FOAM(e) IS GOOD FOR YOU!

Just gave a talk on FOAM (or FOAMe as I spelled it) FREE OPEN ACCESS MEDICAL EDUCATION – an acronym coined by Mike Cadogan at the Dublin ICEM 2012 conference.

The legend will state that the idea of FOAM was borne over a pint of Guinness and, like Guinness,  – FOAM is good for you! [To view my Prezi  click here].

The concept of FOAMe came about because Mike felt that the term “social media” when used in an Emergency Medicine context tends to turn people off. This is particularly evident with older generation docs who are picturing some kid with skinny-ass-hanging-out-jeans Tweeting about Kim Kardashian. This is unfortunate, because, in so doing, these docs aren’t benefiting from engaging in this incredible online conversation.

So, like others, I am trying to be an apostle for FOAM … [and I can understand why Mike has found it challenging to speak about].

Why should we engage in FOAM?

• It’s free.
• It’s relatively easy to access
• Once you know how, it’s  an incredibly efficient use of your time.
• It’s created and curated by the avaunt-guard in your specialty.
• If you’re NOT doing it … you’re missing out.

I have found Twitter CLINICALLY useful. Additionally there is a constant conversation going on about emergency medicine that you really need to be a part of because guess what? YOU have something to share!

Why NOT to immerse yourself in FOAM?

• You’re a tech laggard.
• There’s too much stuff out there.
• You may have concerns regarding peer review.

Here’s my thoughts about your concerns.

My name is Nadim and I am a luddite. I learned how to have an online presence by being challenged by my peers – you can too.

There IS a lot of great stuff out there. If you just want to follow ONE thing -follow LifeInTheFastLane

Your concerns regarding peer review are valid. Most of the avaunt guard that are out there should have a profile that explains who they are and what they are about. The LifeintheFastLane folks have tried to catalogue some of the great-tasting FOAM out there [click here] … BUT Just like any Journal Article – you need to critically assess what you’re reading. In a short while you will sift through the stuff that you find useful.

I would go one step further and sign up for a Twitter account. Follow some of the folks on the LifeInTheFastLane link above. [Here's some rules on Twittering]

Don’t just take my word for it!

Here’s Anne Marie Cunningham’s take on why you should be a Twittering doc

Read Ronan Kavanagh’s blog [click here] -  proof that engaging on the Twitterverse leads to meaningful collegiality and collaboration across international borders.

Here’s Mike’s ICEM2012 Talk on FOAM hosted on the blog of one of my brilliant collegues Andy Neil [click here].

So get out there and sample some FOAM! It has the potential to transform the way you practice – at the very least you will have pushed your envelope a little bit.

Hot off the Pan!

BACKGROUND

The in laws were in town and required breakfast to support them on the long drive back to Calgary. A modification of a previously derived crepe recipe was used to sustain the subjects.

METHODS

The previously derived crepe recipe has been published elsewhere [link]. On July 22, 2012 between the hours of 8 am until 10 am two batches of crepes were formulated and fed to hungry guests [and spouse/myself  as the control group]. The first batch was made using the original crepe formula. The second batch was made using an adaptation of the crepe formula to make it more savory. This was achieved by adding minutely chopped cilantro and onion to the batter*. At their discretion, subjects chose from a selection of garnishes [Nutella®, locally produced Mango Chutney^ and locally produced Jalapeno Raspberry Jelly^]. All subjects received liberal doses of coffee.  The primary outcome was number of crepes consumed.  Secondary outcome measures were self-reported satiety and use of terms such as “fantastic” “excellent” “best crepes ever”. Additionally subjects were polled as to which recipe was their favorite. Subjects were followed up by telephone call at 7 hours to ascertain whether the crepe formula did in fact sustain them and whether there were any ill effects.

RESULTS

Both study and control groups consumed a statistically inordinate quantity of both batches of crepes. Subjects self-reported satiety reached “I’m stuffed” levels. Positive comments such as “hmm!” and “best crepes ever!” were too innumerable to count. There was no significant difference between recipes. One incidental finding was the cat jumping onto the counter and making off with a piece of original recipe. At follow up, subjects reported feeling full until Kindersley where they stopped for coffee only. No ill effects were reported other than mild cravings for the savory crepes.

Figure 1: Savory Crepes with locally produced garnish

DISCUSSION

We report the validation of a previously-derived formula for crepes in addition to a modified recipe. Both recipes were consumed in significant quantities and a high level of satiety and satisfaction were achieved. There were no ill effects other than mild cravings for the savory recipe. Limitations of the study include perhaps that the addition of good coffee and locally sourced garnish may have exaggerated the effects on satiety and satisfaction. Further research should include a subsequent validation at a later date with the addition of a wider variety of garnish.

Acknowledgements

* Cilantro and  Hestia’s Organic Flour both sourced at the Saskatoon Farmers’ Market

^ Also sourced from Saskatoon Farmers’ Market  – Premala’s Mango Chutney and Grandora Gardens Raspberry Jalapeno Jelly

Tagxedo Word Cloud Maker

Just discovered a new Word Cloud website called TAGXEDO [link] … try it out!  The above cloud represents our curriculum for the U of S FRCPC EM Program

Show me a PICTURE and let me LISTEN to your words

from sloanreview.mit.edu

It’s new resident week. One of the talks given was about making great presentations by my brilliant colleague  Rob woods  … Read on to learn from his wisdom.

Why do you need to give a good talk?

We’ve all gone to conference talks that make you want to sleep, only you can’t because you also feel like poking your eyes out…and you can’t just get up and leave because the ushers made you sit in the middle of the row and the rows are so close together you’d be “excuse-me”-bumming your way out for like 5 minutes!!

Why would you inflict that one someone else??? It seems obvious, but generally you’re trying to teach someone to go out and do things right and avoid falling into traps. For you to “make it stick” you need to communicate effectively.

Why talks fail?

We don’t know how to teach effectively – no one ever taught us this.

We do not know how to use presentation software effectively. Additionally, Powerpoint sets you up to fail because it all about text. I prefer Prezi [read more].

“A picture is worth a thousand words”

Even when we know a bit about effective presentations we often try to do too much with our talks [when we have limited time]

… hopefully these few pearls will help you to do it right.

1. Request the Deets

When are you giving the talk? This will allow you to “reverse plan” your deadlines [lit search, creating presentation, editing and rehearsing etc]. Here’s my earlier blog on effective time management [click here]. Anticipate spending about 20 hours designing your talk.

Who is the Audience? How many people will attend? What is level of training of participants? Are there multiple specialties/levels? Will there be any ‘hawks’ in attendance?

Knowing these ‘vital signs’ will allow you to decide about the content and the depth of information and allow you to anticipate questions from the keen-eyed hawks.

What is the goal of the presentation? Who asked you to give the talk?  Do they have a list of objectives to be covered?  If not, think what you would want to know if you were to attend your own talk?  If there are people of different professional backgrounds, poll them to find out what they need to know.

Okay … you’ve got your timeline, vitals and objectives – ready to boot up your Powerpoint? NO!

2. Restrain yourself

Giving a good talk entails way more than just regurgitating content in a confident fashion. One of the biggest faux-pas is to get an article from Uptodate and use the old “cutn’paste techinique”. If you do this you’re already violating the “dual channel rule” [read below]. More importantly … the content needs to be brokered. You do this using Restrained Preparation

Generally you’ll only get a 1-hour time-slot… this means that you’ll need to limit your content. Being concise means that you’ll need to pick 3-5 things/controversies/ practical questions.

Create your handout. It is important to develop your content BEFORE you open up power point or any presentation software.  You need to know WHAT you are going to say, before you figure out HOW you plan to best convey that information.

Contrary to what most of us have experienced a handout is NOT a copy of your power point slides or a photocopied article.
R.W.

A good handout is an organized outline of the content – the “Coles Notes” if you will.  The handout should be made PRIOR to making your slides.

Do your Homework: Good fodder for Emergency Medicine content can be obtained via Pubmed, Academic EM,  the Evidence Based EM book. Here’s a link to my fav EM Links . If you’re still stuck … talk to colleagues and consultants about the common pitfalls, any controversies or any new developments around the topic. Vet these ideas with the person that asked you to give the talk.

Okay … you’ve requested the details and practised restrained preparation. Now it’s time to create the presentation and prepare the delivery. A couple of important influences went into creating the pearls below [and need to be acknowledged]:

Firstly: If you’re not listening to Rob Rogers – you should. Here’s a link to his FREE podcasts on Medical Education [click here]. Scroll down for two great talks Episodes II and III on how to give a great talk (featuring Mel Hurbert, Amal Mattu, Joe Lex and Greg Henry).

Secondly: Kessler et.al.  Recently published a neat article “Qualitative Analysis of Effective Lecture Strategies” – you know … one of those articles that you wish you wrote? dang it!

Annals of Emergency Medicine, Volume 58, Issue 5, Pages 482-489.e7

Thirdly: Manuel Mah  – one of the Master Teachers at the University of Calgary once gave a presentation on Becoming an Insanely Great Presenter. Download it here.

3. Ready the Slides!

“Your presentation should be simple, memorable, visually attractive and interactive.  The slides are not the talk.  If someone were to listen to your talk without seeing your slides, it should still be easily understood.  The slides merely highlight your speaking R.W.”

Ever heard of the Dual channel theory of information processing? … Essentially – You have Eyes and You have Ears – when it comes to attending a talk … you can’t listen to speaker AND read text  on the slides at the same time. LESS WORDS MORE PICS

If you want your audience to read, shut up.  If you want your audience to listen to you, put up a memorable picture and talk. R.W. 

Visual Aids aren’t just gimmicks. They engage the audience. They allow the learner to compartmentalize the content. They allow the learner to focus on what you’re saying. The result is that they reinforce the concepts  and allow for more effective learning.

from johnpictonphotography.co.uk

Most of us are not Flash or Adobe experts, but there’s this INTERNET thingy that has loads of FREE Content. Use videos to show the “happy wheezer” child with bronchiolitis. Type in “Creative Commons” for non-copyrighted material. If something IS copyrighted – ask to use it – most people are okay with educational use.

If unclear – there is a generally accepted rule that 1) as long as you’re not profiting from the use 2) as long as the source is acknowledged – you are ‘fair dealing‘ in your use of media from the ‘net. [read more] (Thanks Andy Neil)

When laying down the content. Adhere to the Law of Repeated Exposure:

“Tell’em what you are going to tell’em. Tell’em. Then tell’em what you told’em.” [anon?]

Okay … you’ve got the talk ready. How do you deliver?

4. Rock it!

Malcom Gladwell in his Book Outliers - says that future success takes 10,000 hours. You probably don’t have 10, 000 hours to practise your talk [if you do  - get a life] BUT … the more you practise the better you get.

‘Amateurs practice until they get it right.  Professionals practice until they don’t get it wrong’ [anon?]

It is not enough to practice in your head.  You need to speak out loud, preferably to another person.  Pick a brutally honest family member – teaching something to a non-medical person will ensure that you can explain it to anyone.

Be your own tech support – Show up early and work out any projector/audio issues well before the start of the talk. Some MAC STUFF WON’T WORK ON A PC! [big surprise] … do a test-run.

If you’re using your own laptop … Bring your own laptop adapter.

It often helps to have every file (pic video, article) in a folder for that presentation.  Drag the entire folder from your USB to the desktop.  This ensures all files will actually appear in your presentation software.

Make sure there’s appropriate lighting. “Mood lighting” will anesthetize your audience.

Dress better than your audience  – at least 10% better than your audience (or 80% better for exclusively Emergency Physicians).

No apologies! – The audience expects you to be the expert … making excuses 1) shows weakness 2) sets the expectation of a weak presentation.

Use non-verbal communication to be more engaging.  Face the audience, get away from the podium (stand on the audiences’ left side of the screen – people read from left to right, so if you stand on their right it makes them feel uncomfortable), make eye contact and speak to the audience like they are one person.

Ditch the Frickin’ Laserbeam! Using that little shaky red laser is also a sign of weakness. Lose it!

SPEAK UP … SILENTLY! Speak in a voice slightly louder than your usual voice and use hand gestures and facial expression to emphasize what you are saying.  Don’t be afraid of silence. If you ask a question and people balk … stand in front of them make eye contact and wait – they’ll speak up!

It’s a natural tendency to insert  “um” and “er” into you speech … this reduces the effectiveness of your talk. Silence is better. Pause often. Sip water.

Always have the Last Word - FACT: Some people who ask questions just want to hear their own voice. FACT – if this is the last thing people hear, it reduces the effectiveness of your talk [and violates the Law of Repeated Exposure]. Don’t let this guy have the last word – Questions should be asked and answered BEFORE you present your summary slide.

5. Reflect and Revise:

No-one becomes a good speaker overnight. It actually takes trial and error.

Read your evaluations. These are good fodder for change. Reflect on the comments and how the talk went. “Oh I wish I had more slides on …”.

Anytime you come across new stuff that should go into your talk … keep this new stuff in the folder for your talk.

Offer to give the same “canned talk” again at a future date.  If you have reflected and made some changes, the 2.0 version of you/your talk will be infinitely better than the 1.0 version.

Okay got it? Any Questions? … NO?

Summary:

courtesy Dr. Rob Woods

My Homework:

Take that ATLS talk and RobWoodsify it!

Conversation on Having a Moment of Silence

Just wrapped up my poster session at ICEM2012. I managed to poll the audience about our survey [get it here]. People I spoke to came form all over the place [Hungary, Finland, Nigeria, South Africa, UK, Ireland, USA, fellow Canucks and even Israel].

Guess what? NO-ONE has a standard policy on taking a moment of silence to acknowledge those that die in the ER. BUT … all thought that it would be a good idea. I even accosted the convention staff and got their opinion as a non medical person!

Even more interesting were the responses of what gestures people DO perform:

Northern Ireland – Open the window so that the spirit can depart

UK – hang a large hand-made butterfly on the room door so that people know to be respectful

UK – pennies over the eyes

Comments I got were overwhelmingly positive. There was one caveat about forcing religion on a patient without family consent [but a simple moment of silence is non-denominational and shouldn't arouse tension].

Nevertheless I think that I started an important conversation. That’s what research is about – getting ideas out there.

Acknowledging Death in the ER

From the NY Times article cited below

Picture the following:

A resuscitation is in progress for an elderly gentleman. Health care providers try frantically to restore signs of life. Chest compressions are ongoing, a breathing tube is placed, large intravenous line inserted, electrical shocks and medications given. Eventually the team realizes that they have exhausted all possibilities. To do more would be futile. The team leader “calls the code”.  People mill away … one resident chides another about stealing her central line. The housekeeping staff enter to clean up the mess on the floor while the orderlies drape the body for viewing. An elderly emergency physician stands contemplatively at the bedside for a moment. He nods his head and then walks out. What was that about? Was he praying? Was he having a moment of silence? Should he?

I had to re-learn how to think of my patients as people after a crazy night in the ICU. We had tried in vain to salvage a not so old man with fulminant pancreatitis and all the complications you can think of. He had no immediate family and died quietly in the ICU surrounded by me and the bedside nurse. Exhausted, I went back to my call room and early in the morning the nurse called to tell me that she had located a distant relative. “You know that guy was famous?” she said ” … he used to coach (insert former World Heavyweight Boxer of renown)”. Wow! … To me he was the patient in bed 9 that we had tried in vain to salvage from the brink all night. Sure he had a name, but not a story – or at least I never considered what his story was. I reflected … What happened to the idealist that got into medicine all those years back? When did he stop feeling? How did it happen?

Around about the same time I read an article “The Code” in the NEJM by Treadway and was struck how many times I had been that character that she describes in her article. In her article Treadway laments the fact that health care providers walk away from codes without pausing to reflect and acknowledge the deceased. They do so for many reasons – mainly because they need a certain level of detachment in order to perform their jobs. In medicine we learn this detachment by early on focusing on anatomy and pathophysiology rather that humanness.

Why detachment is bad:

You may think that you’re compartmentalize and coping, but in truth you’re accruing mental baggage that affects your overall well-being. In our study 51% of respondents had been involved in at least 15 unsuccessful codes. Think about it …How many people do you know who have watched 15 people die? You think that doesn’t scar you in some way?

Here’s an article from the NY TIMES that describes how oncologists struggle with the death of their patients. They distanced themselves and withdrew from patients as the patients got closer to dying – behaviours, the authors point out,  that are most unhealthy, but exist because of the expectation of a stiff medical upper lip. According to these authors,  here’s the kicker:

“The impact of all this unacknowledged grief was exactly what we don’t want our doctors to experience: inattentiveness, impatience, irritability, emotional exhaustion and burnout.”

Providing dignity in death:

When asked how they would like to die – Canadians are unequivocal. Most prefer to die at home in comfort, surrounded by loved ones. In truth almost 50% of people in this country die in hospital – and some of them in the ER – alone, naked, undignified and surrounded by strangers who are oblivious to their life story.

In this journal article, Rohrich muses how quickly our life’s work can fade from record and shares how he would like to be remembered during his “moment of silence” – why should we expect differently from our patients?

In truth many ICU’s and palliative care wards do go to lengths to accommodate spiritual and cultural requests to provide solace and dignity in death – but there are several obstacles to providing this in the ER.

Towards a culture that favours reflection:

What if there was a way to restore a bit of dignity to those dying in the ER? What if there was a way to replace some of the lost idealism? Treadway suggests that we might consider honoring the life lived [and lost] by having a moment of silence after unsuccessful codes. Fantastic! But how do you go about introducing such a practice that flies in the face of our learned unemotional detachment? Start with a lit search … surely someone else has looked into this?! Turns out no one had – until we did.

We created a questionnaire and sent it out to all our ER staff, residents and allied health professionals. The responses [42% response rate] that we got affirmed that health care providers DO in fact perform a quiet gesture after death in the ER – almost 50% of the time. What’s more – most [70%] thought that it would be a good idea to have a moment of silence – for the patient, the families AND for their own benefit in terms of closure. Most thought that a script could be an option [e.g. "please let us have a moment of silence for Mr Smith"] and that the code leader should be the one to initiate the moment of silence.

What’s next? I am off to ICEM in Dublin Ireland to present this research. I hope that I come away with some ideas about how to implement it [comments welcome]. I would encourage all you readers to start this conversation and see where it goes. Because as Treadway states:

“Perhaps if we could discuss this part [death] of our practice lives as easily as we discuss a diagnostic dilemma or the proper management of a complex case, we might create a culture that supports and nourishes us as we try to come to terms with experiences that are part of our daily lives.”

Nothing is for free in America – or is it?

from http://radiopaedia.org

In the era of Intellectual Property and making a one billion [insert Dr Evil pinkie finger in corner of mouth] dollars of your amazing idea … an ER doc [and medical student with and engineering background] on a little city in Canada invented something and gave it away for free.

EDUS2 is a way to create a virtual ultrasound to use in simulation cases. This is amazing in terms of increasing the fidelity of sim cases. It’s an innovation that 100% of people out there [including myself] would have tried to make money off. Paul and Paul decided to let others have it for free

What? There’s a catch right? … No…No catch. The EDUS2 blog [click this link] describes the evolution of their idea and how they came to give it away. Knowing Paul O. and speaking to him he is deeply passionate about EDUS and felt that this is too good NOT to share it freely and widely with anyone who wants it.

These guys in Australia describe their experience [click this link] with creating their own version. Even with a free road map, they found challenges and obstacles that highlight the barriers that exist when trying to innovate in healthcare.

Kudos to Paul and Paul for bucking the trend with their incredible invention and even more incredible philanthropy.