Grand Rounds Recap 7.14.21
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Leadership WITH Dr. mcdonough
Maxwell's 5 Levels of Leadership - Increasing levels of leadership development and leadership traits which build on the previous level
Level 1: Position - Someone gives you a leadership position and so people follow you because they have to because of your title
Level 2: Permission - You develop relationships with people and then they follow you because they want to
Level 3: Production - You have developed as a leader and produced results, so people follow you because of what you’ve done for the organization
Level 4: People Development - People follow you as a leader because of what you’ve done for them
Level 5: Pinnacle - People follow you because of who you are and what you represent
Emotional intelligence-the capacity to be aware of, control, and express one's emotions, and to handle interpersonal relationships judiciously and empathetically.
Self awareness -self confidence, insight into yourself
Social awareness- can you identify the emotions of others and empathize with those emotions, dedication to service to others
Self-management- what you are able to manage in yourself through your self awareness, when you recognize yourself getting angry can you control it, can you demonstrate initiative
Relationship management - Good relationship management requires strong skills in the other 3 areas of emotional intelligence. Are you able to take what you know about yourself and what you know about others and use those thoughts, feelings, and interactions as a catalyst for change.
Leadership Styles
Coercive - Drive to achieve, initiative, and self-control
Authoritative - Self-confidence, empathy, change catalyst
Affiliative - Empathy, Building Relationships, communication
Democratic - collaboration, Team leadership, Communication
Pacesetting - Conscientiousness, Drive to achieve, Initiative
Coaching - Developing others, Empathy, Self-awareness
Major points from small group discussions
It is not uncommon for your leadership style (coercive, authoritative, affiliative, democratic, pacesetting, coaching) to change based on the situation or even throughout a single situation. One individual is not locked to one leadership style, although individuals may have a leadership style that they subconsciously default to.
Your leadership style may also vary based on the team you are working with at that moment. Your leadership style may vary depending on your familiarity and history with the team you are working with and the other personalities or leadership styles on the team.
Your leadership style is also likely to change depending on whether you are the sole leader or if you are co-leading.
When you are leading individuals who are developing into leaders themselves (such as senior residents or attendings who are leading junior residents) you may need to employ the coaching style of leadership in order to teach your junior residents to employ the various other styles of leadership and add these to their tool set.
How to give a lecture WITH Dr. Paulsen
The before hand work: developing a lecture once you’ve been asked to give it
Kern’s Six steps of curriculum design:
Step 1: Problem identification - What do I want my learners to take away from this lecture?
Step 2: Targeted needs and assessment - Who are my learners and what do they already know vs what do I need to teach them?
Step 3: Goals and objectives: Goals are the big picture. Objectives are the specifics within those goals. Objectives should be SMART (specific, measurable, attainable, realistic, time-bound). Objectives should also be verbs (e.g. I want my learners to ___________). Refer to Bloom’s Taxonomy of Learning to help fill in the blank.
Bloom’s Taxonomy of Learning
Remember: Recall facts and basic concepts.
Understand: Explain ideas or concepts.
Apply: use information gained from a lecture in a new situation.
Analyze: Draw connections among ideas and compare and contrast different ideas.
Evaluate: appraise, argue, defend, and judge information.
Create: produce a new/original work.
Step 4: Educational strategies - how will you achieve your goals through this lecture, what medium and activities will you utilize?
Teacher-centered learning - the teacher serves as an expert or formal authority on a subject and they are responsible for imparting knowledge on the learners.
Learner-centered learning - this is a more active type of learning and typically results in better understanding, better retention, and better application of content. Learner-centered learning typically targets higher levels in Bloom’s taxonomy of learning because it is a more active process. In this model the teacher and students work together to move from their pre-existing knowledge point to a level of understanding that aligns with the lecture objectives.
Step 5: Implementation: who needs to approve of the content you are about to share (for example if you are implementing a new practice pattern) and what resources do you need to deliver the content (space, time, tools)?
Step 6: Evaluation: Was the lecture engaging and enjoyable? Did you convey the information you wanted and was it retained?
These 6 steps should be viewed as an interdependent circle. Step 6 may reveal additional problems that then start you back at step 1.
Content Delivery (the design)
Choose a simple font that is easy to read, ideally a sans serif based font (Arial, Avenir, Chalkboard, Future, Geneva, Graphik, Helvetica, Tahoma)
Choose an easily visualized font color and remember how varying colors may impact those with color blindness
Backgrounds
Ideally a black or a white background, just consider how either a black or white background will impact the appearance of your content.
Graphic backgrounds are attractive but can be distracting and overwhelming, and can ultimately distract from the core content
Minimize the word vomit - if your audience is busy reading numerous words on your slide, then they aren’t listening to what you are saying. Consider using charts or timelines to condense information and present it in a logical, easily digested fashion.
Content Delivery (the verbal part)
Be mindful of your pacing. Rapid speech can be tricky to follow.
Vary your tone. Make the presentation conversational and engaging.
Remove filler. Say things as concisely as possible.
Use deliberate repetition with the same phrasing to emphasize learning goals and assist with retention.
Make eye contact with the audience and vary who in the audience you are making eye contact with.
Make sure that your body language, mannerisms, and gestures are deliberate and purposeful.
Preparation and Practice
Always give your lecture to one person before formally giving the lecture to a large group.
Summarize
Recap main content points that address key learning goals and objectives.
Reliability Science WITH Dr. Wright
Healthcare Reliability: the capability of a process, procedure, or service to perform its intended function in the required time under existing conditions.
Levels of reliability
Level 1: 80-90% reliability
Level 2: about 95% reliability
Level 3: about 99% reliability
Reliability less than 80% is considered failure
It is the responsibility of the people who run an operation to determine what facets within that operation require high reliability and which do not. It is then up to those people to determine the means by which these processes will become reliable.
Humans fail at predictable rates. Although in general humans are very reliable, failure rates approach 25% in high-stress fast-paced situations (much like what we encounter in the ED).
Designing Reliability:
Level 1 reliability interventions are often about changing individual behavior and actions.
Level 2 reliability interventions are about changing processes and limiting human behavior. These interventions change the workflow. They make it easy to do the right thing and hard to do the wrong thing.
Level 3 reliability interventions are focused on improving the whole system and culture at an institution to ‘hard-wire’ and constrain human choices. Examples include creating scheduled patterns such as rounding and team huddles.
5 principles of high reliability organizations
Preoccupation with failure - Constantly be mindful of failures. Analyze how the failure occurred and analyze mistakes to prevent recurrence.
Reluctance to simplify - We do highly complicated things which can’t always be simplified. Do not oversimplify things that can’t and shouldn’t be simplified. Develop means to make them safer despite the complexity.
Sensitivity to operation- Incorporate the people who are actually performing various duties into the discussion where operations are designed.
Commitment to resilience - Commit to and embrace a culture of non-punitive measures and processes for improvement.
Deference to expertise - Always default and source information from the expert.
Knowledge Bombs from Bpod WITH Dr. Knight
Bpod is a standard acuity pod within our emergency department where interns staff patients with fourth year residents and then the fourth year residents staff with the attendings.
Be aware of your own wellness bias
Always give every patient at least 30 seconds of consideration for serious or dangerous illness. This is especially true of people who utilize the emergency department frequently; do not dismiss their symptoms purely on the basis of frequent encounters.
Believe your history and physical.
Case 1: A middle aged male with a history of IVDU presented for abdominal pain. He endorsed several days of progressive pain over the pubic symphysis with focal tenderness on exam. A CT scan was obtained and demonstrated osteomyelitis of the pubic symphysis with an adjacent pelvic abscess.
Believe your history and physical. In this case, pinpoint pain and tenderness, rather than generalized abdominal pain, was concerning for bony involvement in the pelvis and a focal pathology.
Trust your gut.
Case 2: A young adult male who was just discharged from another hospital presented to our hospital for a second opinion. The outside hospital note described him as encephalopathic and then detailed an extensive evaluation with bloodwork and imaging which was normal and so he was discharged. On our examination the patient seemed to be confabulating but was otherwise calm, cooperative, and conversive. Although his outside hospital evaluation was reassuring, the confabulation was out of character and could not be explained. Due to this, the patient underwent a lumbar puncture and was found to have neurosyphilis.
Trust your gut. When you feel like something is off it very well might be (not always, but it might be). Trust your gut, but support it with data (your medical knowledge as well as data generated from the ED encounter).
Don’t just do something, stand there!
Case 3: A primary school aged female presented to the ED after a high mechanism blunt trauma. The patient decompensated and required intubation due to hypoxia. The primary provider, who was running the trauma, left the foot of the bed to intubate the patient. The patient was successfully intubated but subsequently had a post-intubation cardiac arrest. It was later found that she had a tension pneumothorax. When the lead provider steps out of their ‘all-seeing’ role to focus on a procedure, it can be easy for things to be missed.
Don’t just do something, stand there! Take a second to step back and gain perspective. Act when you need to act, but make sure that you gain adequate information first. Try to make actions as informed as possible to minimize the potential for detriment (although information can be limited in our specialty).
Trust alarms
Alarm fatigue (from monitors, from EKG machines, etc.) is common in the ED. Do not ignore alarms. Although they may frequently be the result of a computer misinterpretation, ignoring alarms could lead to lethal consequences.
Additionally, trust nursing alarms. If your nurses or other staff express concern or are alarmed about a patient, you should be too.
Vitals are vital
Don’t try to explain why abnormal vitals are ok. Instead, try to explain why the abnormal vitals are problematic and where they are coming from. Don’t dismiss abnormal vital signs, but also know that there are some instances where certain abnormal vital signs are tolerable (although you still need to have a reasonable explanation for them and why you are tolerating them).
Unexpected lab values
If you get unexpected lab values, repeat them to verify they are real. Repeat the lab, but don’t dismiss it in the interim. Mentally treat the unexpected result as real and don't delay life saving therapy while awaiting verification from the repeat.
Know your equipment
Equipment is only useful to you if you know how to use it and use it well, otherwise it can set you up for failure and could be dangerous for the patient. Along those lines, don’t be afraid to check your ego and ask for help when you encounter equipment that you aren’t familiar with.
Know your limits
Know what you are capable of , what you are not capable of, and when to ask for help; then don’t be afraid to ask for that help when you need it. It is not a sign of weakness, but a sign of clinical knowledge and maturity, to ask for help or a consult when the patient needs services outside of your scope or outside of the resources in your practice setting. Do not reach out to consultants unnecessarily, and be sure to have a specific question for them when you consult them, but do not hesitate to reach out, and use the opportunity to learn from them when the patient warrants their involvement.
Review your own images
Open PACS and review any patient imaging relevant to this encounter. You may not be an expert at reading your own images when you start off, but the more imaging you look at and correlate with the findings in the read, the better you will become.
