Learning Resource: Closing the Gap

For fourth year students interested in Emergency Medicine this is the time when most are finally getting to do EM rotations. There are a lot of objectives packed into these four week blocks. You need to figure out if this is really the kind of medicine you want to practice. You need to "audition", showing your aptitude and fit for EM, and secure letters of recommendation evaluation. You also want to start improving your clinical skills and getting some procedural experiences under your belt.  The latter is where todays post come in.

The scope of EM practice includes numerous procedures, including high stakes ones like pericardiocentesis, cricothyrotomy, and resuscitative thoracotomies. While you will learn to do these eventually, at this stage it will be higher yield to focus on the procedures that are more readily available, like wound management. You should get opportunities to do wound repair during your rotations and your future residency will expect you to arrive with some degree of experience with basic wound closure techniques.

The world of FOAMed (Free Open Access Medical Education) is overflowing with great resources for procedural education. The "Closing the Gap" site, lacerationrepair.com, is a particularly nice resource that consists of a set of videos and annotations covering the majority of wound repair techniques you need to know. Start with simple interrupted sutures, check out the corner stitch, and work your way through the advanced techniques, like layered closure.

Enjoy!

Got to Get Away (for a Rotation)

Now that you have picked EM as your area of interest, you need to arrange your year. The first step is your home EM clerkship. Ideally you want to rotate as early as possible.  Use this month to hone your skills, be open to feedback, and show how you can learn and grow as a clinician. This spring you need to find your away rotation. Your away is your opportunity to see a new spot, experience a program your interested in, and compare and contrast what is important for your learning. 

As with most of the residency process, you get out what you put in. First you need to do some legwork. SAEM’s clerkship directory is the best spot to look at regions, narrow your choices, and investigate programs. The map allows you to click on a state and view all the clerkships, with information about the individual rotations. 

Next you need to go on VSAS. This is the visiting students application service. You can use this to apply for the majority of clerkships. The site is cumbersome, so here our my top three tips:

1. Know the programs you are interested in first - you can review their individual applicant requirements. Rotations will have their own block dates, forms, and application timing. You will want to make multiple applications, in order to ensure you have an away rotation. Three to four should be plenty. VSAS has tutorials that will walk you through the process step by step.
2. "Patience Daniel son" - the process is slow but this is how to get the rotation you want. Many programs accept applications on a rolling basis and will notify you if you have a slot 6-8 weeks in advance. You can use the tracking option to keep an eye on your application process, and even change your preferences for rotations at an institution. 
3. Ensure you fill in all the forms -  there are a lot of forms but you need to complete them all. Incomplete applications will either fall to the bottom of the stack, or never even reach the clerkship director. If you fail to meet the requirements you will not rotate. The tutorial for forms is the most important to review: complete and upload them properly.

Some students are met with the dilemma of being accepted into one clerkship, while they are waiting for another to give them an answer. My advice is to take the bird in the hand. While it is tempting to wait it out, what is most important is that you have an away rotation. If you have done your research up front, each of your applications is to a spot you would like to rotate at. Be excited you have the rotation and get yourself ready to shine. If you only have time for one away rotation, let the other programs know you have accepted another spot and look forward to meeting them during interviews. 

So EM is right for you, now you need a plan….

So EM is right for you, now you need a plan….

Step One:
Rotations
You need to do a home and an away rotation in EM as early as possible. Read the link to get all the details about choosing the right rotation.

This will give you exposure, personal advising, and feedback. It is incredibly important to do two things: 1-recognize the feedback you get, 2- demand feedback you haven't gotten in real time.

• You will get feedback on every step, of every encounter - your job is to recognize it. While you present, notice what your supervisor does: glazed eyes = too much information, confused look = add details, fidgeting = speed it up. Every supervisor will want something different and you need to continually adapt to every one that you work with. Start with a formal, organized presentation, and then edit it throughout your shift to fit the non-verbal feedback you are getting. This article gives a great architecture to start with. 
• Next you need to demand feedback. You can ask at the end of your shift, but often you will hear "you did a great job." More effective is a proactive approach. Self reflect and decide what you need to work on, then at the beginning of the shift let your supervisor know what you want to work on today. This lets them focus on the area you need help in and immediately lets them know you are open and eager for feedback and want to improve. This also allows the supervisor to note how you incorporate feedback and feed this into your evaluation. 

Step Two:
Audition

You are auditioning, you need to put your best face forward. You want to present yourself, at your best every day, and in every interaction. You want to be the worry free student, always willing to help, looking to do more, and happy to put in extra effort and time. Don't ask for special treatment, special schedules, or lots of days off. Don't call out unless you are seriously ill. Don't show up late to lectures because you stopped for breakfast.

As Amal Mattu says "be a Tigger": show up with a smile, positive attitude, and energy to spare. Be the person everyone wants to work with, especially the nurses and techs. Always be respectful, professional, and appropriate. EM tends to be a casual atmosphere, but resist the urge to be too casual. It is easy to step over the line when trying to fit in. Realize you are not in the same position as the residents or attendings and err on the side of caution. Be professional at all times. lean forward, look interested and acknowledge areas to improve.


Step Three:
The SLOE

You need to get your letters of recommendation. Your rotation is the basis for your letter, the more you can show the kind of resident you will be, the better your letter will reflect your abilities. The SLOE compares you to your peers. Your goal is to show your positive attributes and that you can grow and improve in 4 weeks. Set a time to meet with the program director and clerkship director, to discuss your interest in their program and get recommendations for your application. Set goals for yourself and meet them.

With these three steps you are well on your way to succeeding in your EM application

EM Mentoring 101

The biggest downside to seeking advice from a blog like this one is the lack of diversity of opinions.  Even if the author has tried to incorporate best practices from many sources, the info you get will still be filtered through their personal biases. This is why you need to seek out more than one opinion on the really big questions. A local advisor is going to be your ideal resource, so long as they are keeping up with trends in the Emergency Medicine application and match process. Another option is the SAEM e-advising program that can match you up with a faculty member from the region of the country you are interested in.

There are also web-based alternatives. One of the best I have yet encountered is the EM Mentoring 101 website put together by Christine Swenton when she was an EM resident at the UF Jacksonville program.  Back in 2012 she interviewed experienced Clerkship Directors and medical student advisors from across the country and collected their ideas and opinions into a one-stop site. Go have a look. I do not think you will be disappointed.

SAEM 2014 for students and residents

The Society for Academic Emergency Medicine (SAEM) is holding their Annual Meeting in Dallas May 13 - 17th. SAEM has a reputation for being all about research, though it is more fair to describe the organization as being all about academics. Their Annual Meeting has a ton to offer the student considering a career in Emergency Medicine (and the resident thinking of staying in academics.  

From a student perspective, the big draw is the Medical Student Symposium and the Residency Fair that follows:

"May 16^th is the highlight for medical students at the SAEM Medical Student Symposium tailored for medical students applying to EM.  Panel discussions with current EM residents, roundtable discussions, and lunch with EM program directors will prepare EM bound students to understand the application and selection process."  

And here is the stated objective for the symposium:

Objectives:  The Medical Student Symposium is primarily tailored to medical students who have identified emergency medicine as their future specialty, but is also valuable for students still contemplating specialty choice.  The symposium includes presentations from seasoned EM educators, roundtable discussions geared for more individuated guidance, lunch with residency program directors, and a panel discussion with current EM residents.  Major themes for the symposium include the application and selection process. The program will be followed by the SAEM Residency and Fellowship Fair, providing students and residents with access to representatives from most EM programs across the country. 

At the completion of the session, participants should be able to:       
1. Assess their personal and career goals that might make EM a good fit.
2. Identify the multitude of career paths that exist within EM.
3. Optimize their fourth-year schedule.
4. Identify key factors and variables in selecting potential training programs.
5. Assemble a strong and compelling application package.
6. Perform their best during interviews.    

But wait, there is more. The SAEM Resident and Student Advisory Committee (RSAC), of which I am a member, has two events developed specifically for Emergency Medicine residents and medical students to provide opportunities to learn, network, and share ideas.  

1.  The RSAC sponsored Abstract Scavenger Hunt on May 14-16^th will allow teams of medical students and residents to seek out abstracts in the SAEM Program Committee Gallery of Excellence.  The mission is designed for participants to answer questions using QR codes with their own smart phones.  The team answering the most abstract questions correctly will win prizes including free registration to the 2015 SAEM Annual Meeting and gift cards to Starbucks and Amazon.  

2.  The Resident & Medical Student Reception will be held on Friday, May 16^th from 5:30-7:30 following the Residency and Fellowship Fair.  This event for medical students and residents is a great place to network with colleagues from across the country while mingling with leaders from SAEM committees and taskforces as they highlight opportunities for medical students and residents to become involved in Emergency Medicine at a national level early in your career.  (Including Ultrasound, Simulation, Women in EM, International EM, Social Media, Membership, Program, Ethics, and more) This reception, only for medical students and residents, is sponsored by ECI who will provide free drink tickets at their booth in the exhibitor hall. 

Both events are free and open to any resident or student attending the meeting. 

If you can make it to Dallas, I promise it will be worth the trip.  

How to use this blog...

EM Advisor is a blog whose purpose is to collect resources and advice that are valuable to medical students interested in pursuing a career in Emergency Medicine.

The blog has a simple construction:

Pages
These are static resources intended to guide you through the process of choosing and matching in EM.  These are periodically updated with the best advice we can find.  Examples of topics covered are: Is EM right for me?, Preparation and Expectations for EM Rotations, and a whole series on the application process covering everything from "Where to apply" to "what are Red Flags".

Posts
These appear periodically on the main page and are intended to be a catch-all of information for students considering Emergency Medicine.  Some are advice posts: How competitive is your application?, How to give good presentations, How to get procedures.  Others are recommendations of learning resources found in the world of Free Open Access Medical Education (FOAMed): the Flipped EM Classroom, EM Basic podcast, Academic Life in Emergency Medicine blog, to name just a few. The application process in EM is a cycle, so some posts provide timely (hopefully) updates and reminders on topics like Interviews, Rank Lists, and the dreaded what to do if you don't match.

The advice and suggestions found in this blog are by no means definitive. What is presented here are the opinions of a small number of EM educators.  However, we do attempt to represent the commonly held opinions and consensus recommendations from the members of organizations like the EM Council of Residency Directors (CORD) and Clerkship Director's in Emergency Medicine (CDEM).  

R.E.B.E.L. EM and the Importance of Airway

In this brave new world of FOAMed one of the big challenges is vetting which sources of information are worth following. The work of Salim Rezaie (@SRRezaie) on his R.E.B.E.L. EM blog, should be a a must read for anyone trying to keep up in EM. He is a prolific contributor to #FOAMed with recent posts exploring the need for an insulin bolus in DKA and what actually matters in post-LP headaches.  But the one that prompted this long over-do "shout out" was a review of preoxygenation and apneic oxygenation that you should go read right now.

Your communication skills are probably those most critical to your overall success in medicine, but you can argue that airway skills come in a close second. If you train at an ACGME-approved residency program in the U.S. you will be required to perform 35 intubations to meet requirements.  Ask any Emergency Physician and they will tell you that 35 is just the beginning. Real competence likely happens somewhere around "triple digits". 

You have to start somewhere, and early in the development of your airway skills you are going to need some extra time to figure out where you are and what you are looking at.  These techniques for maintaining excessive oxygenation during the peri-intubation period are good for the patient and great for your chances of completing the intubation. The FOAMed world is full of wonderful Airway resources, and R.E.B.E.L. EM is a good place to start.  

Also see this primer on intubation from The Short Coat by Lauren Westafer (@LWestafer) and this lecture by Rich Levitan posted on the EMCrit blog by Scott Weingart (@emcrit).