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Emergency Physician’s Photography Featured at New Smithsonian Exhibition

Posted on Wed, Apr 12, 2017
Emergency Physician’s Photography Featured at New Smithsonian Exhibition

Envision physician Jeff Gusky, MD, FACEP, lives two lives: one as an emergency physician and the other as a National Geographic photographer, explorer and now television host. His photographs and discoveries have been featured in media and museums around the world – and even on Broadway.

Dr. Gusky, who is an emergency physician at Emergis ER locations in Dallas and Fort Worth, was fortunate to find and photograph a hidden world of World War I, modern underground cities beneath the former trenches in France that once housed tens of thousands of troops at any given time. They were equipped with electricity, railways, telecommunications and the infrastructure of a modern city. One site is more than 25 miles underground in one place, another housed 24,000 troops underground and had a 700-bed hospital. Almost all of these findings are beneath private farmland and unknown to the outside world, even today. Now in complete darkness are thousands of messages that soldiers left behind: notes to loved ones, museum-quality art and inscriptions, names and addresses – a hidden world frozen in time.

The 100-year anniversary of the United States entering World War I was last week. On April 6, an 18-month exhibition of Dr. Gusky’s work opened at The Smithsonian National Air and Space Museum in Washington, D.C. More than 13 million people are expected to visit the exhibition. This short video, which is part of the exhibition, underscores the connection between emergency medicine, art and exploration.

“My mission as an explorer and artist is identical to my mission in the ER: to help people see and avoid danger,” explains Dr. Gusky. “I strive to inspire hope about the future among ordinary citizens by encouraging people to ask questions about modern life we have forgotten how to ask and by helping to create a language for us to talk about how technology and life in cities affects conscience.”

He made his debut as a television host March 13 on the Smithsonian Channel when the documentary titled “Americans Underground: Secret City of WWI” aired.

Dr. Gusky’s career as an explorer and artist began on a bleak day in December 1995 at the former Nazi concentration camp Plazow, just outside Cracow, Poland. Acting on a hunch while visiting a memorial near the camp’s entrance, he climbed a nearby hill in knee-deep snow. Approaching the top, a barbed wire fence came into view surrounding a Nazi-era compound: an abandoned building with prison-bar windows next to a set of ovens, ashes still present. In the dim light and silence, Dr. Gusky experienced a strong sense that unspeakable acts of barbarism once occurred there. Guided by intuition, he began photographing what he felt, the same method he uses today.
 
Since that day, Dr. Gusky has been on a quest to understand why mass murder and terrorism still threatens us. Exploring places in Poland, Belgium, France, Moldova, Ukraine, Transnistria and Romania, where millions of innocent people have been slaughtered in modern times, he has discovered a common thread to every modern mass murder.
 
“Technology and the inhuman scale of modern life endangers us by making us feel like machines and by disabling our moral compass,” Dr. Gusky said. “My work seeks to help communicate the looming human emergency caused by compromises we make that diminish our humanness.”
 
Dr. Gusky’s first year of medical school at the University of Washington was spent in Alaska as part of the WAMI (Washington, Alaska, Montana and Idaho) Program, created to inspire students to become country doctors. After graduation, he combined his love of flying and rural medicine and used his plane to reach remote hospital emergency rooms on short notice throughout Texas and Oklahoma. Since 1991, he has taught trauma skills to other physicians as an instructor in the Advanced Trauma Life Support program. He is a member of Alpha Omega Alpha and a fellow of the American College of Emergency Physicians.
 
He has published three books, and frequently posts new photographs and videos on his website and social media channels. Several other television productions are in the pipeline.

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6 Strategies for the Organized Mind

Posted on Mon, Apr 10, 2017
6 Strategies for the Organized Mind

Healthcare professionals have mastered the art of multi-tasking. But, the skill that has long been valued is now seen as a liability, especially with the new and increased focus on high-quality, error-free care. This was the premise of a keynote address titled, “The Organized Mind and Information Overload,” that Daniel Levitin, Ph.D., recently delivered. Dr. Levitin is a James McGill Professor of psychology, behavioral neuroscience and music at McGill University in Montreal. He is also the author of several books including the No. 1 best-seller, “The Organized Mind: Thinking Straight in the Age of Information Overload.”

Dr. Levitin told attendees that information overload often causes mistakes and that it can lead to deadly consequences in the hospital. Taking a cue from other industries that have pioneered efforts in safety and high reliability, such as aviation and heavy machinery, researchers are now studying the causes and effects of interruptions and distractions in the clinic.

It is easy to understand the potential impact interruptions have on patient safety. A 2005 study conducted by Alvarez and Correra of a hospital intensive care unit (ICU) identified 838 interruptions in 24 hours for an attending staff of nine physicians. The study identified two types of interruptions – turn-taking interruptions (where the person speaking is interrupted by the person he or she is speaking to) and breaking into a conversation interruptions (a third person interrupts a conversation that is occurring between two people). People tend to interrupt because they feel they need to know something immediately.

A 2010 study of ICU nurses by Anthony identified 75 interruptions during medication preparation in an eight-hour shift. Recognizing the potential for medication errors, the hospital placed red tape around the central medication area and the medication prep cart, designating the space as a “no interruption zone.” Medication errors fell by 50 percent as a result of this proactive intervention.

Dr. Levitin led the audience through six major themes that appear to be getting worse in the hospital setting. First, he discussed the Myth of Multi-Tasking. “The brain simply doesn’t work that way,” he explained. “When presented with a task, a project file opens in the cortex. As additional tasks or interruptions occur, new project files are opened. As the brain shifts from one thing to another, you are not fully engaged in any one thing. You deplete your neuro resources every time you switch because switching releases cortisol that causes interference in a variety of ways – increased heart rate, elevated blood pressure and disrupted digestive system. All of these can contribute to foggy thinking, sort of like being drunk, but you aren’t aware of it.”

“Uni-taskers” get more done, are more creative and produce higher quality work output than multi-taskers,” Dr. Levitin said. Other industries recognize this phenomenon and have instituted policies to mitigate it. For example, pilots cannot have unnecessary conversations below 10,000 feet. This rule enables them to focus solely on critical conversations with one another and with air traffic control. Air traffic controllers are required to take a break after working two hours. Likewise, to stay fresh and focused, translators at the United Nations cannot work more than 90 minutes consecutively.

The second theme was the Importance of Naps and Breaks. Dr. Levitin said we don’t fully understand why a 15-minute break if done correctly, can hit the “neuro reset” button in the brain. He cited research that identified the default mode network comprised of the central executive mode and daydreaming or mind-wandering mode. The central executive mode keeps you on-task and fully focused so that everything goes right. There is a distinct set of neuro circuits that are involved in this state. When you are in the daydreaming or mind-wandering mode, your thoughts are loosely connected from one moment to the next. This is the mode of the brain in which spent glucose is restored. It is also the most creative mode and one that enables us to think and solve problems. People do many things to enter this mode such as listening to music, immersing themselves in nature or going for a walk. In this mode, your mind wanders non-linearly making connections between things that normally don’t go together and, as a result, making solutions more apparent. Snacking during the day is also beneficial in restoring glucose. Dr. Levitin encouraged attendees to incorporate 10 to 15 minutes of mind-wandering a day while working in the Emergency Department (E.D.).
 
Decision Fatigue was the third major theme. Researchers have recently discovered a network of neurons that help people make decisions. The network does not distinguish between important and unimportant decisions. This information is valuable because it can help us govern the ways we schedule our brain power and make decisions during the day. He cited an example of judges, who in a recent study, were shown to make better decisions just after beginning work in the morning or right after lunch. The quality of their decision making declines as time passes between meals. So, if you’re innocent, you want a court case early in the morning or just after lunch. If you’re guilty, you want your case heard late in the afternoon. “Your mother was right,” Dr. Levitin said. “If you have an important decision to make, sleep on it and make it the next day.” He acknowledged that everyone has to make dozens of decisions each day. “But, you have the luxury to know that some decisions will be better than others, depending on the time of day. In some cases, it may be best to consult another colleague who is fresher regarding decisions that have to be made.”
 
The fourth major theme he highlighted was Externalizing Your Memory. “Writing things down reduces the burden of having to remember them,” he explained. “We tend to think our memories are better than they are. Memory is fallible, so it’s best to put things out in the world, so they don’t have to stay in your brain.” David Allen, an efficiency guru, says writing things down on note cards is a mind-clearing exercise. Studies have shown that people who write things down remember them better than those that type them. Use the environment to remind you of things you need to do. Set up a system to remind you where you put things – keys, wallet and/or telephone. Put a bowl by the door to provide a consistent location to place these items. If you check into a hotel room, experts recommend spreading a white hand towel out on a nightstand to designate a place to put your room key, wallet, phone, etc. Dr. Levitin described transactional memory systems as shared information structures. “People who are most effective and have the most power in organizations aren’t necessarily ones who know everything, but they do know the people to call to get the information. These people are extensions of memory because they help the other person keep track of all of the information.”

Managing Channels of Communication was the fifth major theme. “In this era of connectivity, we must figure out ways to manage how people reach us,” he said. “We have to train people in our social networks about how we want to be reached and when. There are truly a limited number of people who need to reach us immediately. Using a second email address for urgent communication is one way to manage contact. The worst thing to do first thing in the morning is to open up email. Every email requires us to make a decision. Before you’ve really done anything meaningful, you’ve already depleted your decision-making capacity.”
 
Dr. Levitin wrapped up his presentation with the sixth major theme – Ways to Handle Information Overload Better. “This really is the age of information overload,” he told the audience. “Every day of last year, Americans took in five times as much information as they did in all of 1986. That’s the equivalent of reading 175 newspapers cover to cover daily. In fact, we have created more information in the last four years than in all of human history before. Specialization has created a glut of information. Consider that last year 2,000 papers were published on the visual system of the squid. For every hour of YouTube video you watch, there are 12,000 additional hours of video being uploaded.”

How severe is the problem of overload and how does it exacerbate the number of decisions we have to make? In 1976, the average grocery store stocked 9,000 unique items. Today, more than 40,000 unique items populate grocery store shelves. Why is this important? Decision making has a neurobiological cost associated with it.
 
Bringing the topic back to the E.D., Dr. Levitin advised attendees to have a serious conversation about collaboration and record keeping. “We can talk faster than we can write,” he said. “Remember when physicians used the Dictaphone to capture their notes? Now we all have this capability on our smartphones. That’s why there has been an explosion of voice to data conversion programs. Developers are currently perfecting automated data entry into the patient record. No interruption zones are a great idea, as are mandatory short breaks that allow for mind wandering. Checklists provide an important avenue for externalizing memory. Examples include surgical checklists, palliative care checklists, medication administration checklists, etc. They reduce the stress of multi-tasking. Finally, I urge you to consider implanting gatekeepers – human or mechanical – to take extraneous calls and messages that create interruptions. These gatekeepers will protect your time and will help put into priority what will come into your sphere of decision making.”

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How a Journal Club Article About Mustaches Sparked a Discussion About Diversity in Emergency Medicine

Posted on Wed, Apr 05, 2017
How a Journal Club Article About Mustaches Sparked a Discussion About Diversity in Emergency Medicine

By N. Adam Brown, MD, MBA, FACEP
 
A few months ago one of my docs had an idea: Let’s resurrect journal club. To some, the idea of hosting a “journal club” made little sense for a community, non-academic practice. In fact, some of our team, especially our physician assistants and nurse practitioners, had no idea what a journal club was. Others who remembered journal clubs of yore thought it could be a great opportunity to discuss up-to-date topics and have the opportunity to socialize with our colleagues in an off-campus, relaxed atmosphere.
 
Initially, I was skeptical. I remembered journal clubs from residency and never really liked them. For one, journal “clubs” were a misnomer, as they were never really club-like (By the end of residency, I could have had a PhD in clubbing and I knew journal clubs were very, very different). And two, the articles seemed so academic, esoteric and boring to a sleep-deprived, barely-holding-on-to-sanity resident. But now after being out of residency for 10 years and amassing a significant dose of maturity, I began to see the value in hosting such an event. So I decided: Let’s do it.
 
To my surprise, our first journal “club” attracted quite a number of participants. After socializing, we took our seats to go over the assigned articles. I picked five articles; three were medical articles and two were non-medicine articles on mustaches and implicit bias (And before you wonder if I made a typo, yes, I picked an article about mustaches. I have a mustache so I was drawn to the title). I wanted our journal clubs to be a little different, where we discussed not only up-to-date medical practice, but discussed “hot topics,” issues surrounding physician wellness, and diversity and inclusion.
 
After discussing the three medicine articles, we started in on men’s facial hair. The article, released in 2015 by researchers at the University of Pennsylvania, hypothesized that men with mustaches were in more leadership positions in academic medicine than women. As I began to present the mustache article, many of my team appeared annoyed and others shook their heads in frustration as I explained the study’s conclusions that men hold 87 percent of academic leadership positions. Further, despite the relatively rare facial hair fashion statement, more mustached men hold leadership positions (19 percent) than women (13 percent). Overall, academic medicine institutions had a “mustache index” of 0.72 (13/19).
 
After presenting the article and discussing some of the initial points, I asked an open-ended question: Why do you believe fewer women are in leadership positions than men? All the women in the room began looking around at each other as if they were all in on some sort of inside joke that I had missed out on. So I asked again. Then there was a collective sigh. Some of the responses of my mostly female group were as I expected. A few discussed the challenges women have with juggling leadership and home duties. Administrative positions simply did not take priority when compared to caring for their children. Others were more pointed, conveying great frustration with misogyny in medicine going back all the way to medical school and residency.
 
“Men have more drive and ego,” one of my colleagues said. To which I countered, “Is that true? Do men really have more of an ego than women or did we as a society condition women and men to believe that it’s more acceptable for men to have a more assertive tone and more drive than women?” Some agreed. Society was partially to blame. Another said, “Dr. XYZ (one of our notorious inpatient attendings) always refers to me as ‘girl’ and is condescending to me on the phone.” Another, speaking about a previous practice experience, expressed the real anxiety she felt being the only female in an all-male practice. She went to work every day believing that she had to exceed the expectations and outperform male colleagues to be considered credible and equal. Now, being in a much more inclusive practice, she feels more at home.
 
What surprised me the most, however, was one of the final comments: “I’m just glad you were willing to talk about this. It says a lot.” (Everyone nodded in agreement.) Think about that for a minute. One of my staff members was just happy that I, a white male with a beard and mustache, acknowledged the gender issues (sexism and misogyny) and gender disparities in medicine. That acknowledgement, she believed, made her feel comfortable to speak to me about advancement opportunities or any other issue. For me, this comment was a “light bulb” moment and a huge win. Could simply talking about these issues open the door to other women or under-represented groups seeking leadership opportunities? Could broaching the subject matter of gender inequality promote greater inclusion in our practice? Quite possibly.
 
As a regional medical director for EmCare and Chief of EM at my two-ED campus, I am positioned to make real impacts on diversity and inclusion both in the people I hire and in the atmosphere of inclusion I promote. I’m proud to say that after two years as the leader of our practice, we are more diverse than ever (60 percent of our providers are female and 67 percent are non-white). Two of my medical directors are female and both advanced practice leaders are female. Furthermore, our practice truly reflects the community we serve—a community where more than 87 languages are spoken in the public school.
 
When I first took the leadership position at our hospital, I had one goal: Become the premier emergency medicine practice in the region, delivering the highest quality healthcare. While the idea is simple enough, executing on such a lofty goal is quite difficult. One area where I knew we needed to continue to improve was on practice diversity. Study after study indicates practice diversity not only benefits our patients, but also our employees and our business. With that in mind, I realized expanding diversity is not just a “nice-to-have;” it’s a necessity.
 
To ensure a healthy, happy workforce and practice, leaders must begin acknowledging the underrepresentation of women and minorities in our field. We must ensure we support an atmosphere of inclusivity and openness. So where do we being? Maybe hosting a journal club where we talk about and acknowledge the “mustache index” is a simple way to get the conversation started.

Dr. N. Adam Brown
 
N. Adam Brown, MD, MBA, FACEP, is a board-certified practicing emergency physician and the system chief of emergency medicine at Sentara Northern Virginia and Sentara Lake Ridge emergency departments in Northern Virginia. He also serves as regional medical director for EmCare’s North Division, where he leads a team of EM providers, six medical directors, and an administrative support staff for hospitals in New Jersey, Virginia and North Carolina.
 

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