AMA with Anand Swaminathan, MD (@EMSwami)

Welcome everybody to Ask Me Anything with Anand Swaminathan, MD, MPH (@EMSwami). We’re live now – type in your questions below!

Thanks for having me on AMA. Excited to take any questions you have. If I don’t know the answer, I’ll make something up.

Chris, great question. Not an easy answer. I recommend starting by exposing them to a “Why FOAM” talk. Chris Nickson has a great one on LITFL http://lifeinthefastlane.co… and Joe LEx gave a good one at SMACC in 2013

I don’t think you should pick one platform but use all of them. Twitter is great to get tid bits and interact with the FOAM community

blogs and podcasts are wonderful for using for flip the classroom endeavors for resident education. Check out the ALiEM project on getting asynchronous credit for FOAM – http://www.aliem.com/new-ai…

Also, check out the very FOAMy Emergency Medicine Australasia articles on how to FOAM http://onlinelibrary.wiley….

Full of tips on how to get started with all of this

Hey Ryan. Great to hear from you. As a father of two (6 and 3) I’ll tell you that you’ll regain productivity when they turn 18.

Good luck, use Happiest Baby on the Block (saved my marriage)

Alternatively, you can read them one of my posts. That should put them to sleep.

Oh Alex, you know just how to make your guests feel loved.

Great question and no good way to answer it but I’ll try.

1 – Antibiotics for the treatment of strep throat in developed countries. More harm than good. Just stop it. Give them steroids and NSAIDs to make them feel better.
2 – PCN Cephalosporin cross reactivity is 10%. I want to get rid of this one simply to not get the pharmacy call every 10 minutes. 1st of all, most people who say they have a PCN allergy don’t (only about 1-5%) and the cross reactivity is similarly low.
3 – Orthostatic measurements are useful in determining fluid status. They’re not. No evidence to defend this. Check out this quick video – http://lifeinthefastlane.co…

This is tricky. I may piss someone off if I leave them out.

Let’s do this based on straight up medical knowledge that I can use tomorrow (or actually tonight since I’m on the overnight) in the clinical realm

1. EM: RAP – I know, I’m just shilling cause I’m on it but really wonderful program. This is also where I first started to learn about non-traditional sources for education back when I was a resident. The old episodes hold up too. Check out the Corey Slovis talk on electrolytes from 2008 (I think). Classic episode.

2. Amal Mattu’s ECG Video of the Week (http://ekgumem.tumblr.com/). Wonderful free resource. I have learned more about ECGs here than anywhere else. Clearly, ECGs are a critical part of our practice.

3. Academic Life in EM (http://www.academiclifeinem…) – Tons of stuff you can use that day in clinical practice. Never boring, always short and sweet.

4. EMCrit (www.emcrit.org) – I’m a critical care junky who couldn’t do the fellowship so I use this extensively. While many of the more recent podcasts are on cutting edge things that I don’t do, the old ones are on classic topics in critical care that you can use all the time. I don’t think I really understood vents until I heard Scott’s series of podcasts. Same with acid-base stuff. I relisten to these all the time as well to make sure I haven’t missed things or refresh my memory

5. Life in the Fastlane (http://lifeinthefastlane.com/) – this one’s a cheat since it’s my 5th. Why is it cheating? Chris and Mike bring the FOAM world together in one place. It’s genius. I get recs on all the best stuff from these guys then I can go out and read it all. Great resource for clinical practice.

Just to close up the question, there are tons of other resources I use every day. I have recently fallen in love with St. Emlyn’s site. There podcast is really for the uber-nerdy EM people but Simon and Iain have a great way of making difficult concepts manageable for anyone. Same goes for anything with David Newman.

I’d also be remiss if I didn’t mention ERCast. In fact, one of my favorite, I use every day concepts comes from Orman’s discussion of PT/INR in liver failure. Wonderful stuff.

Conflict of interest here but I think REBEL EM is a wonderful site with great pearls and evidence based dissection. Love the Skeptics Guide to EM podcast from Ken Milne as well.

And of course, you have to use emDocs.net, right?

Really tough question. Just got clarification on the question
“For the residents who are tough to teach, how do you work around this?”

I think you have to first start with “why are they tough teach?” We have to assume that most EM residents are smart. Residency spots are competitive now and these guys made it through a four year college and medical school

Is the problem that they aren’t being challenged?
Are they having outside problems?
Are they not feeling engaged in the curriculum?

It helps to know where they are not succeeding. Is it clinical or academic?

Tough to teach clinically is sometimes because they may think they know more than they do. This may be the hardest to remedy because it reflects on the residents over-inflated ego

The longer I do this, the more I realize I don’t know and that’s not just a line.

It’s vital for residents to know what they don’t know

One thing I do when residents demonstrate this behavior is to try and show them how little I know. I ask them to teach me something. Doesn’t even have to be medical. Can be outside of the clinical environment as well.

This is basically modeling the behavior I want them to have.

What about the one who’s struggling academically? This is rather easy. You sit them down and find out what they are doing on their own to learn. What are you reading etc.

Often, what I find is that they are overwhelmed by the options or no one taught them how to identify what to read

We often say that residents are adult learners and they should thus, they can direct their own learning. This is somewhat false. Throughout highschool, college and medical school, we are spoon fed information. We are told what to learn and how to learn it

We shouldn’t all of a sudden expect the residents to know how to do it. We have to empower them. This is part of the challenge of residency education. To teach doctors to be independent learners

Back to the question. For the resident struggling academically, I sit down and try to identify resources that will work for them and have them build a curriculum with me to guide their education.
I meet with them every couple of weeks in the beginning to see how things are going and then set them free

I hope this answers some of the question. The main thing is to identify the underlying issue and then figure out how to fix it with the resident guiding you and you guiding them.

Old doctors

Alright, not that simple. Much of the problem is that the established docs don’t trust FOAM. They don’t completely understand it. In fact, I think some are threatened by it. Many of these guys built their careers and names over decades by going through the traditional peer review process and we are sort of cutting the line

I had the pleasure of attending a session at SAEM with Michelle Lin, Nick Genes and Jason Nomura. The panel centered on FOAM to tenure. An older administrator stood up and basically said it would never happen.

Can be very discouraging but I talked to Michelle afterwards and she said this:

2 years ago, that guy would have never come to this panel. Now he’s here. We are making progress

We are a young field that was built on rebels. The younger generation will embrace FOAM and force the change but it will take time. The Approved Instructional Resources (AIR) series on ALiEM is a good way to get FOAM in through things that residencies need.

The key is for us to keep pushing the envelope and challenging those older docs to look at the FOAM.

No. There is no ideal time. I had my first during my 4th year of residency when I was a chief and my second 2 years out of residency. It’ll never be easy

The key is to always prioritize family over career. You’ll always be happy for those choices down the line.

I often have to sacrifice time with the kids to work but I try to challenge myself to make compromises with work first. It’s a hard road.

I think the best way to do this is by modeling the behavior you want to see. Amal Mattu has a great talk on leadership (FOAM talk from The Teaching Course in April 2014). When you walk in to a shift, you must exude the feeling that you would rather be nowhere else. This inspires everyone to work to their best abilities

Same goes for residency education. I try to show the residents how much I read, how much time I spend educating myself. It’s important for them to understand that none of this comes naturally to anyone. The goal of being a productive faculty member must be obtainable

It also helps to encourage them to be involved. I try to spread projects among the residents so that they all get opportunities to produce in areas they are interested in.

This is tough. Senior residents have different expectations depending on what type of program you are in.

My shop is a 4 year where senior residents are treated as pre-attendings. Basically, they have all the same tasks as I do on shift.

In this set up, the goal is to strive to the level of the attending. See all the patients in your area, run the codes/trauma etc.

On a more general level, I try to encourage all residents but especially the senior ones to not fall in to the trap of making plans based on the preference of the attending working that day. After you work with people for a while, you learn to give them the plans they want to hear.

Instead, create the plan you want to pursue on each patient. When that plan differs from the attending’s plan, ask “why?” This is how you learn the nuances of EM and medicine in general. It’s also how you shape your practice of EM.

Beyond the clinical stuff, make sure to develop a continuing education curriculum for yourself. What are you going to read, what are you going to follow etc.

Thanks Chris. Shouldn’t make that assumption. Just had a 30 minute interview with Joe Lex who is clearly in the same boat as you.

The truly great ones in our field don’t ignore new things but determine how best to use them to get what they need.

Never easy questions with you, Ryan.

This is truly challenging. The easy thing to do is just roll over. If you do this, I don’t think anyone, including your own residents, will respect you, take you seriously or, more importantly, change these myths

I try to politely tell them why I don’t think what they’re asking for is useful. I discuss the evidence. This can be tricky as you really have to have a good grasp of it if you are going to try and educate someone else. I often will offer to email them the articles and they can read them on their own. I have everything organized so I can send this stuff immediately.

I’ve done this
a number of times with kayexalate in hyperkalemia and orthostatics and even antibiotics in strep

This often gets me what I want in the immediate situation because no one wants to sit and read the stuff on the spot and tell me how I’m wrong.

To make real lasting change, though, you need to get together with the other involved parties and try to actually make some policies. Sometimes a shared conference with IM, Ortho, Surgery etc can help.

We have done panel discussion with our trauma colleagues on these questions which has worked well for a number of issues.

If you truly believe the information you have is right, just say it confidently. That’s what goes the farthest in the clinical arena.

This is hard. Let’s take it one at a time

Promoting humanism is easy for me. I have wonderful role models (Lewis Goldfrank for instance) in my shop to do this. We often joke that when in doubt, ask yourself, “what would Goldfrank do?”

But not everyone gets to have Goldfrank around. Again, I think this comes back to modeling. If you show your trainees and staff that you respect all of your patients, they
will too.

Easier said than done, right? We’ve all made the mistake of dehuminizing someone for some reason or another. The bottom line is that this is rarely about the patient and much more often, it’s about us.

I start every shift by trying to put myself in the right mindset. Block out the peripheral issues of family, professional stuff etc. and focus on work. I keep in my mind not just what would Goldfrank do but what would I do if the patient’s mother was sitting next to them.

This goes a long way to humanize our patients and make it not about the disease but about a person

When I or someone else misses the mark, I think it’s vital to address it. I have apologized to patients before for my behavior. I have asked them what I can do to try and rectify it and I always ask them to hold it against me and not my staff.

For the trainees, I talk to them about it head-on. Why do you think you acted that way? What do you think caused you to respond/act in that manner? This has to be done correctly and not in a hostile way for it to work and for the resident to take something away from it.

Again, you often find out that there was something going on in that trainees life that had nothing to do with the patient but it came out that way.

Who says I’m not jaded?

I always remind myself that I chose this career, i knew what I was getting into and there was a reason I did it. I think about how my role models would respond, how they would address these feelings.

I’m lucky to have a wife who’s a psychologist so I’m finally starting to get used to talking about these issues a bit to her or coworkers. The comraderie of the ED really helps a lot.

This brings up the larger issue of mentors. The short is that you got to have them. And not just one. You should have many mentors for the many facets of your career and life. I’ve got at least 6 or 7 at my hospital and another dozen or so outside of my hospital.

FOAM helps with this a lot. I’ve met tons of great people who are selflessly interested in promoting my career. They are always available to help and are extremely generous with their time.

The main pitfall here is not reaching out and asking for help or whatever. The vast majority of the FOAM world wants to help and they love being mentors.

Part 2 of your question – when to say “no.”

I’ll tell you when I get there.

I made a resolution at the beginning of the year not to say yes to anything unless I also freed myself up from something else.

The resolution lasted 3 days.

Michelle Lin opened a new section of ALiEM today on “How I Work Smarter” http://www.aliem.com/michel…

She had some great points.

Always ask the question on new opportunities – “how does this fit in with what I’m interested in.” It’s also reasonable to ask the person how much time they think this project will take. These questions are helpful in figuring out if you want to take on the project.

Early on, you really have to say yes to most everything. This is how you build a career.

As you progress, it’s important to not only say no but to also off load things you took on that you are not interested in or are taking too much time. Find someone else who is interested and move the task to them

It’s really hard but vital skill to say no and off-load in order to keep your career moving forward and to produce the best stuff you can.

We’ll have to try and put a podcast together on this topic for iTeachEM. Effects every academic to some degree

Work on finding someone. Identify a resident or faculty member who is upbeat and has avoided the jaded thing

2nd year is often a low point. You’re working incredibly hard, you’re often underappreciated and bearing the brunt of the clinical load

Maximize your off days, find mentors and consider talking to a professional

Mindfullness is a big buzz word in EM right now. Mindfullness challenges us to determine the real basis of our feeling and address them (at least that’s the way I see it)

I try to use this to stay sane and balanced. I’m not a yoga guy but some type of meditation helps. I run every day and that’s my time to think and reflect and completely turn off (no podcasts or even music)

I hope this helps

Too many to count

We’ve all made mistakes or provided suboptimal care. Much of what we do is based on what we think is best at that time. The evidence changes, standard care changes etc.

There have been patients I sent home that in retrospect I would keep now in the hospital and vice versa. I’ve over relyed on my clinical gestalt and in moments of weakness, I’ve said things that I shouldn’t have.

The key in all of this is reflecting and then altering your behavior in the future.

If you’re looking for specific things, not sure I can give you that. Surely there are plenty of treatments that were recommended that are not any longer that I’ve used.

One that will always stick with me is a patient who got tPA for an ischemic stroke when I was a 1st year attending. He clearly had an ischemic CVA and was eligible by the hospital’s criteria but he had lots of relative contraindications.

I got railroaded by neuro and didn’t speak up. I should have counseled the patient and family about the other side of things but I didn’t. Needless to say, he had a bad outcome. ICH identified 30 minutes after tPA

I’ve never let that one go. Not because I don’t believe in tPA (although I’m not a big fan) but because I didn’t advocate for the patient the way I should have.

Question from twitter via Nilesh Patel (APD St. Joe’s in NJ)

If you are lysing a massive PE, what do you do with heparin? hold and restar . . . or continue?

Finally, something clinical. When I do systemic lytics for massive PE, I hold heparin. I’m not sure when to restart, though. Truth is that there’s a lot of conflicting recs on this topic. I don’t think we really know the right answer.

Weingart has a great podcast up this week talking to Oren Friedman from Cornell about PE teams and treatment that I strongly recommend checking out

It was fun and challenging.

I was very lucky to do it with two friends who are both in residency leadership positions now. I had gifted co-chiefs. We also all had our first kids 3 months into being chiefs which was interesting.

The great things are you get a taste of academics. How to build a curriculum, how to craft an educational plan. You get an insight into the inner workings of a residency. The interview process, the challenges that a PD deals with. It’s also basically an administrative fellowship. Managing 60 resident’s schedules, balancing personalities and learning to be in charge

It gives you experience and helps you figure out what you want to do in your career. I learned that I’m no administrator. I don’t know how to play politics and my expectations can often be too high. These lessons helped me determine my career path to this point.

Very challenging, especially within your own class where all of a sudden, you have a certain degree of power over your colleagues. I wouldn’t say I lost friendships but people who were collegial with me are not anymore after that year. That was hard

The greatest attack on EM training in peds comes from vaccines. If only everyone would listen to Jenny McCarthy, our peds training would be awesome

Just for the record, I’m joking. Vaccines rock. I ask for extras when I take my kids in

Outside of vaccine craziness occurring and just finding more sick kids, I don’t have great answers.

Simulation plays a role. It’s not the same as the real thing but many of us are working to figure that out. Stress Inoculation Training has a role here. Instead of doing sim or other training in a safe space, we have to challenge the residents by making the scenarios more real. Get that heart rate up, get the sweat poring out. This will make the sim training more useful.

I do a lot of visualization training as well. I walk myself through how I would approach a sick kid over and over again. You can actually create muscle memory this way and create cognitive pathways that will function when you need them.

Great question. This has been my challenge for the last 4 years as well.

The first thing I did was to cut lecture length. Nothing more than 30 minutes. Some 15 minute talks as well. Trying now to get in 5 minute talks.

Increase small group workshops. Mix in hands on stuff like simulation, anatomy lab etc.

This takes lots of faculty buy in but it works.

Bring in more grand rounds speakers. They give new takes on old i
ssues. If you get really engaging ones, the residents see the passion they exude which will encourage them as well

Feel free to email me and I can send along what we do and you can feel free to steal anything.

1 – look for the reason. simple non-compliance, infxn, MI etc. If no confounding issue and just noncomplaince . . .

2 – Urine dipstick for ketones

3 – VBG for AG

I used to just look for ketones and if not present, I’d stop. Unfortunately, you can have negative ketones on dip and still have a gap

If no gap, no ketones what next?

I restart the meds they are supposed to be on. I don’t believe in targeting a number before d/c. Similar to high blood pressure that’s asymptomatic.

The critical thing is arranging follow up to ensure compliance and further care

Lots of changes but not just for interns, for all learners. I still think it’s important
to read a text book or get the equivalent base knowledge from resources like EB Medicine.

However, I push more to incorporate podcasts, blogs, vidcasts etc into the curriculum. Shorter talks, flipping the classroom, more hands on, more small groups.

I don’t think it’s just a different kind of learner. We’re starting to understand how we should be teaching better.

I do it and don’t look back. We get similar complaints.

1st – there’s no evidence you won’t be able to diagnose compartment syndrome. This is like the idea that you can’t get an abdominal exam if you give a patient pain meds

I document a thorough neuro exam before I do the block. If there’s really a lot of push back, you can tell them that they can come and assess the patient in the next 5-10 minutes but that after that time, you will be providing regional anesthesia to the patient because they need it for their management. This is a reasonable compromise.

Again, though, establishing a policy is probably the best thing to do.

Establish a plan now. Try to think about what in academics you want to do and how to get there. Find mentors in house and out of house and pick their brains.

Try different things. You really won’t know what you like until you try it. I never thought I’d get into twitter, blogging or even podcasting. Try it all out

Tough to give advice when I wasn’t there. If the guy is hypotensive and the forearm is where the bleeding is from, I agree that I would wait and let them fix in the OR. There’s always the chance that there has been partial hemostasis from the dressing and that removing it will dislodge clot and cause further issues. Why not let that happen where definitive management can occur.

You always have to ask yourself, “what information am I going to get that’s going to change this patient’s management by doing X?” In this case, nothing you see will change management

We have time for 1 more.

EB Medicine is great and I have no conflicts. I’ve never written for them. I love it.

The problem has been figuring out what’s best to use and how to know what’s best.

I strongly encourage you to check out the ALiEM Approved Instructional Resources project. The team (many of whom are PDs and APDs) gather relevant blogs/podcasts designed to specific modules and then have a quiz to evaluate. Totally free and a nice place to get your program to buy in.

Thanks to everyone who did this. Have to go. Will surely do this again as it was very fun.

Send me any questions at my email (anandswaminathan77@gmail.com) or tweet me up @EMSwami

Thanks everybody for participating and a SPECIAL THANKS to Dr. Anand Swaminathan (@EMSwami) for taking the time to answer our questions. We hope to see you all again at the next AMA!