The EM Res Podcast: Episode 1

by Bob Stuntz in


The EM Res Podcast: Episode 1

Welcome to the Emergency Medicine Resident Podcast.  My hope and goal is to provide a resource to help educate emergency medicine residents and to provide a resource for emergency medicine resident educators.  

Our goal is to cover high yield topics for our residents.  I want to provide you with the basics from the core curriculum to give you the foundation you need for the boards, wards, and the ED.  We will also talk about new research and topics that is pertinent to your practice as a resident.  We also want to discuss resident wellness, professionalism, talking with consultants, and a slew of other non-medial topics that are vital to your learning and practice as a future emergency physician.  

I want your input and interaction.  Have a topic you want covered?  Cool case you want to share?  Let me know.  Go to the blog, “Like” us on Facebook at the EM Res page, or find me on Twitter at @BobStuntz.  Post content, ask questions, and let me know how I can help you.  We have a lot planned, and some really smart people lined up to teach you some really cool stuff.  

Surviving Residency

A former co-resident and I came up with a primer for our residents to help them get used to our ED, but also to help them figure out how to be a star resident and to avoid some common pitfalls we and other residents have noted.  

  • First impressions are real, and they will follow you
  • Don’t fall in to one of these categories:
    • The procedure hog: You don’t see many patients, but you have 500 central lines in your first year.
    • The late arrival:  You show up late, leave early, and even when you’re on time, you don’t see your first patient until you have had lunch
    • The slacker: Just barely doing the minimum
    • The whiner: Always complaining about every bit of work regardless of what it may be 
    • The debater: You want more information, and you’re not afraid to argue about it in an offensive or abrasive manner
  • RESIDENCY IS HARD...
    • But it’s also short.  You have a short amount of time to get everything you need to be a good emergency physician
    • See as many patients as you can
    • Seek complaints you are not comfortable with
    • Go the extra mile.  Stay late if it means you get to take better care of someone, learn something, or do a procedure (within duty hours, of course...)
    • Obey duty hours, but not to the detriment of your patients.  Duty hours have time built in to allow for good patient care
    • Go to extracurricular activities, and get to know your co residents.
    • Go to residency activities, like journal club
    • Remember at the end of the day, it’s only 3 years of your life, and you will come out on the other end better for it.
  • Show respect for your staff and colleagues
  • Trust your Nurses, they can save you
  • If you have a disagreement with someone don’t say something offensive
  • Keep your staff in the loop in the age of electronic order entry
  • Get your charting done 
  • Remember, you will make mistakes.  
  • Value your family time/your off time.  
  • Read, study, listen to podcasts and blogs, and make sure you are doing something to learn every day.  This will set you up well for the rest of your life. 

Surviving your first year as an attending

The following are some pearls I have come up with my first year working as well as in speaking with my old co-residents.  

  • You are smart, you can do this
  • Taking your tests
    • Qualifying exam
    • Identify what type of learner you are; If you need structure, pay the money for a review course. If you are very self directed, buy a review book and use it as a guide
    • Practice questions until you are blue in the face
    • Make a schedule and stick to it.  You will be very busy with other duties at work and having a set way to do things will be important
    • Study often and early. Just because you did well on inservice exams does not mean you are guaranteed to pass. 
    • Have one primary guide, a high yield review book. Use this to find knowledge gaps and study those gaps in secondary sources
    • Oral boards
      • Come up with a set system
      • Practice cases until you are blue in the face
      • Again, decide what type of learner you are, and that will tell you if you need to do a review course
      • Assuming you pass the qualifying exam (which you probably will)
      • More to come on these tests in future episodes
  • Stick to your guns, and do what you are comfortable with
    • Do what you are comfortable doing and do not worry at first if you are over or undertesting.  Most will probably feel like they are overtesting, and you will settle in to a pattern and a style of practice as time goes on
    • Do not let yourself get pushed around or swayed by more experienced doctors from what you know is right
  • Do the same things you did as an intern
    • Play nice, interact professionally, and listen to others (nursing, consultants, support staff)
    • Don’t fall into one of the intern categories we talked about before.  
    • First impressions still count
  • You will make mistakes and that is ok.  We are all human.  We are all going to overcall or undercall at some point.  Do what you think is right for your patients, and you will be fine.  

Sensitivity, specificty, and clinical decision rules

In order to understand much of your reading and listening both on this blog and podcast, as well as your textbooks, you need to know what we mean when we talk about basic statistics.  This is not to torture you.  Trust me, it’s for your own good.  

  • Sensitivity at the most basic level is the ability of a test to identify disease.  Mathematically, it is calculated as follows:
Sensitivity.png

By this logic, a test with 100% sensitivity would be able to identify 100% of people who have a given condition, and therefore a negative test would indicate absence of disease.  90% sensitivty means 90% of the people with a condition are identified by the test, while 10% are false negatives. 

  • Specificity is the ability of a test to identify a lack of disease.  Again, the mathematical calculation is as follows:
Specificity.png
  • By this logic, a negative result from a test with 100% specificity would mean someone definitely does not have the disease.  Therefore, a positive result in that same test would make you very concerned for disease.  90% specificity means 90% of people without the disease will test negative, but 10% will be false positives. 

The ideal test would have 100% sensitivity and 100% specificity.  however, in real life, most tests, as specificity goes up, sensitivity goes down and vice versa.  In emergency medicine, we usually want tests that are highly sensitive.  When we are looking at studies that want to rule something out (such as the Pulmonary Embolism Rule-Out Criteria (PERC)), we want a high sensitivity, because we want to identify as many positives as we can.  As anyone who has used a D-dimer in someone who is PERC positive can tell you, there are some false positives involved, because that is the cost of finding all the true positives.  This brings us to the positive and negative predictive values of a test.  

  • Positive predictive value (PPV) is the number of positive test results that are true positives.  Looking at it from a calculation:
PPV.png
  • Negative predictive value (NPV) is the number of negative test results that are true negatives.  Again, look at the math:
NPV.png

So why am I doing this to you?  How many more statistics talks must one person endure in a lifetime of medical training?  Because one of the things I plan to do on this blog and podcast is to talk about research and how it relates to you, and you need to know these numbers.  

An important point: sensitivity and specificity are inherent to the test, while PPV and NPV are also dependent on the population.  So lets make this simple:  lets say you have a test that has a low positive predictive value.  If you use that test on a general population with a low disease prevalence, you will get many false positives.  Now take that same test, and apply it to a population where the prevalence of a disease in a population is much higher.  Your positive predictive value is much higher now, because a positive result will more often be associated with a positive disease state.  

Now let’s touch on clinical decision rules.  Clinical decision rules can be very helpful, and they can be very weak.  Many of them come out, as people are always trying to find ways to make decisions easier and more universal.  I have a big beef with many of these, as I feel they are often ways to try to eliminate any thinking from the physician standpoint.  Where they work are with easy questions, like who should I image for potential C spine fractures or possible ankle fractures.  

How do people come up with these?  First, they come up with a clinical question (who do I need to image to evaluate for cervical spine fractures?).  They then perform what is called a derivation study where they look at a pool of people who have the problem they are investigating, and find common traits amongst them.  They evaluate which ones are the most accurate, and follow this up with a validation study, where they apply the criteria to a prospective group of patients and evaluate how it works.  You will often hear people talk about internal and external validation.  Internal validation is done at the study center, and is often the initial validation study done.  The problem with this is that the study center may not be representative of your institution, so we often look for external validity, or that they rule/criteria have been evaluated elsewhere and confirmed.  

In the podcast, we talk about the NEXUS criteria (National X Radiography Utilization Study).  This is a nice clinical decision rule.  the criteria are as follows, with the original source for this picture shown below.  

This was a well validated study, looking at about 34,000 patients.  These criteria were 99.6% sensitive for finding C spine fractures.  It has since been externally validated, and shown to reduce the amount of imaging studies performed by physicians (thus reducing cost, radiation burden, and length of stay).   You should know these.  They are day to day useful, and you will be pimped on them.  

The San Francisco syncope Rule, on the other hand, was made at one site and seemed promising.  However studies have since shown little to no external validity.  Be leery of the clinical decision rule that tries to answer such a complicated question as syncope, chest pain, or pulmonary embolus.  There have even been studies showing an experienced clinician’s overall impression, or clinical gestalt, can be just as good or better as some of these decision rules.  

References

The above images of calculations are from Wikipedia.  

- San Francisco Syncope Rule:

Screen Shot 2013-12-19 at 11.06.06 PM.png
Screen Shot 2013-12-19 at 11.06.15 PM.png
Screen Shot 2013-12-19 at 11.06.25 PM.png

- NEXUS:

Screen Shot 2013-12-19 at 11.06.33 PM.png

- Comparing Gestalt to PE Rules: 

Runyon MS, Webb WB, Jones AE, Kline JA: Comparison of the unstructured clinician estimate of pretest probability for pulmonary embolism to the Canadian score and the Charlotte rule: A prospective observational study. Acad Emerg Med  2005; 12:587.

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