EM rotation - getting low reviews on Differentials and formulating plans

[tarsuc]

Have been scoring well in other parts of daily clerkship evaluations, but keep getting low evaluations in this part of the evaluation form.

I understand this is the part where knowlege comes in, and theres nothing i can do about it, as a quick fix.

But can someone suggest me someway i could fix this?

An app or handbook that i can refer to, to make sure i dont miss anything important?

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[TheOne13]

You may have already heard of it, but I thought WikEM was a pretty good resource. It's often got flowcharts and tables as well as just little blurbs. I used that pretty frequently and got good feedback about my differentials and plans. It's not perfect and your attending/resident may not always agree with it, but it's a decent place to start. If my superior disagreed with my plan, they wouldn't dock me as long as it was pretty reasonable and I could defend it.

There's plenty of other podcasts/websites out there to help shore up your knowledge (EMBasic, EMCrit, RebelEM, emDOCS, etc.) although some of these require a basic foundation. Since you seem to recognize that you lack that foundation, try the EM Clerkship podcast. It's made for students rotating in EM. Each episode is about 10 minutes and goes into some basic details about mostly high yield topics. I made cheatsheets from the podcast (and WikEM) which I referred to frequently when on rotation.

I also had a book called "The Chief Complaint: Emergency Medicine Handbook" which you may find useful.

In general, you want to keep your differential broad. You obviously want to think of the worst case scenarios because it's the ED. Young lady who is healthy but has chest pain with SOB? Worst case scenarios include ACS, PE, dissection, pneumothorax. Is it likely for a young healthy woman to have an ACS? Probably not as likely as an older man with HTN, DM, HLD, but it's your job to think of it and check for it. Don't forget your less-threatening causes of chest pain (muscle strain, costochondritis, anxiety, etc.) either.

For your plan, you need to figure out what you're supposed to help investigate your differential. What are you going to do to evaluate for the chest pain to make sure you don't miss an MI or something? EKG, troponins, chest x-ray. Your history, physical, and clinical judgement will help add or subtract to your plan. Your patient happens to have unilateral leg swelling and is a smoker with recent surgery? PE is now much more likely. Probably should add a D-dimer or CTA.

Emergency medicine is a disposition based specialty so you also need to think about what to do with your patient as part of your plan. What are you going to do if everything is negative and she has a low HEART score? What if her EKG shows ST elevation in II, III, avF? What if her CXR shows air bronchograms and opacity in the right lower lobe? What if her D-dimer is elevated? You don't necessarily need to tell your attending what to do in each of these scenarios during your initial presentation, but you better know what you'll do in each scenario. Again, WikEM kind of has the basics for it, but you're right in that there is no quick fix.

Keep reading and keep thinking. You'll get better with repetition. I've got a long ways to go, but I (and my attendings) noticed improvement from day 1 to day 20 because I made sure to read up on at least 1 topic a day.

 

[tarsuc]

You may have already heard of it, but I thought WikEM was a pretty good resource. It's often got flowcharts and tables as well as just little blurbs. I used that pretty frequently and got good feedback about my differentials and plans. It's not perfect and your attending/resident may not always agree with it, but it's a decent place to start. If my superior disagreed with my plan, they wouldn't dock me as long as it was pretty reasonable and I could defend it.

There's plenty of other podcasts/websites out there to help shore up your knowledge (EMBasic, EMCrit, RebelEM, emDOCS, etc.) although some of these require a basic foundation. Since you seem to recognize that you lack that foundation, try the EM Clerkship podcast. It's made for students rotating in EM. Each episode is about 10 minutes and goes into some basic details about mostly high yield topics. I made cheatsheets from the podcast (and WikEM) which I referred to frequently when on rotation.

I also had a book called "The Chief Complaint: Emergency Medicine Handbook" which you may find useful.

In general, you want to keep your differential broad. You obviously want to think of the worst case scenarios because it's the ED. Young lady who is healthy but has chest pain with SOB? Worst case scenarios include ACS, PE, dissection, pneumothorax. Is it likely for a young healthy woman to have an ACS? Probably not as likely as an older man with HTN, DM, HLD, but it's your job to think of it and check for it. Don't forget your less-threatening causes of chest pain (muscle strain, costochondritis, anxiety, etc.) either.

For your plan, you need to figure out what you're supposed to help investigate your differential. What are you going to do to evaluate for the chest pain to make sure you don't miss an MI or something? EKG, troponins, chest x-ray. Your history, physical, and clinical judgement will help add or subtract to your plan. Your patient happens to have unilateral leg swelling and is a smoker with recent surgery? PE is now much more likely. Probably should add a D-dimer or CTA.

Emergency medicine is a disposition based specialty so you also need to think about what to do with your patient as part of your plan. What are you going to do if everything is negative and she has a low HEART score? What if her EKG shows ST elevation in II, III, avF? What if her CXR shows air bronchograms and opacity in the right lower lobe? What if her D-dimer is elevated? You don't necessarily need to tell your attending what to do in each of these scenarios during your initial presentation, but you better know what you'll do in each scenario. Again, WikEM kind of has the basics for it, but you're right in that there is no quick fix.

Keep reading and keep thinking. You'll get better with repetition. I've got a long ways to go, but I (and my attendings) noticed improvement from day 1 to day 20 because I made sure to read up on at least 1 topic a day.

Thanks a lot for your detailed reply! it helps a lot!!

 

[TheComebacKid]

Ddxof.com has some decent quality content to supplement your use of WikEM which is a phenomenal resource for on shift reference.

One of the problems with med students is that they harp on the history and exam in the ED. They anchor on it because that's what they feel comfortable doing, that's all they've done through all of medical school. Stop doing that. You are a medical student, you have already proven that you have good info gathering skills. If you can't figure out how to do a good history/physical at this point, you are SOL. I believe your history/exam skills.

In the ED, I want to spend all the time on your MDM. You can give 1-2 minutes of HPI/exam stuff. Focus on the thought process.

The problem with med students when it comes to making differentials and formulating plans is not that they don't know the differential for chest pain, it's that they won't commit to a certain plan. A huge portion of EM is making decisions with limited information, which is what makes it so hard to commit.

Patient has a headache? Say something along the lines of: "Given the history and the fact that this is similar presentation to her prior migraines, I suspect she has a primary headache disorder like migraine that explains her symptoms. She has no red flag symptoms or exam findings concerning for SAH, meningitis, CVA, hypertensive emergency, cerebral venous sinus thrombosis. I'd like to try symptomatic treatment with IVF, toradol, compazine, and reassess her symptoms. If her symptoms do not improve, I would consider imaging at that point.

Short and sweet. Be confident. You know the differentials for the basic complaints. EMRA also has a pocket differential diagnosis guide based on chief complaint (which is what EM is all about) which I found to be helpful. Good luck.

 

[GonnaBeADoc2222]

Ddxof.com has some decent quality content to supplement your use of WikEM which is a phenomenal resource for on shift reference.

One of the problems with med students is that they harp on the history and exam in the ED. They anchor on it because that's what they feel comfortable doing, that's all they've done through all of medical school. Stop doing that. You are a medical student, you have already proven that you have good info gathering skills. If you can't figure out how to do a good history/physical at this point, you are SOL. I believe your history/exam skills.

In the ED, I want to spend all the time on your MDM. You can give 1-2 minutes of HPI/exam stuff. Focus on the thought process.

The problem with med students when it comes to making differentials and formulating plans is not that they don't know the differential for chest pain, it's that they won't commit to a certain plan. A huge portion of EM is making decisions with limited information, which is what makes it so hard to commit.

Patient has a headache? Say something along the lines of: "Given the history and the fact that this is similar presentation to her prior migraines, I suspect she has a primary headache disorder like migraine that explains her symptoms. She has no red flag symptoms or exam findings concerning for SAH, meningitis, CVA, hypertensive emergency, cerebral venous sinus thrombosis. I'd like to try symptomatic treatment with IVF, toradol, compazine, and reassess her symptoms. If her symptoms do not improve, I would consider imaging at that point.

Short and sweet. Be confident. You know the differentials for the basic complaints. EMRA also has a pocket differential diagnosis guide based on chief complaint (which is what EM is all about) which I found to be helpful. Good luck.

I've never met a med student who had an ability to do this. This is legit pgy2 level.

There are basically a handful of EM chief complaints that I would expect a med student to have some clue of differential for:

Chest pain
Dyspnea
Abdominal Pain (young/old/female)
Headache
Altered mental status
Fever (young/old)
General trauma stuff
Maybe a couple others

EMRA guide good. I like hearing two lists from students/interns:

1) most likely to kill patient
2) most likely

I make them give me both lists of differentials. It makes them demonstrate their acknowledgement of the stuff we care about ruling out, while also showing me that their thinking has a basis in reality. Not every patient needs an AAA rule out and not every patient can be assumed to have a simple viral gastroenteritis.

Be normal, be on time, be coachable.

There are gonna be haters, sometimes undeservedly. There are gonna be people who sing your praises, sometimes undeservedly. My own feedback on em rotations ranged from "you're great!...honors", to "you're great!...pass", to "blank...honors". The haters are gonna hate and then you'll match and it won't matter.

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[TheOne13]

The problem with med students when it comes to making differentials and formulating plans is not that they don't know the differential for chest pain, it's that they won't commit to a certain plan. A huge portion of EM is making decisions with limited information, which is what makes it so hard to commit.

This is what I struggled with during my auditions. My superiors always told me it was clear I had the medical knowledge expected of a MS4/PGY1, but they wondered why I wouldn't commit to a plan or wasn't confident in my plan. For me, I was afraid that I would have a different plan from them or I was trying to predict what I thought they wanted me to say based on my shifts with other attendings/residents. You've probably discovered that everyone has their own style. It turns out that my attendings did not care if my plan differed from theirs as long as I wasn't egregiously wrong and I could clearly/succinctly defend my plan. I'll be honest and say that I had a lack of confidence and had a fear of being "wrong". Eventually, I just said "F*** it" and presented my plan and defended it confidently. n=1, but I got better comments on my evaluations about my decision making and thought process after I started doing that. What probably separated the superstars from myself was that my plans often needed more fine-tuning.

Chest pain
Dyspnea
Abdominal Pain (young/old/female)
Headache
Altered mental status
Fever (young/old)
General trauma stuff
Maybe a couple others

Syncope, dizziness, back pain, vomiting/diarrhea were also common for me.

 

[deleted109597]

Ruben Strayer's "How emergency docs think" lecture.

 

[thegenius]

Ruben Strayer's "How emergency docs think" lecture.

It's great...i've watched it several times

 

[Jabbed]

Start thinking and acting as if you are the only doctor that will see this patient before they leave the hospital.

-Are they sick/not sick?
-What do you need to do to prove to yourself that they're well enough to go home? What are you going to do for them so that they feel well enough to go home?
-What do you need to do to stabilize them enough to go to the floor/unit? What resources do you need to organize to make those interventions happen?

Most things that happen in the hospital are truly not that complicated. Especially in the ED, your options are essentially a) test b) intervene c) call someone. You've probably already seen/read about the bulk of the tests and interventions that we have on hand.

The difference between a MS-3 and a PGY-3/4 is that the MS-3 is expected to only verbalize the plan while the PGY-3/4 actually carries it out. Both require independent decision-making of a sorts. "What is my attending going to think" doesn't fall in the algorithm-- they are a safety check and another resource to draw from.