Han’s Holler – Regional teaching 7/6/2017

From Dr Neil Long (senior registrar) and Dr Hans Hollerer (DEMT Footscray), wrapping up Regional Teaching from the Northern Hospital 9/6/2017. See summary and click on each for further notes:


Hot Hints and Heuristics

– a talk by the ED director at Northern about shift management – what works/ what doesn’t work and different approaches


The Biggest hurdle

– an interactive lecture about the different phases of exam preparation and how to go about it


Getting to Yes

– a lecture about one of the most difficult things at work – how to deal with “The wall” when making referrals to inpatient units


What doesn’t kill you

– how EPs and registrars experienced the thunderstorm asthma day and how to deal with aftermaths of disaster.


Are you OK?

– burnout and fatigue in ED trainees



Hot Hints and Heuristics
– a talk by the ED director at Northern about shift management – what works/ what doesn’t work and different approaches.
The Northern hospital have adapted an approach of a consultant managing flow, something to consider as you get more senior. The consultants aim was to expedite admissions, pick out the “list blockers”(those patients no one wants to click on) and trouble shoot referrals i.e. stopping the RMOs having to make 15 phone calls to get a patient admitted.
The learning points for me were to consider:
What type of leader you want to be? Someone who demands everyone gives 110%, or someone who tries to manage the shift and pick up patients as well? There are various styles that we can observe as trainees especially at Sunshine and perhaps it’s a case of not one style will work all the time- bit like managing AF, you need to build up your toolbox and just have some trial and error when doing shift reports.Do you front load the ED? Their consultant was picking patients out of the waiting room and initiating early investigations where appropriate (or assigning registrars to pick up a couple in the waiting room). Highly topical at Sunshine currently but we all need to think about how best to approach the triage 3 problem.
Links that may be useful include the ACEM leadership module found in elearning (https://elearning.acem.org.au/course/view.php?id=433) and those who are really keen, Leadership Victoria run courses (http://www.leadershipvictoria.org)
The Biggest hurdle 
– an interactive lecture about the different phases of exam preparation and how to go about it

Written advice:

  1. Most importantly of all, everyone has an opinion on how you should study. Remember you have been through 100+ exams all on your own. Whatever revision method works for you carry on.
  2. Decide if you are going to cram revision into 6 months, or a full 12 months. Think about whether you are working full time, part-time and what are your family commitments.
  3. Talk to your significant other or friends. Everyone will need to make sacrifices while you revise and having their support is important. You also need to plan time out to spend with them so you can unwind. I sat down with my partner and stated she would need to be like a 1970s house wife, fortunately after some furrowed brows she understood what I was saying and was able to support my exam campaign. Don’t underestimate how much friends and family are impacted by your revision.
  4. Make a revision plan and stick to it. Here is an example plan from Sir Charles Gairdner Hospital.
  5. You will quickly see there is not a lot of time to go into vast depths on each topic therefore join an exam group, this will help keep you on track but also help discuss concepts or areas where people constantly make mistakes. There are also not a lot of MCQs out there so this is time well spent in your group quizzing each other.
  6. Talk to examiners to give you the tips on the high yield topics and how best to answer the questions. Understanding the game is half the battle. For example with a hypotension question there is no point writing “1. IV access, 2. Noradrenaline” Everyone knows noradrenaline has to go IV, the examiner will get annoyed. Better still write “Noradrenaline 1-10 mcg/minutes titrated to a MAP of 65”. Remember to think how can I write the most succinct information on one line. Anything outside these lines will not be marked and the first answers will be marked in order.
  7. Write your own questions. now you do not need to go over the top here but at least try it a few times. You will be amazed at how long it takes and what short cuts you take. For example, an MCQ is hard to write, when you see a table it is so much easier to create. This is exactly what the examiners do. Once you start noticing how to they would think you read the textbooks with a different mindset.
  8. Textbooks. Now this divides opinion, some of us read them cover to cover, while others will never open one. We have a list of recommended textbooks and as Joe Lex states ‘it is worth you reading one cover to cover at least once during your career’. For those that despise textbooks I would recommend using one to reference when you are struggling with an answer or concept particularly with MCQs. Also its worth looking at all the tables, as mentioned in point 7. This is where the examiners’ lists will come from.
  9. Go on a course, there are a few around and we have a list of courses. Speak to colleagues before signing up, they are varied and slightly different in style, they also cost a lot of money and some are better value than others.
  10. Practise, practise and practise. This sounds stupid but the best advice I got was from Jo Dalgliesh an examiner in Melbourne who gave me a Nike enema when I’d only done 2 full practise exams 2 months out from the written. By the time the exam came I had done 3o full papers to time and was able to complete a paper in 2.5 hours. By doing the exams you will see what your common mistakes are, what the examiners are looking for and your answers will become more concise.

OSCE advice:

  1. As per point 3 from above, make sure you have the support of your loved ones.
  2. Although your knowledge should have been tested in the written, now is not the time to take your foot off the break. The OSCE sometimes feels a bit like the hunger games and they can ask you about anything in the curriculum. They want to combine your knowledge with everyday practice.
  3. Consider going on an OSCE course or at least making sure you have done one full OSCE set, preferably a three day event. Doing one and then getting feedback does not prepare you for the mental fatigue and stamina required for a full three days.
  4. Develop a coping strategy for when you bomb on a station. Remember not even the prize winners make it through unscathed. It is important to keep going over the three days and to enter each station hungry for those FACEM letters.
  5. Develop a strategy for stress, particularly on the day. I don’t believe anyone had a heart rate less than 120 about a minute before stepping into the exam corridor. My technique was using mindful square breathing (hey whatever works for you) or doing the “power pose” outside the room (see the TED talk – Fake it til you become it).
  6. Develop a framework for the different OSCEs but not a script. You need to know an approach to breaking bad news or a complaint but you also need to come across as a caring human being. The examiners will not like it if you come across pre-formatted or like a robot.
  7. Do what the tasks ask for. Nothing more and nothing less. It was my technique to read the tasks first, then the start of the question. Finally pick out the discriminators, i.e. its late at night, a rural hospital, your talking to a consultant/intern/registrar.
  8. Remember your agenda may not be the same as the examiners agenda. Listen to the cues, if you get asked a question, do not dodge it, they are trying to get you marks.
  9. When the one minute warning goes, change tact, either thats summarising or asking if there are any other questions but you must make sure you have left the room with a consultant plan. Do not tell the intern 20 different management strategies without summarising and giving them a to do list.
  10. Practise, practise practise, it does become very personal and you can feel like you are always being attacked but the more stations you do the better you will be on the day answering them. Who else gets this much attention to learn while getting paid at the same time (think of the positives).

Other wise words:

EDExam written fellowship advice with Luigi Marino and Andy Buck

Getting to Yes
– a lecture about one of the most difficult things at work – how to deal with “The wall” when making referrals to inpatient units referenced the “Art of War”.Phyllis Fu had her 6 steps to getting to yes:

  1. Prepare your story, get it concise and to the point. Have bloods and investigations you think maybe necessary at hand.
  2. Prepare to answer some of the flaws in the patient story and have a response i.e. the old abdo pain with D+V – “I agree with you it could be gastroenteritis but I am worried in this patient because his abdomen is so tender it makes this diagnosis less likely and would like your review”
  3. Keep the patients interests at the forefront of the discussion – “I would like you to see the patient because they need a surgical impression and differential, we can then discuss their ongoing care after you have reviewed them” or if you believe they are a slam dunk admission “In my (or our) experience these patients do poorly when not cared for by the surgical team and an intra-abdominal sepsis will be life threatening if not treated and diagnosed early whereas gastroenteritis will quickly resolve with supportive care”
  4. Remember these are your colleagues and likely friends outside of work. Say hello in the department, try and refer face to face (its much harder to refuse in person) – try to help where you can or bribe them with a cup of tea or biscuit (the British way – everything is better after a cup of tea)
  5. We often don’t tell the inpatient teams what specifically we are worried about per se. Say “ I cant exclude intra abdominal sepsis and would like your opinion”They may then say because of ‘x’’y’and ‘z’you don’t need to worry about intra-abdominal sepsis, or alternatively, turn around and say “I agree you can’t rule it out and I will see them”.
  6. Try to avoid the “Its departmental policy and therefore you need to admit and re-refer if required or I will speak to your boss” All you end up doing is aggravating the registrar. The subtle art of highlighting the policy without specifically being threatening is the key “I think this elderly man requires a surgical admission in the first instance, perhaps you could see them and then if it is unclear we could discuss it with your consultant or the ED consultant?”


By trying some of these steps, you hopefully avoid that chronic stress of the referral process and feel happier at work. On a separate note Phyllis recommended we all read Middlemarch by George Eliot – number 21 of all time books according to the Guardian newspaper and gives us insightful behavior into the challenges of a physician.


Are you OK –This led on from the thunderstorm asthma talk and it was new to me that ‘Burnout’ is not a diagnosis, its actually chronic fatigue. For those that have not heard of some of the key features, it includes (not an exhaustive list):

Lack of enjoyment at work

Feeling under appreciated, tired and stressed.

Finding yourself arguing lots

Getting annoyed with patients or staff

Instead of enjoying a drink finding you “need” a drink

In Victoria we are lucky to have the Victorian Doctors’Health Program:




VDHP provides assistance to doctors and medical students who have any of the following concerns:

  • Stress and anxiety
  • Substance use problems
  • Mental or physical health concerns
  • Any other health issue

We can listen to your problems and work with you to help you find solutions. Sometimes, even though as doctors we are very good at helping others, when it comes to helping ourselves it’s difficult to be objective and ‘see the wood for the trees’. One of the VDHP Senior Clinicians can help you untangle the mess and find a way forward.

Advice is also provided to anyone who is concerned about a doctor or medical student. This includes family, friends, colleagues, university staff and clinical staff.

Since the commencement of VDHP, we have assisted doctors and medical students presenting with numerous issues ranging from those having a mild impact on quality of life to those threatening careers and lives. VDHP deals with each individual case on its merits and offers a range of interventions.

VDHP develops individual management plans and co-ordinates treatment, including arranging appropriate referrals to external treatment providers.  We conduct our service with the utmost discretion. Confidentiality is of utmost priority to VDHP. However, like all health practitioners, we are required to remain in compliance with the Health Practitioner Regulation National Law Act 2009.


If you are lucky enough not to require their help it is likely you will come across colleagues that will and helping to signpost them will be one of the most important things you ever do. Suicide in doctors is very common and it maybe easier to spot those doctors who are more vocal but it is important we ask and care for everyone in the department (including the quite ones).

If that does not inspire you just to take a quick look at the website then consider the OSCE. There is a station on the “impaired colleague”, you will need a plan on how best to support them at work and outside the agency, VDHP is a good answer and a practical solution.


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