I’ve always been an active learner who learns best in “need-to-know” situations — and the point-of-care context is the epitome of “need to know.” It’s hard for me to retain information if I don’t know why I need to know it. Thus, I enjoy incorporating learning into my everyday practice.
At the Boston VA, I manage teams of clinical students, including medical students, physician assistant students, residents, and fellows. I have a deep knowledge of nephrology and certain aspects of internal medicine, but I’m still early in my career and there are areas of medicine (like surgical wounds and trauma) that I have only superficial knowledge of. When a student asks me a question that I’m not sure about, I tell the student that we’re going to look it up together and learn. So we attack the internet together until we both have a better understanding of the issue.
Point-of-Care Learning Alongside Medical Students
A few weeks ago, a student in her third year, doing an ER rotation, encountered a patient with scabies — strangely fairly common in the Boston area. The student asked me how to manage the scabies on the patient’s clothes and in the patient’s home. Sure, in medical school, we learn the symptoms (extreme itchiness) and the treatment (usually permethrin or ivermectin). But what to do about the extremely contagious scabies still in the home?! We made an appointment to sit down together and looked it up on the web.
We started with the usual suspects for reliable medical information — New England Journal of Medicine articles, UpToDate, PubMed — and we got a nice review of the itchiness, the rash, the treatment options, and if I wanted to be confident in the diagnosis and charge the patient more money, I could do a skin scraping and pop the slide under a light microscope (not common in emergency departments) …but the patient specifically asked about what to do with his clothes and his mattress! He said, “Doc, I don’t want to end up back in the ER for a re-infection of the scabies. What do I do with my mattress?”
Surprisingly, the best answers came from something called “Scabies.lonecrow.net” that was corroborated with EHow, the CDC, and the Los Angeles County Department of Public Health. But “Scabies.lonecrow.net” hands down had the best explanation — you somehow have to desiccate the scabies — covering the mattress in plastic, flipping the mattress, vacuuming the mattress, or some combination of these (though I wonder if people just throw out their mattress).
Together, the student and I learned valuable knowledge about scabies that is likely not taught in school and helped our patient prevent a re-infection.
Learning with My Patients at the Point of Care
When time allows, I quickly skim UpToDate for the treatment recommendations for about half the patients that I treat before giving them my final recommendations and sending them home. This is a nice way to verify that my information is still current for basic cases, like otitis media, shoulder pain, rashes, and so forth. I usually pick up a few new facts and refresh older ones.
Since I can’t guarantee that I’ll see the patient again, I often spend more time explaining and counseling patients than I would in a primary care setting. For this reason, I sometimes spend significant time looking for educational discharge handouts for patients. Then I walk the patient through them, often two to three times. This allows me to learn the finer details of post-discharge management, like what to do with bed sheets and mattresses when you’re treating scabies.
Asking a Colleague
I am lucky to have super approachable, world-class trained colleagues working the ER with me along with amazing consultants who are training at all the Boston hospitals. What’s the fastest way to figure out a strange rash at the point of care? I call the Massachusetts General Hospital dermatology fellow on call and sometimes walk the patient up to the consultant’s office so that I can learn at the same time as treating the patient.
For example, antibiotics are critical to give early in a suspected infection — even more important in an infection requiring admission to the hospital. But what do you give if you have an older gentleman with mild renal failure (arguably, eliminating the use of some nice antibiotics) fever, elevated white blood cell count, blood cultures pending, pain all over (so no clear localization); and an allergy to vancomycin and piperacillin–tazobactam (yes, that is the magic bullet to cover everything for my generation of trainees)?
Hum—currently there’s no clinical support system or website that I can go to ask these questions.
So I call the infectious disease fellow at 10 at night. They are super helpful, also wanting the patient to get the best care; and they usually take an extra 15 minutes to explain which antibiotics are used for broad coverage with mild renal failure in someone with allergies. Why? Because this prevents me from calling them the next night; and I get a free ID lecture! I usually write this info down on my phone in a cheat sheet of common questions that Dr. Joe encounters but has trouble remembering the answers to.
Five Tips for Everyday Learning
Every day, I try to incorporate constant learning by doing the following:
Everyone has their own learning styles. I’ve been lucky to feed my active learning style by being surrounded by so many brilliant people. When in doubt, or just thinking through a point-of-care problem, I use the resources around me and just make a phone call and ask.
Jennifer Joe, MD, is the CEO of Medstro.com and Editor-in-Chief of MedTechBoston. She has been a physician in the Boston VA emergency room and urgent care since 2011 since moonlighting during her research year in a nephrology fellowship at Massachusetts General Hospital and Brigham and Women’s Hospital.
This post is part of the “Lifelong Learning” series. Posts on this topic include:
A Mid-Career Perspective on Lifelong Learning in Medicine, by John Mandrola, MD
Keeping Up with Core Medical Knowledge, by Natalie Levy, MD
Keep Learning Even When You’re Not Studying for the Boards, by Sara Cohen, MD
I Studied for the Internal Medicine Boards on the StairMaster, by Monique Tello, MD
Getting It Done: Four Tips for Learning Efficiently, by Jalan Burton, MD
Why Is It So Hard to Ask for Advice? by Sara Cohen, MD