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About Michelle Lin, MD

ALiEM Founder and CEO
Professor and Digital Innovation Lab Director
Department of Emergency Medicine
University of California, San Francisco
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Article review: Improving case presentations with theater training

“To be or not to be?”

What could be more strange on a medical school curriculum than a theater training course? The authors of this study in Medical Humanities innovatively designed a 1-week elective course to help medical students at Mayo Medical School to improve their case presentation skills in partnership with the Guthrie Theater.

In this pilot course, seven medical students (six 1st year students, one 4th year student) participated. The learning objectives were:

  • Hear stories: those told by patients, colleagues and in written narratives
  • Identify the elements of a narrative, and examine stories for narrative structure 
  • Share stories: through case presentations, body movement, storytelling and acting 
  • Present a patient’s story with elements of traditional medical presentation and narrative

Students were evaluated for the following competencies:

  • The cognitive capacity and flexibility needed to evaluate and acquire reliable clinical information. 
  • The ability to actively and generously observe and listen to another. 
  • An understanding of the components of narrative leading to effective story construction. 
  • A performance sensibility that ensures the delivery of a good story, otherwise known as stage presence. 
  • The finesse to communicate empathically with a patient to create an environment in which she or he feels safe, satisfied and heard.

Eleven sessions, over 25 hours, comprised of the following topics:

  • Improvisation activities
  • Introduction to case presentations
  • Body language – contact improvisation
  • Performance of story
  • Neutral dialogue and elements of a narrative
  • Narrative in context – what’s lost, what’s gained?
  • Listening with a neutral mask
  • Storytelling
  • Writing and presenting case histories
  • The art of personal monologue
  • Final presentations with professional critique

Survey responses uniformly found that students valued this creative, non-traditional approach to learning about interpersonal communications and oral presentations. The art of focused storytelling to an audience  is exactly what physicians do every day when presenting clinical cases.


Reference
Hammer RR, et al. Telling the Patient’s Story: using theatre training to improve case presentation skills. Medical humanities. 2011, 37(1), 18-22. PMID: 21593246
.

By |2016-11-11T18:53:06-08:00May 30, 2011|Education Articles, Medical Education|
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Paucis Verbis: Outpatient treatment for diverticulitis

The classic prior teaching for the treatment of diverticulitis includes:

  • Hospital admission
  • Bowel rest (NPO)
  • IV fluids
  • Broad spectrum IV antibiotics

Do ALL patients need to be admitted? There is some early literature suggesting that there is a small sub-population who fare well with outpatient treatment.

This article from Annals of EM in the “Best Available Evidence” series summarizes the existing literature well.

PV Card: Diverticulitis


Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

Word of caution

This paper only provides guidelines, based on the limited evidence out there. Still use your common sense. For instance, I’d still admit patients who are elderly (>80 years old) or have evidence of any perforation on CT. If on the fence, admit the patient.

Still it’s nice to see that the treatment of uncomplicated diverticulitis on an outpatient basis has some supporting literature.

Reference

  1. Friend K, Mills AM. Is Outpatient Oral Antibiotic Therapy Safe and Effective for the Treatment of Acute Uncomplicated Diverticulitis? Annals of Emergency Medicine. 2011;57(6):600-602. doi: 10.1016/j.annemergmed.2010.11.008
By |2021-10-13T08:49:38-07:00May 27, 2011|ALiEM Cards, Gastrointestinal|
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Trick of the Trade: Ring removal from a finger

 

 EPSON DSC pictureA patient presents with a swollen finger after falling and fracturing it. The patient is more distraught by the fact that she can’t get the ring off her finger. She implores you not to cut the ring off.

There are textbook chapters written about tightly wrapping the digit with string from distal-to-proximal and sliding the string under the ring. Theoretically, the provider can pull and unwind the proximal end of the string to gradually coax the ring over the coils of string.

I have personally found little luck with this maneuver.

 

(more…)

By |2016-11-11T18:53:07-08:00May 25, 2011|Tricks of the Trade|
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Paucis Verbis: International Registry on Aortic Dissection (IRAD)

What do these 3 people have in common?

  • Lucille Ball (comedienne)
  • Jonathan Larson (wrote the musical “Rent”)
  • John Ritter (comedian)

They all died from an aortic dissection. We commonly consider this diagnosis for Emergency Department patients presenting with severe chest pain. There is an International Registry on Aortic Dissection which published a retrospective, descriptive study of 464 patients with dissections.

I find this list helpful, because it illustrates the fact that the classic signs and symptoms aren’t actually very common. Here are some scary examples:

  • A pulse deficit in the carotid, brachial, and femoral arteries is only present 15% of the time.
  • A tearing or ripping quality of pain is present in only 50% of patients.
  • Not all patients have a widened mediastinum or abnormal aortic contour (only 78.7%).

PV Card: Aortic Dissection


Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

Reference

  1. Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD). JAMA. 2000;283(7):897. doi: 10.1001/jama.283.7.897
By |2021-10-13T08:51:53-07:00May 20, 2011|ALiEM Cards, Cardiovascular|
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Article review: Clinician attitudes about commercial support of CME

 

CoffeeDid you know that a cup of coffee can cost over $9… when planning a CME conference?

In an interesting survey-based publication by Dr. Tabas (one of my colleagues) that just came out in Archives of Internal Medicine, we learn more about the ins and outs of CME activities. The authors set out to determine the audience members’ opinions about:

  • Commercial/ pharmaceutical support and its impact on bias
  • Their willingness to pay extra conference registration fees to eliminate outside support
 

(more…)

By |2016-11-11T18:53:09-08:00May 16, 2011|Education Articles, Medical Education|
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Paucis Verbis: Head CT clinical decision rules in trauma

HeadCTbleedThe ideal clinical decision tool has a sensitivity and specificity of 100%.

You need a high sensitivity to be sure that your negative result indeed predicts a true negative. That means if your clinical decision tool suggests that you don’t need to get a head CT, then your head CT would have been normal.

On the flip side, this realistically means there is a low-moderate specificity. That means a clinical decision tool with at least 1 positive criterion does not always mean that there will be an abnormal finding on head CT.

There are 3 major clinical decision rules that I’ve heard tossed around in the literature:

  • Canadian CT Head Rules (CCHR)
  • New Orleans Criteria (NOC)
  • National Emergency X-Radiography Utilization Study (NEXUS)-II

There is no perfect tool.

Take a look at these decision rules and their inclusion criteria.

  • The CCHR included patients with GCS 13-15. The NOC initially enrolled only patients with a GCS of 15.
  • All factor in age (≥65 years for CCHR and NEXUS-II; ≥60 years for NOC).
  • Interestingly only the CCHR, for better or worse, take into account mechanism of injury. I’m not sure I would obtain a head CT on a pedestrian with a graze wound on the foot from a slow-moving vehicle.

Which do you use? I use a combination of all 3 and my clinical gestalt.

PV Card: Head CT in Trauma – Clinical Decision Tools


Go to ALiEM (PV) Cards for more resources.

By |2021-10-15T10:59:57-07:00May 13, 2011|ALiEM Cards, Radiology, Trauma|
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