Latest news with #MacGyver-like
Otago Daily Times
28-05-2025
- Health
- Otago Daily Times
Med school training great then and now
While many things about the training at the Otago Medical School may have changed over the past 150 years, many things remain the same. John Lewis compares the training of a doctor who graduated from the school in 1965 with that of a doctor who will graduate later this year. Pete Strang describes himself as a "strange specimen". He's not your typical doctor. In fact, he would make a great lead character in a medical drama, about a MacGyver-like doctor who can do Caesarean sections, using nothing but a sharp stick, a torch and some gaffer tape in the back blocks of third-world countries. Some of his experiences, working in remote parts of Papua New Guinea, are not that far off such a story line — minus the sharp stick and gaffer tape. And the reason he was able to do it was because of the fantastic training and medical connections he made while studying at the Otago Medical School. His reason for becoming a doctor was so he could do medical missionary work and, when he graduated from the medical school in 1965, everything he did was geared toward that dream. Over his 40-year career, he has worked at some of New Zealand's main hospitals, been a general practitioner, a psychiatric registrar at Dunedin Hospital and, more latterly, the director of Student Health and Counselling at the University of Otago. Interspersed with that was a significant amount of missionary work in places like the Papua New Guinea highlands and the Solomon Islands. His training at Otago had given him the skills to do medical wonders with relatively little equipment — a risk many modern doctors may not be so keen to take, he said. "There was a massive investment in anatomical knowledge at med school in our day. "I suspect with the advent of scans and so on, the emphasis these days has shifted more to the analysis of scans to work out what is happening inside. "X-rays were very helpful for us, but you still had to imagine much. "Things tend to be a bit more concrete now and somewhat sorted. There is more of an emphasis on specialisation now. "I am a strange specimen. I have done many Caesarean sections by torchlight in Papua New Guinea because of power failures — there was no-one else to do it. "I have given thousands of anaesthetics and used gases, intubation, muscle relaxants, and spinal anaesthesia. "GPs, as a rule these days, don't do anaesthesia. That is a specialist area. "I was also doing acute abdominal surgery, laparotomies, removing bits of spear and arrows as well as bullets from people, but that again is not a GP area." He said he often had a textbook out in front of him, to help him do surgery that he had not done before. "I also was on the radio a lot, getting advice from specialists, sometimes as far away as Auckland. "Plastics and burns were frightening, especially in children who fell into fires and needed skin grafts. "The help from specialists far away was fabulous — colleagueship was very, very important. "It may be feasible to do these things in a more sophisticated society, but not in a war zone, or in the developing world." By comparison, trainee doctor Yuvraj Sandhu, who will graduate from the Otago Medical School at the end of this year, said he, too, was also aiming to work in emergency medicine but prehaps without the risks that Dr Strang was forced to take. Mr Sandhu said he and his fellow students still practise procedures on each other, but he believed the things they were allowed to do to each other now, "are a lot tamer than back in Dr Strang's day". "We learnt how to put our very first intravenous cannulas in and take bloods by practising on each other. "Then we moved on to patients. But it is very limited to just that. "Any kind of procedure that might be deemed too much more invasive than a needle going into the skin is something that us, as medical students, will probably not practise on each other." He recalled how daunting it was, trying to put the needle in the right place. The thought of harming a patient is a "scary one". Dr Strang said in his day, they used to practise on each other a lot. "We would have a superviser to make sure we were not going to dislocate a shoulder or other joint. "There was a 'reality' about it." Mr Sandhu said today's students were taught a lot about practising "evidence-based medicine", rather than the more "textbook-based" learning in the internet-free era. "Medical knowledge at present is estimated to double every three to four years, which is insane to think about." While there have been many changes in the way medical students are trained at the Otago Medical School, many things remain the same. Mr Sandhu said what made Otago so special was the student culture that came with being there and having a hospital that prided itself in being not just a healthcare provider, but also a teaching institution. "What's meant the most to me are the friendships and relationships I've built. "Coming down to Otago as the only student from my high school was daunting, but the people I've met have become my best support system." Dr Strang agreed. He said the relationships and support network built during his time there remained a good source of support and information throughout his career. "The most memorable thing about training at Otago Med School was the companionship and support from fellow students — both in work and in play. "My closest friends were all climbers, and we were away climbing a lot. "It was a wonderful release from our study, and we had an understanding that if we got more than a C pass on an assessment, we had not done enough climbing/mountaineering ... and we were climbing very seriously." Both said the special feeling a doctor got from helping someone in need had also remained over the decades. Mr Sandhu said speaking with patients during some of the most significant moments of their lives was an honour. "Whether it's being in the room when a baby is born, or with someone in their final moments, it's incredibly humbling. "I went into medicine wanting to help people, but I never realised just how much impact you can have, even as a student. "Just talking to someone, making them feel heard, and learning from their stories has made this journey all the more meaningful. "I've come to believe that kindness is one of the greatest strengths a person can have." Dr Strang and Mr Sandhu are among more than 300 doctors from around the world who have returned to Dunedin for the Otago Medical School's 150th anniversary, which starts today. The event celebrates 150 years of medical teaching, clinical training, research and innovation across the three University of Otago campuses years of medical teaching, clinical training, research and innovation across the three University of Otago campuses — Dunedin, Christchurch and Wellington — with a range of events, including academic sessions and tours of the present facilities. It will also provide the perfect opportunity for classes to reunite and remember what the students got up to.
Medscape
13-05-2025
- Health
- Medscape
Running the ED Like a Pro: Your Residency Playbook
This transcript has been edited for clarity. Robert D. Glatter, MD: Hi, and welcome. I'm Dr Robert Glatter, medical advisor for Medscape Emergency Medicine. Joining me today to discuss tips for success in emergency medicine (EM) residency is Dr Amy Ho, an emergency physician and also a member of Medscape's advisory board. Welcome, Amy. It's really great to have you join me. Amy Faith Ho, MD, MPH: Thanks again for having me, Rob. Glatter: Preparing for success in EM residency requires careful planning, especially in the age of a plethora of informational apps and digital technologies that we all know about. It also involves anticipation of the needs of patients, finding hacks to maximize efficiency, and most importantly, developing a great rapport with all members of your team and your emergency department. There was a recent Reddit thread that my editor, Anya Romanowski, had sent to me, and it brought back thoughts of our prior interviews in which you had explained MacGyver-like techniques as approaches to patient care challenges in the emergency department. I was hoping you could share a list of procedural and informational approaches and hacks to help ensure success for those entering EM residency, in the spirit of MacGyver and also the Reddit thread. One of the first things you and I had spoken about is that EM is a team-based have to treat your team well. I'll let you go from there. Teamwork Makes EM Work Ho: Absolutely, Rob. I love this topic because it's really the art and the style part of being an EM physician. You mentioned this is great for residents, but I think it's great for anyone practicing EM, not only residents and not only if you're new at a job. You're totally right. EM is a team-based sport. On the Reddit thread that you referenced, the number one tip was not something medical at all, but it was 'Definitely don't date your coworkers,' which I'll not comment on. I do think there is a large amount in terms of the team. Know who your team is and respect them. Introduce, acknowledge, and thank everyone, and try to learn their names. This isn't just your nurses and technicians, but also scribes, chaplains, the radiology technician, environmental services, and the police. There are so many people we depend on, and it means so much to acknowledge who they are. With that, it's not only acknowledging them, but also helping with all tasks. Nothing will fail you more in a department than the attitude of 'not my job.' Help roll and transfer patients, clean up if you have time, and always clean up sharps yourself from any procedure you do. That is just the fundamental safety point. Knowing Names and Pitching In Glatter: You mentioned knowing names. Obviously, we all forget names, but knowing someone's name is very personal. When you know their name, it makes them feel better and shows respect. It shows that you're focused, and I appreciate you pointing that out. Ho: Absolutely. Knowing what the team members bring to the table, being willing to help, respecting them, even learning parts of their trade and helping. Like I said, rolling, knowing how to turn off the beeping monitors and drips, getting a sandwich or a blanket for patient. It's really about being considerate. Glatter: It's not that it's not your job. Everyone pitches in, and when that happens, team building occurs naturally. Ho: As you build rapport with your team, you just start to know how you practice, you know how they work, and many things just become natural. One of my big things is doing sensitive exams for patients all together. As the staff get to know me, they know that if we're going to do a pelvic, we'll all go in together, we'll knock it out, we'll be done, and then the patient also only has to do it one time. Utilizing Apps Can Significantly Improve Workflow Efficiency Glatter: Moving on to apps. The number of apps is just exploding by the week and by the month. I would love to know what you think are the best apps going into residency, and for attendings as well. Ho: There are so many apps out I trained, we had numerous cards, which we would have on our badge tag, ready to use. These days, who doesn't have their phone on them at all times? Apps are only as good as you know how to use them. I've broken this down into the apps I think are key. One is MDCalc, because we are the specialty of knowing very little and trying to risk stratify. I think MDCalc is so core, but you have to know which tools you use and when. Second, I think you need one core EM app. There are many of them. There's EM-RAP Core Pendium, there's palmEM, and there's WikEM. I suggest to try them out, see what's natural to you, and then just commit to that one. Third is an electronic health record (EHR) app. For example, Haiku for Epic, It's key to your workflow for adding pictures, looking at the board, signing orders, and so on. It's also worth talking about artificial intelligence (AI) apps (eg, ChatGPT and OpenEvidence). We literally have intelligence at our fingertips now to ask any question of, 'Hey, what's the workup for X, Y, or Z?' Of course, do not share personal health information (PHI), but AI is really the future for references. Lastly, our special EM apps (ie, Emergency Ultrasound Handbook, epocrates for meds, UpToDate, Full Code, and Pedi STAT). There's a handful that might be really relevant to your practice. So, just pick which one those are and again, get familiar with them. AI Tools Are Becoming Integral in EM Glatter: Do you find that your residents are starting to use more AI right now in terms of that immediacy and being able to get answers? Are there too many hallucinations you're seeing from the AI in reference to, say, more specific things in EM, or more nuanced things that AI hasn't yet caught up to? Ho: Absolutely. I see residents using AI often. I think the big danger is that, especially if you are a new resident, you haven't built in the gestalt to be like, wait a second, that doesn't feel right . I do always say for anyone, but especially residents, take it all with a grain of salt. Anything that you're going to act on needs to be cross-referenced yourself manually to make sure that is actually true, and again, not a hallucination. I feel like, as an attending, having AI as a reference is great. I'll read something as a response and be like, yep, that totally cues . I just couldn't get it at the tip of my tongue . Efficiency Hacks: Templates Now, AI Tomorrow Glatter: You made a comment about discharge instructions that, if you're typing them in multiple times, you need a template. I'll let you expand upon that. Ho: I'm actually an informaticist as well as being an ER doctor, so I love efficiency and workflow. Anything you're typing or clicking more than three times (eg, discharge instructions), you need to save as a template such as RICE. Favorite orders or order sets with the instructionsand the dosing, you need to have saved as template. Same for things such as medical decision-making (MDM), if you have common differentials you always use for certain chief complaints, and for history of present illness (HPI), because we do ask the same questions over and over. I think all those just let you fly out of notes in like 60 seconds. Glatter: In terms of scribes, I don't know if you work with scribes or even if AI now is integrated into your EHR, but things are changing quickly. Scribes had been the advance in the last decade, but AI now is coming into the forefront. It's not ready for prime time in my opinion, but maybe 10 years from now there may be a role. How do you see the role of AI in EM as sort of a hack? Ho: It absolutely is a hack. I think it'll be faster than 10 years. I think in 3 years, we will all be using AI. I know many people using AI scribing platforms. There are ones that are released by EHRs. There's Abridge, which I think is one of the really common ones. Not only do they help you in terms of scribing, but they also offer you some MDM. They give you pearls to look for. You can customize them for cues for yourself. They're incredible and will likely be a key part of residency soon because you have to know how to use these tools. I will just say, please do not use those tools without the explicit approval and rollout by your hospital, because that is all patient data. Using Ultrasound to Engage Patients and Speed Diagnosis Glatter: You talk about using the ultrasound machine in the midst of doing a physical and multitasking in this capacity. Sometimes it's difficult to do, but what's your hack for doing that? How do you do these things all together? Ho: I love ultrasound, as do most EM physicians. I make sure that I actually do the ultrasound as I'm talking to the patient. They love it. I show them what I see on the screen, and it gives me some immediate answers on what's going if I see cholecystitis, I already know the answer. Staying Prepared: Keeping Essential Supplies Within Reach I think also keeping equipment nearby is key. In general, I always have a flush and an IV because you never know when you're going to do an ultrasound-guided IV. At the beginning of shift, I'll grab one of these big pink buckets and just fill it with the suppliesI think I might need. For example, bandages, if I'm working in urgent care area. If I'm working trauma, I'll have Dermabond and all the common things that I might want for that shift, and having it near so I can just grab it and go. Anticipating Needs: Preparing the IV for Seamless Care Glatter: If you spot a patient who has poor access, why not put the ultrasound-guided IV in ahead of one of the residents or nurses and just save time? That's an aspect of team building that I see working in the department. If you're going to go ahead and be proactive, that says something about you. Ho: Absolutely, and it's good for the patient. It decreases pokes and it is procedurally amazing for getting good at central lines, too. Fighting Anchoring Bias: Stay Open-Minded Glatter: In terms of anchoring bias, we have kind of fallen victim to this at times. It's hard to fight this. You think something is quite obvious, but it may not be obvious. How do you deal with anchoring bias, specifically? Ho: This was one of the arcs that I felt like I really went back and forth on in residency. There were times when I wanted to chart review everything before seeing the patient. There were times when I chart-reviewed nothing and just went and saw the patient. What I settled on is doing a really light chart review. I read the chief complaint, I look at vitals, I look at meds, and maybe their last office note. I already know that I might've been anchored by a nurse, especially an experienced nurse in triage, on how they write the complaint. So, I just keep that in my mind. If the patient says something that doesn't quite sound like what the nurse documented or what's documented elsewhere in the chart, then I try to explore that so that I mitigate my own anchoring bias. Avoiding the Nastygram: Staying on Top of Core Measures Glatter: I wanted to talk about nastygrams because you brought those up for the core measures. What's your approach in terms of avoiding the nastygram? Ho: This was always what I found most demoralizing. I'd work a busy shift. I'd feel great about seeing a sick patient, and then the next day I would get the nasty email from the quality department that said, 'Hey, you missed sepsis by50 cc.' It was soul crushing. It's really important to identify at your facility what those big core measures are that are going to get you into trouble, whether it's sepsis, stroke, STEMI, trauma, or open fractures. Those tend to be the big ones. Then I constantly think about it when I'm running my list. I look at the sickest, and then I look at the things that are in this nastygram bucket. Then, I look for all my other to-do's, things that will move dispositions, and so on. The Human Side of EM: Navigating Family Conversations in Crisis Glatter: How do you multitask and deal with a family member when you have a sick patient? Do you tend to bring in the resident or a nurse or someone from the social work team that could help a family when you're in the midst of a crisis? How do you nuance that? Ho: I'm with you. There's a large amount of nuance there. I do always bring a social worker, case manager, or chaplain to help because there's so much support that's needed. This is the human side of EM. We are not just 'moving meat.' We are really helping save lives and give support to families. There are some conversations where it really should take as long as it needs to take. Telling a family about a bad outcome is something where I actually give my phone to someone else before I come in the room. I tell them to come physically grab me if they need me, but I need to spend as much time as this family wants from me. There are other times when you are going to bounce between rooms. That is part of what you learn in residency, and you'll pick up what resonates with you as your style, too. Glatter: One of the things I was taught is that sitting down in a chair really helps, too. If you consult a patient in a chair vs standing, there's a big difference. Ho: Sitting in the chair is probably the number one tip we get from a patient experience standpoint as well. We do not always have chairs in emergency departments though, so I am known for sitting on top of trash cans often. Getting on the level of the patient or the family that you're talking to slows you down and puts you in the moment at a time when you really should be in the moment, Glatter: These are serious issues. If you spend that extra minute at their level, they feel something. Your energy is there, and that you're relating to them. That really is worth a mountain of gold. Ho: It's worth noting that we go into the ER every day, every other day, or whatever it is that our shift schedule is. It's normal for us to be there, but for most people, they probably don't go to the ER but maybe once in a lifetime. It is an extremely important, vulnerable moment for them, and you're the one that is supporting them through it. Documentation Is Crucial for Legal Protection and Continuity of Care Glatter: Are there any additional things you'd like to bring up that you feel that merit discussion at this point? Ho: Document well. Document what you said, document what the responses were, document what consultants said, their names, and what family members said. It's not only a medical legal thing, but it also is a document that you're passing on to the next clinician that sees the patient. For me, it actually helps me work through that thought process. Don't shortcut your documentation because of time. Sometimes it really matters. Glatter: What about copy and pasting? This has always been a big issue that I've faced. Obviously, it goes on. Medicolegally, there can be some aspects to this, too, because of things your recommendation? Ho: I usually do not copy and paste, because you run yourself into trouble. However, I do believe in templates. On those templates, I leave many clear blanks where I think I shouldcontemporaneously free text what it is that's happening. 'Note bloat' is real. Also, copy and paste is hard to review sometimes. If you are copy and pasting, maybe that information is not that important, and maybe it already exists somewhere else. So, I really like to spend my time on the free text part of it, such as the MDM, the real-time changes in emergency department course, — those sorts of things. Running a Smooth Procedural Sedation: Break It Into Pieces Glatter: One last thing I wanted to talk about is procedural sedation. We've all had a busy shift where we have a patient with sepsis, a shoulder reduction, or someone who's screaming in pain. We want to get them medicated, and we want touse techniques that maximize our time. We may not need a full procedural sedation. There are other hacks and techniques. Ho: Something like procedural sedation is the definition of a team sport because there are many moving parts. I try to chop these longer procedures into pieces. Piece one is getting all your orders, getting all the consents in, and all the medications. That can happen really anytime as you're running between other patients. Piece two is getting all the human resources together. That's when you're about ready to start respiratory therapy then x-ray after. We always forget about x-ray. Splinting, so maybe having a technician ready to help you in case you have to run out. And, obviously, nursing and pharmacy. The procedure itself doesn't take that long. You push medicines, you do your procedure, and you get your confirmatory x-ray. You splint them up, which you can have someone help with, but you need to be in the area in case there are any complications. What I do is I try to save my charting to come up to that point, and I'll grab a mobile computer or just be on the computer right outside the room and work on all of my charting. I still need to be within earshot and eyeshot of the patient while the nurses and the rest of the staff help them,as they're finishing up the splint, coming out with sedation, and those sorts of things. Ordering an X-Ray Remains the Standard of Care Glatter: Would you ever use ultrasound in place of x-ray to save time and confirm that the joint has been reduced? Ho: I actually do love using ultrasound, but I think standard of care is still an x-ray. For me, I personally still always wait for the x-ray. I make sure that I ask the technicians to be right there as I'm doing the procedure so we're ready to go with the board in place and everything else. Glatter: This has been an excellent tutorial from an expert like yourself who is very seasoned, efficient, really knows the hacks, the apps, and the ways to relate to patients. I want to thank you so much for joining me and sharing your knowledge. Robert D. Glatter, MD, is an assistant professor of emergency medicine at Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York. He is a medical advisor for Medscape and hosts the Hot Topics in EM series .
