Thursday, November 26, 2009

Free game to facilitate faculty development on feedback

As an educator one is often asked to help other faculty and house staff learn about some key education principles when working with medical students. Some of these principles apply to any education setting.

1. Understanding the audience - their education level
2. Setting expectations
3. Giving formative feedback or useful feedback
  • Timely
  • Non judgmental
  • Based on observed interactions
  • Include what was done well, what could be done better.
I created a brief interactive game to help facilitators discuss these topics. The game uses an example of a student at a flying school. Facilitators should use this with faculty and house staff by discussing what a student might feel or think at each point before clicking on any option.

Let me know what you think.

Tuesday, November 17, 2009

The Logical Flow of a Physical Exam

The other day I was observing a 2nd year medical student examining a patient in my outpatient clinic. The student did a very good job- doing a very thorough examination of each organ system.

The only problem was the flow of the exam or the lack of one. He would start at the head and examine the mouth and then move down to the neck. Later he would come back to the mouth to check for the midline tongue and the gag reflex.

The patient would have to lie down for the abdominal exam, and then sit up to have the lumbar spine examined; lie down for the Straight Leg Raise test and sit up for the knee and ankle jerk; you get the idea.

It seemed an example of a logical flow of a physical exam that combined the elements of:
  1. Going down from head to toe
  2. Patient comfort and convenience
  3. Efficiency
might be helpful. Of course everyone will have a slightly different protocol for doing this.

As I was wondering how to present this information, I came across a cool mindmapping tool. So I created the following schema of the Logical Flow of a Physical Exam using

The problem is that the site is transitioning to beta and is very very slow! Also if you use the beta it does not let you share the mind map or embed the code. So here it is in its slow but still glorious 1.0 form (Click the - sign in upper left to zoom out. Click and drag to see different elements, to see the full size, click the read only link at the bottom):

If you want to check it out on, here is the read only link

Monday, November 16, 2009

What EMRs can learn from Twitter

One day I got a message in the EMR from a consultant cardiologist. This was a patient I had sent to the cardiologist after a positive stress test. The message said, click to review the consultant's note in the EMR.

I opened the note and saw an incredibly long note with results of every stress test, lipid, echo and cath done on the patient in the last 10 years pasted into the note. In addition there was even the informed consent statement prior to the cath included in the note. There was a note by the PA and then a note by the consultant buried in this morass of digital ink. It took me 10 minutes to find the consultant's assessment and plan which said to continue medical management. Apparently there was one small vessel that was stenosed and was not worth the risk of intervention.

Got me to start wondering if EHRs have caused us to lose our way; we have forgotten that the primary purpose of the medical record is communication. It seems that E/M coding and medico-legal issues are all that EHRs are being used for.

Can we save the EHR? What if we have a field at the top of each EMR note that allows only 140 characters like a Twitter update and each doctor has to populate this with a summary of assessment and plan before the note can be closed? E.g. "80% 1st diag, stable angina, not worth risk of intervention, recc aggressive medical Mx" This would still leave 53 characters to reach the 140 character limit! Could use this to provide a link to the actual chart note!

We could even make the poor Infectious Disease consultant happy. Every time someone copies and pastes their note into their own, there would be automatic attribution like a RT @IDdoc!

We could have a twitter like list of our patients that we follow and we can see tweets about them by all docs!
So what do you think? Any takers?

Sunday, November 1, 2009

Social Media and the balance between work, personal and social lives!

I have been struggling with this question, more so recently since I started spending more time on FB, Twitter, Second Life etc.
I find these Social Media sites to be terrific in several ways
  1. Learn a lot from Tweets by other people with similar interests whom I follow on Twitter
  2. Helps me keep up with updates in medicine, technology, education and combinations of these
  3. Stay current with friends and family efficiently and effectively - Friended Dad on FB so he can see my daughters soccer videos and dance performances.
  4. Learn about interests and hobbies of "friends" on FB - developed even more respect for them and got something new to talk about when we meet next
  5. Twitter helps me find and exchange ideas with an amazing group of people on the planet - something that I cherish more and more
  6. Learn techniques of communication - mutual respect, prompt feedback, sharing with attribution that I can bring back to live meetings
The question that keeps niggling in the back of the mind is "Is the time I spend on Social Media take me away for 'real work'?" Recognition in academic medicine is tied to research and publication in peer reviewed literature. I don't see medical schools promoting a faculty to full professor for the number of tweets, followers, friends in Twitter and FB anytime soon.

But why not?
One of the key parameters used in promotion is "recognition by your peers". So if your peers who work at other academic medical centers follow you on Twitter, it should help right?
When you post a blog and get comments from several followers, is this not a transparent peer review process?
If you do meta-analyses and you poll the twitterverse for unpublished studies, your systematic review will have less of the publication bias right?

As far as other "work" goes, I am on the social media committee for my institution and that blurs the distinction even more. Experience with social media has helped me suggest/develop solutions like
  1. Using Yammer and biomedexperts within the institution to help people find mentors and coaches - creating groups for each major competency or area of interest
  2. Creating a FB page for a non-profit physician organization to improve communication between members
  3. Using Google groups for our medical students to share information and resources
  4. Using Zotero for our medical students to collect evidence from their online assessment system and cite it when writing their ePortfolios
  5. Creating a Chronic Disease curriculum with students and selected patients communicating in private groups in FB/Ning
  6. Using Second Life to help students practice and learn history taking and communication skills in a non-threatening environment
  7. Etc.
On a personal/family level it has been incredibly gratifying.
  1. Pre-teen daughter picked up blogging as a way of journaling her thoughts and experiences. She has now gone on to help several of her classmates set up their own blogs.
  2. She learned with me how to edit and stitch together her soccer videos using windows movie maker and post on YouTube and share with her friends (private limited URL) - She had to select the "good" parts and eliminate the videos of "mistakes". This helped her to review her soccer skills and identify areas for improvement. (Sneaky heh? Hope she does not find this post!)
  3. Wife and daughter get invited to dance at various social events (e.g. weddings). Helped them create coaching dance videos and share with attendees before the event on YouTube. The people who saw the videos felt comfortable joining them for a group dance at the end of their performance!
  4. Found that wife and I tend to post news items of each others accomplishments on FB. Recognized that we value and respect each other more than we might have let on before! It seems to mean even more than telling each other - great job on that seminar or dance!
  5. Etc
Seems like a win-win right?
Still I think we still need to find a balance in our work, personal and families and computers and the Internet can be a challenge in this struggle. Used creatively social media might actually help solve the problem.

Before you jump headfirst into this, one suggestion - if you can, use 2 computers:
  • Computer 1 (AKA work computer) - turn off e-mail, FB and Tweet alerts. On that computer, make sure you don't visit any social media site. Use this for collecting and analysing your research data, writing your articles, completing your patient visit notes and other electronic health record tasks, etc.
  • Computer 2 (AKA SM computer) - keep several tabs open on your Social Media related sites. Google reader, Tweetdeck etc. also get used on this computer. Make sure to keep it on mute so you cannot hear alerts.
Then every 1-2 hours (or whatever works for you) when your mind is exhausted turn to computer 2 and have a refreshing, rejuvenating experience!
Does this work? Well seeing that I started doing this only recently and this is my first Blog in over a month, it seems it does.
So which computer did I use to write this blog? The work computer of course!