USEFUL SECRETS ABOUT EDUCATION…LEARNING & RETAINING KNOWLEDGE!
In 2002, I did not know that the Emergency Medicine Resident’s Association (EMRA) had been performing a study of the top CME providers for Emergency Medicine education. I was one of listed with 7 of the top ranked organizations. The 6 others were either universities or the most active large ACEP state chapter CME providers. I was declared the most “expensive” because my programs are twice the total teaching hours (78 versus 35-37 hour programs) when compared by total cost. By the hours we all charge about the same amount. They did not mention that per hour the cost is the same, but felt compelled to cite , “Dr Collman is worth every penny even though he is the most espensive educator and he is the only speaker at his 6 and 8 day programs.” (paraphrased only because the site took down the study years ago…it was created to advise all emergency medicine residents where to spend their money on their most difficult exams which, if they fail, they cannot be board certified. So when people choose they think either I want to save money or I want the best money can purchase or something in the middle or perhaps they don’t think they ask what was your experience and all of my attendees virtually all come to me from multiple exam failures and from advise of a prior attendee who may or may not have ever failed an examination. Most docs never fail any examination. But emergency medicine is a relatively new specialty compared to all but pain management and it flexes it’s muscle by administering difficult exams for good reason. Part of the reason is the fault of the very board that controls most candidates for this set of exams…They wrote in a very important and highly respected journal if they certify a doctor the Advanced Life Support programs including ATLS, ACLS, PALS…etc are just “merit badge programs” and that no board certified doctor ever need take after completing an emergency medicine residency. That was in the late 1980s published in the Annals of Emergency Medicine and it damaged many people and killed many when physicians forgot this knowledge. When the board realized their mistake they then made annual Life Long Study mandatory. Even their own examiners called me in a fury or anger saying they should not be allowed to control what we study nor whom we pay yet again…you see the board charges fees for their LLSA exams. Many view this with disdain as it is a source of new revenue for a board that does not create enough great doctors or even average ones to meet the needs of the US population. This keeps supply low and demand high so the certified docs can ask for higher salaries. They there is the issue of how they are often transient in their location. So most hospitals are in chaos and the public does not ever feel joy going to any ED…knowing not whom they will see there just once for a possible life or limb threat. If none of this were true no one would have ever paid me. They would not need me. We have a massive number of suicides in our speciality. We in general have the shortest life spans due to absurd scheduling practices. The average emergency physicians body is so damaged by the hours and lost sleep that they lose 9 years of life…and die much younger than much of the US population. So to me no amount of money is worth dying for and yet they put up with a system that is so flawed.
When you do not solve your own problems you are in a sense…part of the problem…This is a message to all physicians who know they are exhausted and not well and mistreated…Join me in the fight to stop the corruption. I have maybe close to 4 more decades of life in me…who knows…it could even be longer…as long as I live and breath I will be here fighting for the patients and those who are the real servants of their patients. I was called tonight but a mother of a doctor who my son attended grammar school with but she remembers me as a single father of three…her son has a high functioning form of autism and made it through medical school no problem and he is a missionary to many countries…and he is kind. I have known him since I think he was in first grade. His mom called me because some head of his program in family practice, some “kind” female residency director with many degrees and awards has asked him to sign a letter of resignation because he is just not fast enough and when he notes abuse of patients he is verbal about it…abuse by other residents….well they are taking a great person who has a disability whom they hired who is an MD and if he chose not to sign that letter for his Hospital he will be fired yet his life is not secret and they inspect every candidate before they hire him. His medical education like most is over $300,000.00 and they think all of his work and effort should be better in some little residency in some tiny community hospital where he will never get much of a real education because this woman is supposed to be highly “academic” and an expert in helping the impoverished and that is what this doctor devoted his life to before becoming a doctor…he is still a missionary. I asked is she is pregnant…perhaps the hormones have turned her into a person who is not herself. Nope it’s not that. I want to go to her personally with my polite aggression and tell her I will report her to every agency possible for her transgression. I see this abuse of residents all the time. It has pushed some to suicide in many specialties. It has pushed many to a life of depression. Wasted doctors who had so much harsh treatment and she thinks she is being kind…no she is being, at minimum lazy. She hired him or her predecessor did. She should have been able to distinguish by that time with all of his education and lifelong efforts that he did it all on his own despite his disability and she should figure out he has Aspergers even though he has not been tested. He has been labelled ADHD and I think this is wrong based on many hours of testing him and talking. She is acting like the evil. He is the good…or she is just plain dumb or does not care.
His wife is a prior prosecuting attorney for the state of FL. I got the call on the night before my son’s 29th birthday, my son who is a minister studying now for his fourth degree, his PHD at a very prestigious university like an MIT but in Europe. My eldest son is an attorney for 11 years and he is now in medical school and practicing law. I think with my forensic background (that is my second board), and my two sons…and his wife…we shall tear this injustice down…but first we are always polite. So now I
I learned he decided to stay out of that toxic environment from him so…his career will never be the same. He has to find a new residency. I don’t think it is wise to just walk away and look for a new residency…and that is what she wants him to do…She should have to prove his is so incompetent and that he uses illegal drugs (which I know he does not) or that he sells crack or some other outlandish thing before I would consider her proposal…if you face such a situation you have my phone number. I don’t charge for this I charge after the evil not with threats…just the facts…possibly some law…and some prayer and morality. The best doctors have his personality. She must have lost her mind to do this. Now so far I have only one side of the story so to be fair I would have liked to heard hers. But this just smells like rotten eggs…and some of you think I just sit at home and paint…nope.
I have long known no one can teach a truly comprehensive program in 3 or 4 days and I have always taught what some consider an impossibly long program, but there is nothing impossible about it. Originally National ACEP wrote to me and stated they declined to participate in the CME because they wrote that it would take at least 14 physicians to teach such a long program (i.e., speaking for 8 days)-that was in 1988 but I did not let it stop my plans or change my design. I had spent a long time reflecting and observing some of the finest educators of young children. This convinced me that the continuity that comes from one designer, one speaker is a force multiplier when you want to increase the long-term recall of what you teach. Those were the two most simple yet most common and glaring factors I see over and over in how young children can recite paragraph after paragraph. Adults do not take the time to “rehearse” anymore. If you are a true professional this is a lifelong commitment.
By early 1989 National ACEP learned that I had taught several of the week-long programs through sponsorship with the Florida Medical Association and then reversed their opinion and became the primary provider of accreditation for all of the programs I have presented since that time.
It is true that there are very few people who can both practice and teach with the same degree of skill, pace, and focus. Many have cited me as a “world-class” educator (whatever that means). I appreciate the compliments, but I have simply proven the power of repetition and reinforcement. Thousands have come to simply realize these two concepts. I also started my medical, and art careers so young and have personally authored, designed, and illustrated all of this massive content hundreds of times that it is just simple proof of the power of these two simple elements.
Reinforcement is a way of saying or demonstrating the same process, concept, or fact from a different viewpoint just like the 12 leads of an EKG see the same electrical events of the cardiac conduction system from 12 different positions. Each lead has a very different appearance and recored the exact same electrical evens of cardiac depolarization and repolarization.
Then there is the need to know pathophysiology. The “science of medicine” (the “why” of what we do for medical management) improves your memory as much as it explains the underlying basis for your decision-making. Like the initial difficulty many have in understanding EKG interpretation using “vector science” to explain the 12 leads also simplifies what seems so complex. Reinforcement is often more difficult to overcome in once’s understanding initially without a proper understanding of physiology and pathophysiology. I believe it is critical to have simple (and detailed) explanations of the why of everything. One you realize how the tracing is produced it takes on new and vast meaning. It then is a powerful clinical tool able to diagnose dozens of cardiac presentations each with a unique set of goals for management. Ideally you go deeper and deeper in your understanding with time, repetition and reinforcement…and drill down the information as you mature in your career. You are also constantly relearning what you learned before if you keep studying. All of this is important and vital to maintaining knowledge and it definitely involves what is called the plasticity of the brain.
Reinforcement promotes much more than simple recall of facts. Related ideas can be very different visually or in concept. Recall by using wrote memorization is “a backwards method” when you want to learn something you will retain forever. It is why I have said we need to put down our “assistive devices” and use our minds again. Using software programs in education to look up answers and doing this in clinical practice degrades your memory if you do not actively study and also participate in interactive study.
I have revised each of my programs including the live presentation and manuals more than a dozen times over decades of teaching the material. So I am constantly bombarded with repetition and reinforcement. It should be no surprise that it is simple proof of how natural it is for us to learn if we use our minds for decades to build the requisite connections in the brain; new memories and expanding memories and functional knowledge and growing it all involves new protein synthesis and new axonal connections in the brain. This is important because we are all losing brain cells but we make up for this by activating all regions of our brains if we do different tasks and we modify how we learn and keep it “interesting.” I also believe having one speaker provides continuity of thought from day to day and so I am the only speaker at my CME programs for the boards. There is nothing special or “magical” about having a large fund of useful knowledge and clinical acumen to speak for 6 or even 8 days which I have done for decades. All of the writing and illustrating the same facts and then modifying them as time advances and knowledge changes forces me to stay in a state of perpetual learning.
Using these simple three elements is very powerful. Repetition, building on concepts from day to day (that are linked) and combined with reinforcement you have the recipe for long-term understanding and thus long term recall. It requires commitment there is no doubt about that. So….if you are not motivated to do this you will struggle and you will make many more mistakes. Board exams instill a sudden but temporary motivation because it is your financial health on the line and your ego. It never ceases to make me laugh a little bit when I see how people exceed what they say is their limit to learn when it comes time to prepare for boards. The concept that a 30 minute rule is all the human mind can handle at a time is ridiculous. I have proven that for decades with my attendees.
I send out all of the materials well in advance for the same reasons-to get as much early engagement of the mind of each participant. Most still do procrastinate, but those who do not are truly changed after true total participation. That is the last element. I am now talking about interactivity. People come with questions they did not realize they had if they read the manuals and we need to talk about them and I have the audience engage in every image I display. I ask them to speak. This is difficult for many at first only because the fear of public speaking is still a number one fear in humans.
Finally, oral boards are much more reality that most initially realize. What I mean is that what you say is likely what you really do in life in clinical practice. However, physicians have no idea what they will say until they record themselves. We now have a deep problem of producing true accomplished knowledgable physicians because academia has bought into the flaws of how we use computers and fancy phones. They damage or impair learning because of how we use them for fact finding instead of truly learning all of the requisite core content knowledge we should know.
I had a simple cardiac case ” a code” today. He arrived 20 minutes from the time he arrested witnessed by the paramedics. I still do the H’s and T’s. Why? One reason is that If you are cold and dead you are NOT DEAD. We are all supposed to know this; Prolonged resuscitation of simple CPR is required in cases of lightening strikes. Florida is the most common place on the planet to be hit by lightening so this one is easy for me to remember because I have lived here for so long. So there are different ways we use even our living environment to learn and retain useful information. It affects outcomes. So the 10 minute rule is not applicable for pulseless patients to stop a code after a lightening strike or hypothermia or when drugs that can be reversed may be involved or tension pneumothorax…(the H’s and T’s again). For every rule or concept their is likely an outlier exception concept or even many. We need to know those too. If you don’t pursue these you will never be as effective as you should be in clinical medicine.
Yesterday i saw a patient who returned with shoulder pain worked up as cardiac pain the day before. it was clear the patient was never fully undressed or examined. The problem was obvious and was on the posterior thorax (severe paraspinous muscle spasm) and it was referring to the shoulder which “confused” the prior physician examiner. Confused is not the word. The truth: The patients backside was never examined and shoulder pain in an elderly patient resulted in an unnecessary full cardiac workup and a repeat troponin. Such a simple thing which was resolved with a trigger point injection. Just to walk in the ED it is hundreds or even thousands of dollars. Start with the same rules and never deviate. UNDRESS and expose the entire patient when you do your core physical examination whether it is a simple chief complaint or a complex patient. You have to do it during that physical exam in trauma we call the secondary survey in trauma. Don’t short cut the examination. If the shoulder hurts think of it as an organ that is attached to the thorax. Two adjacent organs must always be examined if one is presenting with a symptom. Also, any two organ systems that work in concert (like the kidneys and the heart, the lungs and the heart, the brain and the heart) must also both be examined when one is examined.
Keeping all of your emotions in check is a major part of the definition of what it means to be a professional. I take 3 minutes and pray in my car before I ever enter the hospital; I made it a habit. You can just meditate if you wish. Have a method so you do not make an error of omission or commission because of becoming emotional; do not enter a hospital for work in an emotional state and plan to defuse your personal life so you can be at your best when you see patients.
I see “professionals” as reactors or nonreactors…the ones who stay calm and do not react no matter the issue always out perform the “reactor” types. Most learned this behavior from their parents…it is not always easy to unlearn…but it is a necessity to practice the best medicine possible. For most, this becomes a lifetime issue of learning not to do this…it did not develop in a day and it will usually take twice as long to unlearn a “behavior” such as over-reacting. If you do not have balance and outlets for your emotions you will not succeed in comfort. You will always say you are under duress or stress. It is truly in your head…your perception of your reality is truly your reality and it affects everything about you including even your health. An abrupt reaction to a stressor releases gobs of epinephrine and this has been shown to actually kill muscle and brain cells. So yes over-reactor types are not as nimble in their minds in the moment of the stress. The “deer in the headlights” phenomenon is quite real. It is hardwired into all of us. It is a primitive ancient reflex that you have to learn to manage.
So what I am going on about in how we learn and what we keep as useful knowledge…well it is not just about information storage…it is also about lifestyle, what we eat, if we exercise and definitely we must sleep. Most experts agree you are supposed to sleep ⅓ of your life to be a top performer. There are always exceptions. I know I inherited a less need for sleep from one of my parents. We are not all the same. You have to “know yourself” then to become your best. Sounds silly too but it is also quite true.
Finally, I will end with this for now…Yes it is true that bedbugs produce massive hives in SOME patients. However, what look like urticaria occurs in many conditions. A rash should itch if it is truly an urticarial reaction (truly urticarial). Seems like a “silly” fact; silly facts are often useful. Medicine is replete with silly facts, mimicker illnesses, and illnesses that are not diagnosed by any laboratory test.
Many issues like tension pneumothorax is (for ideal or best care) always a CLINICAL DX and not a radiological diagnosis or you did not manage it correctly! You should never have a chest film that shows such a finding or you did not do the exam and the management and this is one of the worst mistakes you can make (since it can take a patient’s life in seconds). Relief of tension pneumothorax can also make a nonbearing heart begin to beat again. This is an example of related thinking of a subject that you must often experience to know is possible so you never forget it. So a patient with no heart beat for less than 4 minutes who happens to be mildly hypothermic can be and should be fully resuscitated. Decompressing the TPX may start the heart now that it can fill.
[Some of you may feel that I said nothing special here except you must have the core content in your head…it is 2500+++ pages minimum of 8 point helvetica and that is an enormous task. How you accomplish this varies from one to the next. Ultimately…(usually on the last day we spend time together) This is what I tell my students: “Don’t worry, when you tip your head to the side and it all spills out after boards there wil be no permanent damage!” Did you picture a liquid of words or letters flowing out of one of your ears? Never forget that it is constantly happening even when we are perfectly upright…no pun intended. Knowledge is always leaking out of us (lost memories)…so you must constantly put them back in…yeah that mean a lifetime of study. It is part of being a nurse, physician or any healthcare provider!]…DDC