Stimulus – Learn Tools to Crush It in Your Medical Career

Do you work in medicine and love patient care but feel like parts of the job don’t measure up? Stimulus equips you with tools, mindset shifts, and strategies they didn’t teach you in training—so you can practice medicine like a boss, flourish in your career, and not let it crush your soul. Emergency physician and executive coach Rob Orman, MD, goes in-depth with thought leaders on how to avoid burnout, improve communication, lead without drama, and stay calm amidst the storm. Don’t just suck it up, think differently.

Latest Episodes:

ERcast turns 10. Failure, Growth, Choices, and Karate Jan 30, 2020

Show notes

In this 10th anniversary special, GFOP Josh Russell interviews Rob and digs deep into...

Failing at work
Finding the right job (and being honest about the wrong one)
Top Gun
Origins of ERcast
Why Rectal Foreign Bodies was the subject of episode one
Advice for young doctors
How failing a black belt test was a pivotal moment
Guiding principles
Memento Mori

This pod contains absolutely no clinical medical education. There is no CME attached to it.

The Moral Injury of Modern Medicine with ZDoggMD Dec 20, 2019

Show notes

Are we calling burnout by the right name? Some would say no, we should call it 'moral injury' because what we see happening in modern medical practice can be antithetical to our core values. In this episode, ZDoggMD is our guest as we examine moral injury, as well as dealing with the EHR, stress, universal health care, meditation, and much more.

Aim To Be a Zero Nov 30, 2019

Show notes

What does emergency medicine have in common with astronautics? A lot, it turns out. Dan Mccollum and Rob break down the skills learned by International Space Station commander Chris Hadfield as explained in his autobiography An Astronaut's Guide to Life on Earth.

Become a Full Member of ERcast Here

Pearls:

You can be a “plus one” -- someone who actively adds value -- without behaving like an arrogant person craving significance.
Avoid trying to impress others by showing off.
We learn much through adversity, when things don’t go well.
What we say matters. Critique a behavior, not a person.

The pitfalls of thinking too highly of yourself. [1:48]
On the importance of being a “plus one” and the wisdom of not proclaiming your plus-oneness. “If you’re really a plus one, people will notice”. [2:25]
Aim to be a zero -- having neutral impact. Observe and learn. Pitch in with the grunt work. Being a zero is a good way to get to plus one.[5:10]
What Mccollum looks for in EM residency applicants: people who treat the receptionist or program administrator well. [8:02]
Focus on the simple core things which are most likely to save lives, as opposed to shooting for the stars with cutting edge treatment. [8:50]
On why the weight and power of ego impairs our ability to learn and harms patients. [11:04]
Sweat the small stuff. [13:03]
The quintessential nature of EM and how they’re similar to flight rules: solving complex problems rapidly with incomplete information. [13:51]
Why we should be using checklists, particularly when we think we don’t have time for them. [14:49]
Even when you follow all the rules, sometimes bad things happen. Perfectionism is not part of the flight rules. [15:51]
Why early success is a terrible teacher. If you’ve always been the star and never experienced failure, this can be a barrier to learning. [18:29]
Jocko Willink video, Good. When bad things happen and you get knocked down, “get up, dust off, reload, recalibrate, re-engage, and go out on the attack”. [20:15]
When in a position of leadership, be careful with your words. Don’t ridicule. The small things we do or say can have a big impact. [22:02]
Expeditionary behavior is the willingness to endure hardships for the sake of the mission. And why whining poisons the pool. [24:15]

References:

An Astronaut's Guide to Life on Earth by Chris Hadfield

The False Assumption of Admitting Errors Oct 03, 2019

Show notes

Should we admit medical mistakes? Most risk managers (and med mal attorneys) might say no, but Dr. Peter Smulowitz says that’s the wrong thinking. Admitting errors can be good for patients and good for us.

Links mentioned in this episode

Register for Essentials of EM. San Francisco May 21-23, 2020
Become a subscribing member of ERcast

Shownotes

Pearls:

The victims of our current risk-management strategy (which is to pretend it didn’t happen, and, if discovered, to deny and defend) are the patient, the provider, and the system.
Communication, Apology, and Resolution (CARe) programs have been developed to encourage providers to talk about adverse events and create a transparent process with the patients and families.

The status quo for the way we handle mistakes creates multiple victims, but no winners. [00:40]
- When a mistake is made in a hospital, the common response is to pretend that it never happened. And then if it’s discovered, we’ve learned to deny and to defend, before beginning a prolonged process of resolution.
- - This adversarial process leads to a lost opportunity to learn from the mistake, on the individual and institutional level. It also prevents providing closure to the victim of the mistake.
  - Our approach to managing adverse events often comes under the guise of risk management. But perhaps we need to reframe these events from managing risk to managing patients.
- Who are the victims of our current risk-management strategy?
- - The patient: According to the Institute of Medicine, the liability system is the number one impediment to patient safety. Further, when something bad happens and compensation is deserved, the patient receives 30 cents on the dollar. The rest goes to administrative waste and legal fees. Oftentimes, the patient never even receives an answer when a major adverse event happens.
  - The provider: Providers spend much of their careers worrying about and trying to avoid lawsuits. And when lawsuits happen, there are significant impacts in terms of depression, substance abuse, and burnout.
  - The whole system: One study showed that we spend about $1.4 billion a year on defensive medicine. That is a significant impact on health care costs.
It was the aftermath of an unfortunate case that sparked Smulowitz’ interest in this subject. It motivated him to try to make systems better so that others did not have to go through the same trauma. [03:40]

Case

A 24 year old man presented with thoracic back pain after lifting boxes. An MRI was ordered due to a history of substance abuse and was read as normal. In the ED, the patient had a sudden PEA arrest and died. The MRI was re-read as showing an aortic abnormality.

- Smulowitz felt horrible after this case. He had zero confidence in himself, and he almost quit practicing medicine.
- The hospital’s response was not ideal. Risk management advised that he only speak to a psychiatrist about the case. He felt completely alone.
- He imagines the patient’s family must have felt terribly as well. They couldn’t talk to anybody about what had happened. Even though the case settled, Smulowitz isn’t sure they ever truly got answers. And they probably have no idea how badly he felt.
- Smulowitz regrets that he didn’t have the chance to talk to the family and to apologize that such a horrible thing happened to their loved one.
- The current practice of pretending that bad things don’t happen is absurd. We’re going to make mistakes, and we practice in imperfect systems where bad things are going to happen to people despite our best efforts.
- The institutionalized isolation that we’re almost obliged to enter after an adverse event contributes to the second victim syndrome. The patient is the first victim, and the healthcare provider, who is traumatized by the event, is the second.
We are taught not to apologize after an adverse event. But is this good advice? [11:00]
- Many states have apology laws which protect you either partially or fully when you admit fault after an adverse event. But Smulowitz believes these are almost useless in terms of their ability to protect from legal action. The laws are in place primarily to support and promote the apology process.
- Excerpt from an article about apology laws:

“Although physicians may feel the need to apologize after an adverse medical event, physicians’ gut instincts to apologize are often hampered by the fear that their statements will be used against them in court. This fear is further solidified when their attorneys advise them to be careful not to admit fault or liability. This seemingly well thought out strategy to remain silent actually creates an unexpected paradox. Refusing to apologize can precipitate litigation to an even greater extent. Consequently, the lack of an apology can dilute the doctor-patient relationship, hinder patient safety, and increase litigation.”

- Communication is critical and an apology can be beneficial.
- - It is the responsibility of the provider and the hospital to communicate with patients in the aftermath of an adverse event.
  - An apology is not an admission of fault. Apologies are beneficial to the physician as long as you’re not saying something crazy within the apology. Apologizing for something bad happening can be protective in the court of law because it makes physicians look like human beings.
Communication, Apology, and Resolution (CARe) programs have been developed to bring providers out of the shadows, encouraging them to talk about adverse events and encouraging a transparent process with the patients and families. [13:05]
- Communication -- There should be early and ongoing communication in the aftermath of an adverse event.
- Apology -- There should be an apology when mistakes happen.
- - Sample verbiage: “It is so horrible that this bad event happened to you. We are devastated that this occurred. We are going to continue taking care of you/your loved one and our hospital is going to be carefully reviewing what just happened. We’re going to get back to you with the results we find.”
- Resolution --
- - Make sure that patients receive just and timely compensation when bad things occur that are directly attributable to deviation from the standard of care.
  - - Note that some patients/families do not desire financial compensation and just want explanations.
    - Patients who receive financial compensation through CARe must sign a waiver saying they will not later file a lawsuit.
  - But if the adverse event is not attributable to negligence or the lack of standard of care, there should be robust defense of the hospital, provider, or system. Providers should be supported if the event was outside of anybody else’s control.
- Institutionalizing this process is the only way to make it work, because you have to tie the communication and the apology piece to a true, just, and timely resolution.
How would you apply the CAR process to this hypothetical scenario: a young woman with a viable pregnancy is mistakenly given methotrexate (which was ordered for the patient with an ectopic in the room next to her)?
- First, the provider needs to communicate the mistake to the patient. “You were given methotrexate and we don’t know the reason for it yet. We also don’t know what the outcome will be for you. We’re going to continue to investigate what happened and we will continue to support you.”
- Second, the error should be shared with your institution’s designated contact people responsible for investigating adverse events. This could be the ED director, the chief medical officer, OB/Gyn, and/or the risk manager. Their involvement early on is necessary for communicating to the patient what the likely possible outcomes might be and how they’re going to continue to provide care and support.
- - The rule of thumb is that the more severe the case, the more the institution needs to pull together quickly to discuss what’s going to be said, how it’s going to be said, and who is going to say it.
- Third, there will be a point person who will follow along with the patient and be continually communicating. This should not be the initial treating provider.
- All hospitals should have the infrastructure to provide ongoing support to patients when untoward events happen.
What is the best way to deliver bad news and apologize effectively? [21:20]
- The core of an apology is an explanation which demystifies the offense, but does not excuse it.
- Make sure that the facts (as you know them) are delivered. Don’t go above and beyond what you think you can explain. And don’t blame yourself or anybody else. Be honest and transparent. Deliver it in a way that makes the patient feel supported.
- At Smulowitz’ institution they have put in place “Just-In-Time” coaching. When something bad happens, you can page someone who has years of training and can coach the provider on what to say, what not to say, and whether he/she is the right one to say it.
The University of Michigan made the CARe program an institutional process. What happened after they started using it? [22:05]
- They saw a dramatic reduction in the number of claims, the number of lawsuits, and overall costs related to lawsuits. Equally important, there has been a dramatic increase in the number of incident reports.
- Those results have been replicated at several other large institutions.
What are the barriers and strategies for implementation of CARe programs? [25:55]
- Providers are wary of it. They feel vulnerable.
- Hospitals are worried they will be paying a lot of money due to an increase in lawsuits.
- Some plaintiff and defense attorneys are against these programs.

References:

Bell SK, Smulowitz PB, et al. Disclosure, apology, and offer programs: stakeholders' views of barriers to and strategies for broad implementation. Milbank Q. 2012 Dec;90(4):682-705. PMID: 23216427.

Davis, Erika R. I'm Sorry I'm Scared of Litigation: Evaluating the Effectiveness of Apology Laws. The Forum: A Tennessee Student Legal Journal. Vol. 3. No. 1. 2016.

Mello MM, et al. Communication-and-resolution programs: the challenges and lessons

learned from six early adopters. Health Aff (Millwood). 2014 Jan;33(1):20-9. PMID: 24395931.

Shostek, Kathleen. Communication and Resolution Programs: Where are we now? American Society for Health Care Risk Management. 2017 Jun 28.

McDonald, Timothy B., et al. Implementing communication and resolution programs: Lessons learned from the first 200 hospitals. Journal of Patient Safety and Risk Management. 2018 April 11.

LeCraw, Florence R., et al. Changes in liability claims, costs, and resolution times following the introduction of a communication-and-resolution program in Tennessee. Journal of Patient Safety and Risk Management 23.1 (2018): 13-18.

We are an N of One - Essentials of EM Keynote (Video) Aug 27, 2019

Show notes

This is the keynote address from Essentials of Emergency Medicine 2019. Transcript below...

There are moments in this job that are glorious ... magnificent. The great save, a moment of kindness, and unexpected show of gratitude, nailing a difficult procedure or diagnosis. There are times that this job will make you want to cry tears of joy. Think about the last time you felt that way

There are moments in this job, however, that are dark. Moments when we, inside, feel Darkness. While I was putting this talk together, a friend of mine texted me that a patient had just died, it was a young man who had bee alive and laughing the day before. Darkness. We see death, feel stress, see cruelty, feel burnout. At the end of some shifts, you feel so beat down it’s an effort just to think. There are times when this job will make you want to just... cry. Think about the last time you felt that way.

There are very few callings in life that evoke such extremes of emotion. And these extremes happen in each one of us, individually.

You do the work and have your own unique experience. You are the one that goes to the shift. You are the one who feels the excitement, feels the anxiety. It's all inside of you. An N of one.

But Being an an N of one can be lonely, isolating. Yet here's the thing. In this room, look around....

In fact, and I know that this feels weird but, take 20 seconds. Turn to the person on either side of you and say hello and introduce yourself, tell them your name, where you’re from and them give them a high five.

That person you just met, as well as everyone else you see in this arena… this is your tribe, your team. It’s a big team. No matter how big it is, though, we are a collective with shared experience, knowledge, and ethics. Whatever sad, joyous, crazy thing you see or do, these people, your people, are right there with you.

You know...50 years ago, this group, this specialty barely even existed.

I can remember my dad, whose formative years were in the time when there was no one who specialized in emergency medicine. When I told him I wanted to be an Emergency Physician, he said “Why are you going to waste your time doing that, is that even a real job?”

That was how much of the world saw us.

Let’s be honest, we still get asked by some of our patients, "What field we’re going into when you’re finished rotating through the ER?"

In the big picture though, we are now leaders in the house of medicine. You could say our specialty is a leader, but more so, it’s our community. How empowering to be part of something larger than ourselves where the ethos is to care for others in the best possible way.

You may be a first year resident, new nurse, in paramedic academy, or maybe you’ve been doing this for decades, a grizzled old dog. It doesn’t matter. What we do in each day is the same.

Think about walking into your shift. There is endless potential. And in that day, you will treat the young, the old, Rich, poor, drunk sober. Care for the the well, and the dying.

Taking on the difficult and dirty tasks, doing what most others don’t want to do. Doing it 24/7/365- weekends holidays, nights, days, and we get the job done with a smile and a common goal of excellence. We. Our community.

And that community is made up of of each of you, each of you with your own story. Each of you an N of one. Doing hard work, good work. Each of you is like a single drop whose ripples change the world.

You are emergency medicine.

Decision-Making Capacity, Newsletter, and The Pale Blue Dot Aug 25, 2019

Show notes

In this episode we discuss the elements of documenting a patient's decision-making capacity, pearls from the last month of ERcast, our new newsletter, and Carl Sagan's Pale Blue Dot.

Links from this episode

Sign up for the ERcast newsletter HERE
THIS is the newsletter discussed in today's podcast
If you want to learn more about the full on, full cowbell, full BAFERD, total ERcast experience, Click Here

In case the links above don't work

URL for newsletter discussed in this podcast: https://mailchi.mp/hippoed/some-things-just-dont-work-on-a-podcast-2090489
URL for newsletter signup: https://mailchi.mp/hippoed/ercastnewsletter

Acute MI in Cardiogenic Shock with Weingart and Mattu Jul 06, 2019

Show notes

Scott Weingart and Amal Mattu are our guests as we break down the critical decision points in a case of a patient with an acute anterior STEMI and cardiogenic shock.

Want weekly episodes, world class show notes, CME, and a super sweet app? Go to ercast.org and subscribe to the kit and caboodle.

Infected and Obstructing Nephrolithiasis Apr 13, 2019

Show notes

Patients with infected ureteral stones present a true medical emergency. I very well may be obvious what's going on but, often, it's not so clear. Maybe the patient has no fever but a few white cells in the urine, or maybe they look sick but have a negative UA. In this wide-ranging discussion, we interview urologist Nora Takla about her approach to infected stones, how she manages those with equivocal presentations, as well as the logistics following up non-infected stones, the significance of extravasation on CT scan, and the sometimes surprisingly complicated decision making when it comes to admitting ureteral colic patients.

Subscribe and hear the rest of the show. CLICK HERE! For access to more incredible education and 2.25 hours of CME each month.

How to Use the Pulse Ox Like a Boss Mar 11, 2019

Show notes

From Essentials of Emergency Medicine NYC 2017, Reuben Strayer explains how the pulse ox might be the most useful bit of tech in the ED.

Pearls:

The pulse ox waveform is an excellent indicator of mechanical heart rate and peripheral perfusion.

For patients breathing room air, pulse oximetry can be used to monitor for hypoventilation.

Nail polish has minimal impact on the accuracy of pulse oximetry.

If you are unable to get a good pulse ox waveform by adjusting or repositioning the probe, be concerned that the patient is poorly perfused.

“The respiratory rate is the most vital of the vital signs.” Experienced doctors look at a patient who seems well, but understands that they’re not truly well, because they subconsciously notice tachypnea. Subconsciously is the only way to notice tachypnea, because respiratory rate is often not measured accurately. Since we don’t always have access to reliable respiratory rate, Strayer’s go-to vital sign is the oxygen saturation.

“Reusable pulse oximeter probes are gross.” One study found that even when these probes are cleaned by standard procedure, ⅔ had bacteria cultured from them. Strayer recommends using single use probes in your department.

Wilkins MC. Residual bacterial contamination on reusable pulse oximetrysensors. Respir Care. 1993 Nov;38(11):1155-60. PubMed PMID: 10145923.

Data is conflicting about the effect of nail polish on pulse oximetry readings, but overall it is felt that the impact is minimal.

Earlier data suggested that nail polish decreased sat readings by 2-10%, but more recent studies found minimal effect.

If it seems that the waveform is affected by nail polish, you can remedy the situation by turning the probe 90 degrees, so it goes sideways through the finger.

Yamamoto LG, et al. Nail polish does not significantly affect pulse oximetry measurements in mildly hypoxic subjects. Respir Care. 2008 Nov;53(11):1470-4. PubMed PMID: 18957149.

As long as a patient is breathing room air, pulse ox can monitor ventilation and function as a hypoventilation alarm.

Significantly hypercapnic patients saturate less than 95% when they’re breathing room air. So if you need to monitor a patient for hypoventilation, such as due to intoxication or procedural sedation, the pulse ox will do a great job of telling you if the patient is still breathing.
If you need to give supplemental oxygen, then use capnography to monitor respirations.

The pulse oximeter does so much more than provide oxygen saturation.

It provides the photoplethysmogram (PPG) which is a waveform that tells you the “mechanical” heart rate. While telemetry gives the electrical heart rate, what really matters to your organs is the mechanical rate. This can be especially helpful during transvenous or transcutaneous pacing. When you have reliable tracing, the pulse ox heart rate is more reliable than the telemetry heart rate.

The pulse ox can measure the peripheral perfusion index which is a more sensitive and earlier indicator of hypoperfusion than blood pressure. This is a numerical value which indicates the strength of the pulsations read by the pulse oximeter. It is based on the amplitude of the pulse ox waveform and expressed as a number between 1 (low) and 10 (high). The perfusion index dips before the stroke volume drops and long before the heart rate rises. Many monitors will report the perfusion index in tiny print after the word PERF.

Lima AP, Beelen P, Bakker J. Use of a peripheral perfusion index derived from the pulse oximetry signal as a noninvasive indicator of perfusion. Crit Care Med.2002 Jun;30(6):1210-3. PubMed PMID: 12072670.

van Genderen ME, et al. Peripheral perfusion index as an early predictor for central hypovolemia in awake healthy volunteers. Anesth Analg. 2013 Feb;116(2):351-6. PubMed PMID: 23302972.

What if you don’t have a reliable pulse ox tracing?

Most of the time this is because the probe is poorly positioned, the patient is moving too much, or there’s a lot of ambient light.
If you’ve corrected for these problems and you still don’t have a good tracing, you should be concerned that the patient is poorly perfused.
One study of 20,000 anesthesia cases showed that pulse ox failure was directly related to worsening physical status.
- Moller JT, et al. Randomized evaluation of pulse oximetry in 20,802 patients: I. Design, demography, pulse oximetry failure rate, and overall complication rate. Anesthesiology. 1993 Mar;78(3):436-44. PubMed PMID: 8457044.

How does the pulse ox measure oxygen saturation and what is the best way to position the oximeter probe on the finger?

One side of the pulse ox puts emits visible (red) light and infrared light. On the other side is the detector. The percent oxygen saturation is calculated based on the different way in which oxyhemoglobin absorbs visible and infrared light compared with deoxyhemoglobin.
The pulse ox measures carboxyhemoglobin as if it were oxyhemoglobin, giving a falsely elevated pulse ox reading for a victim of carbon monoxide poisoning.
The best spot for a peripheral pulse ox is a place with a lot of capillaries and arterioles, like the fingertips, earlobes, nose, or forehead.
Functionally, it doesn’t seem to matter whether the emitter is on the dorsum, volar aspect, or even side of the finger. For convenience sake, most find it ergonomically superior to have the cord and emitter on the dorsum of the finger.

Mannheimer PD. The light-tissue interaction of pulse oximetry. Anesth Analg.2007 Dec;105(6 Suppl):S10-7. Review. PubMed PMID: 18048891

Vegfors M, Lennmarken C. Carboxyhaemoglobinaemia and pulse oximetry. Br JAnaesth. 1991 May;66(5):625-6. PubMed PMID: 2031826

DeMeulenaere, Susan. "Pulse oximetry: uses and limitations." The Journal for Nurse Practitioners 3.5 (2007): 312-317. Link.
Chan ED, et al. Pulse oximetry: understanding its basic principles facilitates appreciation of its limitations. Respir Med. 2013 Jun;107(6):789-99. PMID: 23490227

Essentials of EM: Post Tonsillectomy Bleed Feb 11, 2019

Show notes

Not all post tonsillectomy bleeds are created equal, and not all portend decompensation into hemorrhagic shock (though some do). Emergency physician Gene Hern and ENT surgeon Clay Finley give their thoughts on approach and management.

Our TOPPODCAST Picks

Follow Us

Stay Connected

Stimulus – Learn Tools to Crush It in Your Medical Career

Related Podcasts

Links

Stay Connected