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Welcome back! Time for #tweetorial part 2 of #periopmedicine meets #meded
This time? #GME!
I’m going to continue to look at this through the lens of my experience practicing perioperative medicine as an #IMproud internist

1/N
Let’s start with an “origin story”.

Do you know what my first exposure to the concept and question of “is this patient of an acceptable risk to proceed to the OR?” Was?

Want to take a guess?

2/N
It was on a hepatology elective! We were consulted to inform #periop risk discussions for a young patient with cirrhosis scheduled for an open abdominal surgery (fyi, this can be high risk)
It was a lightbulb moment for me as an IM resident!
Periop wasn’t just cardiac…
3/N
One of the things I’m passionate about is improving educational opportunities for internal medicine residents in perioperative medicine

Why?

For starters, 12% of the ABIM board exam is perioperative and consultative medicine, yet there’s no standard curriculum in this

4/N
BEYOND teaching to the test, why might IM residents crave exposure to perioperative medicine?

✳️Many are becoming Hospitalists
✳️PCPs have a role in periop medicine
✳️Any medicine sub specialty (not just cardiology) might be asked periop questions
(Ex. From @OHSUIMRes)

5/N
Residents often don’t get enough exposure to these questions on inpatient rotations
This is from a survey I did of @OHSUIMRes residents several years ago
But WHY is this a necessary AND such a fantastic learning opportunity? What can you teach via time in preop clinic?
6/N
I will aim to not be redundant with the prior #periop #meded #tweetorial.

Any of the teaching themes for UME apply, but the learning objectives for a learner in GME should be different

How are my teaching and expectations different for residents?
7/N
provide exposure to the guidelines themselves, share papers, discuss available periop EBM
& take it up a notch!
Compose teaching #medthreads & share #postitpearls





8/N
Talk about high value care!
Ordering an EKG, CXR, or labs “per protocol” at your institution? Slow down and discuss “how this will change management”. Share the Choosing Wisely recommendations

9/N
Want to get granular on teaching about population health and how guidelines and risk calculators were developed and derived? Channel @AdamRodmanMD @BedsideRounds and epistemology!
Btw, did you know periop’s cool history with risk calculators?

10/N
Build on the physical exam skills you might teach a med student AND incorporate the concept of pretest probability:
⏺Is that murmur in the X pathologic? Could it be severe AS?
⏺Is that atypical chest pain in a 25yo athlete concerning for CAD? In a 80yo woman with DM?
11/N
Model handling diagnostic uncertainty and the power of saying “I DON’T KNOW”

Ex. The 2014 ACC/AHA guidelines recommends ECHO when there is certain degrees of suspicion—but how do you know what your suspicion is???

How do you articulate your uncertainty??

12/N
Apply modeling “I don’t know”, especially at it applies to risk/benefit counseling and attempting to predict complications

How do we counsel patients re risk when we’re not sure if they will be the X% of patients who might have a complication?


13/N
Seize chances to teach about how surgical pathology presents

Granted, you’re seeing the small N% of patients actually need surgery, but…

Teach a budding PCP how cervical myelopathy, prosthetic joint infections, ovarian cancer might present

Work. Backwards.

14/N
More “big themes”
ACGME once used 6 core-competencies
though we moved to EPAs, I still find these valuable for #periop goals:
🔵Practice-Based Learning
🔵Patient Care
🔵Systems-Based Practice
🔵Medical Knowledge
🔵Interpersonal/Communication Skills
🔵Professionalism
16/N
We’ve essentially covered the “patient care” and “medical knowledge” domains
However, as excited as I get about the “medicine” of #periopmedicine, it’s everything else that I’m really excited to teach in preop clinic
17/N
interdisciplinary, professional communication:
whereas I might want a student to hear me talk to a surgeon about cancellation/postponement…I might want a resident to take the reigns on that conversation herself
18/N
Beyond connecting with surgeons and anesthesiologists at YOUR institution…
How do I get my patient who lives 8 hours from Portland a stress test before their surgery when they live in a care dessert and don’t have the gas money to drive back to Portland??
19/N
So what are the opportunities for @OHSUIMres?
❇️Primary care track residents
❇️Second continuity clinic (embedded over a year)
❇️Elective time

@ohsufamilymed residents before rural & ambulatory surgery rotations

@OhsuAnesthesia residents rotate at @vaportland

20/N
How many half-days are enough?
You want your learner to see enough of a “random” assortment of both surgical pathology and medical comorbidities

What are my “I want you to have experienced/worked through this”??

21/N
Goals—
🌀See (and feel) “stable and optimized”
🌀See the clearly unstable/not appropriate for surgery at this time
🌀the “grey zone”—the diagnostic dilemma:
🌀🌀MACE > 1%
🌀🌀Stress for atypical symptoms
🌀🌀ECHO for difficult to assess murmur or volume status
22/N
Thank you for reading!
I hope this excites and empowers you to teach in the #periop space—clinic, PACU, wards, clinic
It’s nothing to hide from
I’m also excited to be giving a breakout session on this at @spaqiedu @periopsummit #Periop2010 with @selzer_angela @hnyesf
23/FIN
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