Emerge Better: Completing an Elective in Emergency Medicine
Tiarnán Byrne UCD School of Medicine and Medical Science, University College Dublin, Belfield, Dublin 4, Ireland
Elective placements are a feature of most undergraduate medical programmes throughout the world. They are characterised by a period spent in a clinical speciality and setting of the student’s choice and are usually undertaken during the final year of medical school. Some see this as an opportunity to make a declaration of intent regarding their postgraduate careers, with budding surgeons entering the operating theatre and enthusiastic medics, the wards of their coveted specialty. Others, perhaps less sure of their path, may see it as a time to sample different specialities or different healthcare systems. However, as more barriers to practical learning emerge within the clinical environment, many are beginning to view their elective period as an opportunity to experience the type of clinical exposure that their core clerkships may have struggled to provide.
It is in this context that emergency medicine has emerged as a favourite amongst medical students undertaking clinical electives. A fast paced and dynamic speciality, it offers a combination of a strong teaching culture and a unique clinical environment that enables students to consolidate and improve their clinical skills before entering practice. For my own elective I travelled to Westmead Hospital in Sydney, Australia where I trained in both a busy emergency department and with a pre-hospital emergency medical team. The experience not only improved my clinical skills, but also changed my understanding as to how and why I learn. Based on this experience, I intend to lay out some of the specific reasons why an elective in emergency medicine can provide a high quality learning experience.
elect for emergency medicine
“For days and days, you make out only the fragments of what to do. And then one day you've got the thing whole. Conscious learning becomes unconscious knowledge, and you cannot say precisely how.”
– Atul Gawande, Complications
Over the course of the last five decades emergency medicine has transformed the treatment of acute illness. From a collection of ad hoc processes performed to inconsistent standards, it has morphed into a highly effective and evidence based system of urgent care, whilst still maintaining an ethos of multidisciplinary teamwork and proactive change at its core. Furthermore, in emergency medicine the number and diversity of learning opportunities that exist for the motivated student to take advantage of is unrivalled. For the purposes of this discussion we can categorise these opportunities into one of five ‘P’s’; patients, presentations, practitioners, procedures and performance.
Patients and Their Presentations
The emergency department receives patients from across the clinical spectrum. They range from the intoxicated, but otherwise healthy persons, to older persons with extensive co-morbidities and complex social support needs, to patients with serious injuries in need of urgent resuscitation. For the medical student this represents a valuable introduction to the heterogeneous and often complex nature of treating real patients in the earliest stages of their care.
Simple, single-system complaints, such as those often found in minor injury units or urgent care clinics, allow students to practice focussed history taking and examination as well as familiarisation with common clinical signs and symptoms. Here students can also experience the overt progression through the process of forming a differential, ordering investigations, making a diagnosis, and initiating treatment.
More complex presentations such as acute exacerbations of chronic diseases, particularly in patients with multiple co-morbidities, can expose students to the multidisciplinary and often assiduous nature of organising the constellation of interventions. Such interventions may be both immediate and long-term, and are commonly required to arrest disease processes, restore patient function and prevent readmission, to whatever degrees these objectives might be possible.
Patients with life-threatening illness and injuries, such as those with major trauma, may not be as physically accessible to medical students as others in the department. Nonetheless their management represents an important opportunity to witness emergency teams in action and the crucial role that strong leadership, efficient communication and other team dynamics play in influencing patient outcome. One of the most impactful moments of my medical training so far was witnessing the mantra of ‘Airway, Breathing, Circulation’ applied in stressful and complicated clinical circumstances by multidisciplinary teams in Sydney.
Practitioners and Procedures
Another key reason for my positive experience in Australia was my working alongside many different types of clinicians, the vast majority of whom were motivated to provide high quality supervision and instruction. While the levels of staffing that is typical of Australian hospitals facilitated this, it was the willingness of the staff to teach that was the most important factor. This was an attitude I had also recognised from prior clerkships in emergency departments in Ireland. Their support is of immense benefit for students as it quickly reveals gaps in their knowledge and training and deliberately remedies them with expert guidance. In my case it was often basic clinical tasks such as the interpretation of electrocardiograms, administration of intravenous medications and clinical examinations where I found myself to be wanting and where subsequently I made concentrated efforts to improve.
Another benefit of the strong teaching culture is the number of opportunities to practice basic procedures and clinical skills, limited only by time and stamina. Competency in many basic procedures, for example intravenous cannulation, can be achieved quickly in the emergency department provided one is proactive and prepared. Exposure to more complicated procedures such as fascia iliaca block for patients with hip fractures is also common. Familiarisation with constituent tasks, such as aseptic technique or ultrasound guidance, alongside time with clinicians from different specialities such as anaesthetics and cardiology, provides invaluable holistic training. Witnessing rare and dramatic procedures, such as an emergency thoracotomy, can prompt reflection as to how practitioners decide and carry out these types of procedures under significant pressure, which brings us to our next topic.
As I progressed through my elective my thoughts turned toward improvement as I gained further insight into my own strengths and shortcomings. Scarcely fifty years old as a speciality, emergency medicine has always had continuous individual and collective improvement at its core and draws widely from the contemporary theories of other sciences such as psychology and performance. Through both formal and informal discussions with clinicians and peers, and independent yet guided exploration of the literature, I came to better understand some of the factors that were affecting my performance.
The term ‘Cognitive Bandwidth’ for example refers to a person’s capacity to process information, make decisions and perform tasks. It is of interest to emergency physicians due to the psychological and environmental stressors that they often encounter. These stressors can reduce this ‘bandwidth’ and lead to poor performance and patient outcome. What I found enlightening was how principles such as cognitive bandwidth also applied to students. Take for example a student performing a relatively simple procedure, like placing a urinary catheter for the first time. Minor stressors such as patient or supervisor dissatisfaction, can nonetheless produce as strong a stress response in the student. In the same way, this can reduce their cognitive bandwidth and therefore their ability to perform. It is also interesting to note how theoretical preparation and practical familiarisation with a given procedure, perhaps by utilisation of techniques such as simulation or visualisation, could tangibly reduce a student’s stress response and improve performance.
An elective offers opportunities that translate into a greater likelihood of experiencing many of the important ‘firsts’ that may have passed a student by during previous placements. Some of these may be dramatic, such as assisting in the performance of compressions during cardiopulmonary resuscitation. Others can be more mundane, like ordering a full blood count. All however, equally as important for your future career.
Sir William Osler, the first Professor of Medicine at John Hopkins Medical School, understood and championed the importance of a hands-on, immersive approach to medical education. He once wrote; “He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.” Increasingly, it seems that students are at risk of finding themselves stranded on the quayside. Though the reasons for this may be complex, multifaceted and largely beyond a student’s control, ultimately it is the student who must take responsibility for their own learning. In this context the elective placement can adopt a redemptive role, affording students the much needed immersion into modern clinical practice.
I would never argue that emergency medicine enjoys a monopoly for enthusiastic clinical teachers who can facilitate high quality learning. One need only search social media for the term ‘#foamed’, free open-access medical education, to find evidence of the many dedicated clinicians and academics who are eager to share knowledge of their own branches of healthcare. Personally, the frequency with which I have met teachers of this type during my time in the emergency department, coupled with the abundance of opportunities I encountered there, made my elective the most valued experience of my training so far. I firmly believe that for students who wish to truly test themselves and build on what they discover, an elective in emergency medicine is one of the surest ways of doing so.
I am indebted to all of the clinicians, of all professions and specialities, who took time to teach me part of their craft. In particular I would like to acknowledge the staff at the Emergency Departments of St. Vincent’s University Hospital in Dublin and Westmead Hospital in Sydney, as well as the staff of the Greater Sydney Area Air Ambulance. Their generosity of time and knowledge served as the inspiration for this article. I would also like to thank Mr. James Condren for his honest and insightful advice.