Laura Holmes, MD
EMERGENCY DEPARTMENT, UHC
email Dr. Holmes
phone: 844-1636

The challenge of Emergency Medicine lies in meeting many new patients with potentially serious illness or injury, properly prioritizing/triaging them into who is most ill, processing large amounts of information and making rapid reliable decisions toward disposition. The final decision to admit or discharge involves "working down" from a question of "Does the patient have a life-threatening problem?" to "Can this problem be further explored as an outpatient?" Correct action is more important than definitive diagnosis. This unique skill of Emergency Medicine is often not recognized by medical students as different from the usual approach to patient problems in Internal Medicine, where they often view the approach to any patient problem as the painstaking but time-consuming "work-up" to a definitive diagnosis. Teaching this essential difference in patient approach is all the more paramount when the Emergency Medicine experience occurs in the context of the outpatient Internal Medicine rotation at University Hospitals.

PROJECT DESCRIPTION

This project will explore five common problems in emergency medicine: chest pain, shortness of breath, abdominal pain, headache and back pain. The Scholar, an experienced EM clinician, will explore with the students the thought process for each problem. The medical students will be guided through the "work-down" that the emergency physician makes when faced with each of these complaints. They will begin with triage and end with disposition. The questions that occur between these two points will include:

What is the broad potential differential diagnosis?
Which of the diagnoses are life-threatening?
What are the "red flags" in the history that point toward a life threat?
What are the key elements in physical examination to rule out/in life-threatening diagnoses?
What diagnostic testing is necessary in the ED to exclude life threat and narrow the differential diagnosis?
What is the safest and most appropriate disposition for the patient?

Definite life threat:
Immediate Rx in ED, consider consultation, admit

Life threat possible:
Rx in ED, admit for further evaluation and treatment

Life threat not found:
Definitive diagnosis - initiate Rx, admit or discharge
No definitive diagnosis- empiric Rx, define follow-up criteria including MD/Clinic visits, or admit for further work-up

The students will document this process in decision tree format, check their understanding with the clinician and then recheck the decision tree against evidence in the medical literature. After review and revision of the tree with the clinician, the students will then have the opportunity to observe, record and critique the steps in the process as the faculty member demonstrates a patient encounter. The students will then move on to their own interaction with a patient. These encounters will be videotaped to allow feedback. The group will observe the taped experience and critique the steps. Select tapes could then be used as teaching resources for future CWRU medical students. In addition, if project costs permit, programming each decision tree for the eCurriculum would be considered.

This project is consistent with the CWRU model of small group student-faculty teaching experience and the fostering of "learning to learn". In addition, I believe it is essential that students have an appreciation and understanding of the particular thinking process of the various medical specialties. This scholar's project seeks to achieve this goal in Emergency Medicine, and thus fulfill a curricular need in this area.