratory distress
  • Shock

Because the length of the rotations can vary between institutions, the topics list can be extended according to the length of the clerkship and local needs.

Click for Core EM Clerkship Topics Page

References and Further Reading

  • Hobgood, C., Anantharaman, V., Bandiera, G., Cameron, P., Halperin, P., Holliman, J., … & International Federation for Emergency Medicine. (2009). International Federation for Emergency Medicine model curriculum for medical student education in emergency medicine. Canadian Journal of Emergency Medicine, 11(4), 349-354.
  • Manthey, D. E., Ander, D. S., Gordon, D. C., Morrissey, T., Sherman, S. C., Smith, M. D., … & Clerkship Directors in Emergency Medicine (CDEM) Curriculum Revision Group. (2010). Emergency medicine clerkship curriculum: an update and revision. Academic Emergency Medicine, 17(6), 638-643.
  • Penciner, R. (2009). Emergency medicine preclerkship observerships: evaluation of a structured experience. Canadian Journal of Emergency Medicine, 11(3), 235-239.
  • Santen, S. A., Peterson, W. J., Khandelwal, S., House, J. B., Manthey, D. E., & Sozener, C. B. (2014). Medical student milestones in emergency medicine. Academic Emergency Medicine, 21(8), 905-911.

How to make the most of your EM Clerkship

How to make the most of your EM Clerkship
~ Sumaiya Hafiz, UAE ~ Leave a comment

Emergency Medicine has something for everyone!

Starting the Emergency Medicine (EM) Clerkship is one of the most exciting times of any medical student’s life, regardless of whichever specialty they plan on specializing in because EM has something for everyone. It is like solving all those questions that begin with ‘A patient presents to the Emergency Department with…’ but in reality, at a faster pace and with more tricky situations. This can make students feel overwhelmed, as they find themselves juggling between books and resources as to which one to follow or which topics to learn, and I am here for just that! To share the approach that helps many students get the hang of EM and make the most of their time in one of the best learning environments of any hospital.

Prepare a list of common conditions

The basic approach would be first to jot down all the problems you can think of.

Here is a list to help you get started: Core EM Clerkship Topics

core em clerkship topics

There are problems that you may be heard a lot such as Chest Pain, Heart Failure, Shock (and it’s types), Acute Coronary Syndrome, Sepsis, Pulmonary edema, Respiratory Failure, Coma, Stroke, Hypoglycemia, Subarachnoid Hemorrhage, Fractures, Head Trauma, Status Epilepticus, Diabetic Ketoacidosis, and Anaphylaxis.

As every doctor you meet will always say, common is common, so always focus on things that you have heard and seen most about, read about them, make notes on their clinical features, differentials, investigations and management. Most importantly, do not forget to read about the ABCDE approach in every critically ill and trauma patient.

Brush up on your history taking and examination skills

Know what to ask and when to ask. Patients in the ED are not in their most comfortable composure, so try to practice and frame questions that provide you with just enough information to make a diagnosis in the least possible time.
The same goes for examination, never forget the basics of examination and their importance. Practice examination as much as you can and you will automatically see it come to you naturally at a faster pace. Also, do not forget focused history and physical examination is a cornerstone of EM practice and saves a lot of time.
Where investigations can help you exclude a differential, 80% of your diagnosis will be built from what you ask, what you see and what you feel. Keep in mind that if you are not thinking or looking for something, you will not see and find it. So, be suspicious of life, organ and limb-threatening problems.

Read about common ED procedures

ABG, Intubation, Central Lines, FAST Scan, Suturing, Catheter and Cannula placement are some of them. As a medical student, you will probably not be required to perform any, but it is good to have an idea about the procedures when you see them. If you can practice, then that is even better, ask a resident or intern to show you how and you can have a go yourself under their supervision! Remember, “see one, do one, teach one.”

list of selected procedures

Watch videos on examination, interpreting X-rays, & procedural skills

Youtube is an asset when it comes to medical education, make good use of it. There are also plenty of videos on the iEM website that you can watch and learn from.

Interpretation of ECG & X-rays

Google is your best friend for this! You have the list of common conditions, all you need to do is a google search on the most common ECG findings and x-rays in medical emergencies and you will be good to go. You can also always learn these from the doctors around you in the ED, as the more you see and try to interpret, the better you get at differentiating the normal from abnormal.

How to read c-spine x-rays

How to read chest x-rays

How to read pelvic x-ray

Books

Before the rotation

Before the rotation, read a review book, recall your basic knowledge from internal medicine/family medicine and surgery because EM almost covers all of the acute problems of those fields. Moreover, do not forget, EM is an independent specialty and has its’ own textbooks.

iEM Clerkship book is a very good source to get started with! Download Now! – iEM Book (iBook and pdf)

If you are the kind, who likes solving questions, the Pretest Emergency Medicine is a great source.

FREE DOWNLOAD

iEM Book Announcement

During the rotation

During the rotation – Learning what you see is the best way to keep things in your long term memory. After your shift ends, and you go home, get some rest, recall the cases of the day and read about them on Up to Date/ Medscape or any resource that you prefer, this will help you relate what you saw with what you are reading and will help you recall it better later on.

These are just a few tips to help in making the most of your EM rotation. Remember to study hard, but also practice, brush up on your communication skills, talk to patients, be there for them. The EM Clerkship prepares you for life as a doctor, as you practice every aspect of medicine during this time and learn to answer questions about acute medical problems and their severity when asked by those around you.

Cite this article as: Sumaiya Hafiz, UAE, "How to make the most of your EM Clerkship," in International Emergency Medicine Education Project, October 4, 2019, https://iem-student.org/2019/10/04/how-to-make-the-most-of-your-em-clerkship/, date accessed: September 27, 2023