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Right Place, Right Time
Intrepid faculty and residents work together to create a distinctive Emergency Medicine Residency Program

Residents

Six residents have a year of residency under their belts. Not only did they have the typical exhausting experience as newbie interns, but they did it in a brand-new residency program at SIU School of Medicine: Emergency Medicine (EM). The first class of SIU Emergency Medicine residents, now in their second year, took a risk by entering a new program, but they are finding it a rewarding experience.

The six men are an energetic bunch, at great ease with each other. You can tell they are close, ribbing each other like college buddies.

“We had to be up for a challenge,” says EM resident James Waymack, M.D. “But it’s been a unique opportunity to be at a new residency. We’ve established this program as our own and are having a lot of fun.”

The residents have created a culture that resident Ryan Joshi, D.O., labels assertive, independent, and confident. “We’re not competitive with each other about who is getting the most experience or the most procedures. We work together and help each other out. We knew there would be more expected of us than at other residencies.”
They agree that they are getting more autonomy than they might at an established program. EM resident Rich Jeisy, M.D., says, “We have a willingness to do pretty much anything.”

The residents divide their time equally between the two teaching hospitals, Memorial Medical Center and St. John’s Hospital, which have a combined annual emergency department volume of 120,000 patient visits per year. With the full might of the teaching hospitals behind them, the emergency medicine residents have all the niceties of an urban, academic medical center. The residents appreciate the supportive experiences each hospital provides. “At Memorial, we see more burns, and we’ll see more trauma patients at the Southern Illinois Trauma Center,” says Dr. Joshi. The SITC rotated to St. John’s on January 2 and switches annually between the two hospitals. At St. John’s Women’s and Children’s Center and the St. John’s Children’s Hospital, residents gain significant experience with pediatric and OB/GYN patients.

The enthusiasm of the residents matches that of the faculty at those two hospitals. “The entire faculty is so forthcoming and outgoing,” adds resident Tony Cummings, M.D.

“It’s the friendliest learning atmosphere that I’ve ever been in,” Dr. Joshi adds.

“That’s an SIU thing,” alumnus Dr. Waymack replies.


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Dr. Chris McDowell, Dr. Jonathan dela Cruz, and Dr. Ted Clark are leading the Emergency Medicine Residency Program. Dr. Chris McDowell, Dr. Jonathan dela Cruz, and Dr. Ted Clark are leading the Emergency Medicine Residency Program.

The specialty of Emergency Medicine is about as old as the 40-year-old SIU School of Medicine. As health-care reforms are implemented, emergency medicine physicians believe the number of visits to the emergency department will increase, according to a 2011 poll from the American College of Emergency Physicians. Only four percent of the nation’s physicians are emergency medicine specialists, the AMA reports.

Former chair of surgery Roland Folse, M.D., and others considered adding EM to the medical school in the late 1980s. In 2005, about 11 percent of SIU graduates matched in emergency medicine residencies. In 2008, the Division of Emergency Medicine formed within the Department of Surgery. Interestingly, five of the eight core faculty are SIU School of Medicine alumni: Program Director Chris McDowell, M.D., ’05, Michelle Alepra, M.D., ’02, Ted Clark, M.D., ’06, Jonathan dela Cruz, M.D., ’06, and Jason Kegg, M.D. ’07.

“We have a loyalty, an allegiance to SIU,” Dr. Clark says.

“We all felt a kinship to the medical school,” agrees Dr. dela Cruz. “There’s something special about the training here that makes you want to come back.”

“SIU School of Medicine instills pride in its alumni,” observes Clinical Associate Professor Linda Nordeman, M.D. “They wanted to come back here and grow something new. You don’t see that very often.”

In a “too good to be true” moment, the alumni returned to SIU School of Medicine fresh from their own residencies to begin from scratch a new Emergency Medicine Residency program. In 2009, the program received a three-year accreditation, becoming the first SIU residency program accredited since dermatology about 20 years ago. Six spirited residents took a chance on the new program in 2010 — half are alumni of SIU School of Medicine. This summer, they have entered their second year of the three-year program, and six fresh interns have begun their first year.

With no senior residents to guide them, the first class of residents relies on the supportive attending physicians. “They give us instant feedback. That makes us much more independent workers in the rest of the hospital,” Dr. Cummings says. “We know what needs to be done. We’re doing things that our attendings have only done once or twice in their careers.”

He adds that the supportive nature of the faculty is contagious. “I want the class coming in to have even better experiences than us.”

******The residents work in the Clinical Simulation Center.

At SIU, this isn’t your typical EM residency. The faculty is focused on training not just stellar clinicians, but educators, leaders, and innovators. They are instilling innovative and forward-thinking ideologies. The fast-pace of emergency medicine, the diversity of cases, and the opportunity to practice acute care brings vigorous minds and bodies, and a culture of modesty and humility combined with self-directed learning and physical stamina.

The residents are well-equipped to work the 80 hours a week to learn emergency medicine. “We are so fortunate with our EM residents,” says Dr. Nordeman. “They are smart, highly motivated, and very capable. For most residents from other programs, the ED is just a rotation they have to do. It’s been fun to have residents who are eager to learn emergency medicine. They have engaged the entire faculty, including clinical faculty, who love teaching the residents.”

First-year residents get experience in anesthesia, trauma surgery, orthopaedics, plastic surgery, OB/GYN, internal medicine, cardiology, and adult ICU. “There’s a great opportunity to not only build our residency program but to change the residencies around them. The EM residents can promote the culture we want to instill,” Dr. dela Cruz says.

That culture includes using the latest technology tools for residency training and clinical care. Memorial’s Clinical Simulation Center allows residents to sharpen their skills in a supervised setting, using 3-D and 2-D training modules, including SimMan™ and iStan™. They also have access to child mannequins and a birthing simulator. Residents are videotaped and review their clinical performance. Clinical Educator at Memorial Medical Center Chris Reavis says the residents are frequent visitors to the lab. “They are learning how to assess different patients, from those with head traumas or GI bleeds to surgical candidates.”

Such hands-on simulations, as well as online learning, are the tools from which today’s medical students learn. Students and residents can do more self-directed learning by having access to digital lectures via Podcasts. The faculty is developing a centralized electronic curriculum formatted for a tablet. “We are nearing the point where Web integration and electronic device integration can be useful, not frustrating,” says Dr. Clark.

The residents have suggestions about modifications to the EM curriculum, and they say no matter how small the issue, the faculty listens. “We’ve given our input about how to change rotations or do different rotations to give us a better learning experience,” Dr. Jeisy says. “They’ve implemented those changes for next year, and in some cases, even during our first year.”

The EM curriculum potentially will impact all the medical students at SIU. The division hopes to implement an EM clerkship for the third-year medical students and eventually embed an acute care curriculum throughout the four years of medical school. The ED provides a unique experience for students and residents to learn the diversity of medicine. “Every part of medicine somehow touches the EM department,” Dr. McDowell says.

The curriculum also includes instruction in ultrasound technology, a tool newly used in the ED. The American College of Emergency Physicians has created guidelines for ultrasound use, and SIU is training residents on the technique to get better, more efficient evaluations. “Ultrasound is an extension of the hand,” says Dr. dela Cruz, who did a mini-fellowship in the technology. “It is safe, portable, and a great device for many specialties, such as OB/GYN, cardiology, and radiology. I foresee it in the primary care department as well as surgery. The Emergency Department can use it just like other specialties to improve bedside procedures. Ultrasound has become a multidisciplinary art.”

Currently, each of the two hospitals has two ultrasounds available in the ED. Dr. dela Cruz and Emergency Medicine Chair David Griffen, M.D., are testing a portable device that may make ultrasound even easier for ED physicians.

“I want the residents to extend their expertise in ultrasound during their many off-service rotations,” Dr. dela Cruz says. “This is an opportunity to spread the knowledge throughout the hospital.”
Working throughout the hospital, the residents are giving back by contributing to process improvement and quality care, patient safety, team training, and public policy. “Our goal is to improve the way the system works in the hospitals,” says Dr Griffen.

In accordance with that goal, the SIU residents are involved in a three-year, longitudinal Quality Improvement Project with the hospitals. Few EM residency programs have residents involved in such a quality project, according to Dr. Griffen. “It’s important that residents have a role in improving processes for best practices.”
The project aims to reverse anti-coagulation for patients with intracranial hemorrhage. The six residents are developing protocols for the hospitals and have produced a training video. “It’s been an excellent cross-service experience,” Dr. Cummings says. “It’s been nice to work together as a group.”
The board-certification process mandates experience in hospital’s quality management practices. “But it’s also just good medicine,” Dr. McDowell notes.

Another unique learning experience is a newly-established rural rotation. “Not all residents are going to practice in urban areas, so we want our residents to have experience so they can deliver top-quality care regardless of the services available,” says Dr. Clark, a native of rural Carterville.

Nationally, only a handful of the 150 EM residencies have required rural rotations, says Dr. Clark, who had the goal to bring a rural component to the EM residency. Rural EM physicians may be in a one-room department, with 10 to 14 beds. “Whoever walks through the door is your responsibility,” Dr. Clark says. “These physicians have to do more on their own and be more resourceful without the sub-specialty backup.”

During the second- and third-years at SIU School of Medicine, the EM residents will work one to two shifts each month at Taylorville Memorial Hospital, a Memorial Health System Affiliate, assisted by a board-certified attending. “In Taylorville, residents will get hands-on experience in a location that doesn’t have all the resources we have at an urban academic center,” Dr. Clark says.

Plans are in the works for a second rural experience at a Hospital Sisters Health System site, possibly in Litchfield. “Residents will learn the skills needed to do appropriate transfers and manage more things on their own,” Dr. Clark says. “Hopefully we can increase the number of graduates who ultimately practice in rural areas, in line with the mission of the school.”

Another distinguishing feature of the EM residency is the experience in pediatrics at St. John’s Children’s Hospital, considered a hospital within the hospital. St. John’s has a fully-equipped pediatric emergency medicine department. “We have all the age-based and size-based equipment needed for young patients,” says Dr. Nordeman.

The SIU Emergency Medicine faculty also includes two board-certified pediatric emergency medicine physicians working at St. John’s: Myto Duong, M.D., and Kathy Lehman-Huskamp, M.D. The residents learn about the special needs of children, including learning from a child-life specialist. A sizable pediatric curriculum includes simulations, procedural labs, and other didactics. “We teach the medicine, but we also teach all the other things that make the care for children at St. John’s special,” Dr. Nordeman says. “I don’t think most residents are exposed to these things.”

That includes understanding family issues surrounding the care of children, Dr. Duong explains. “Residents need to know how to treat a sick child at any age and also address concerned parents and grandparents.” The residents also will spend time at the Pediatric ICU at St. John’s hospital, where they will learn from pediatric anesthesiologists, cardiologists, and other specialists. “The residents are learning about the complete development of children, including the subtle nuances of how children are different from adults.” Dr. Duong says. She is working to integrate the residents’ pediatric exposure throughout their three-year residency, instead of a set block of time.

Dr. Nordeman says the all the SIU residency programs have helped the two hospitals share protocols for issues such as medications for sedation and sepsis. “We’ve got two different groups of doctors, patients, and nurses. We’ve got two different cultures, and because of the residents, we’ve come together and shared knowledge.”

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The SIU Division of Emergency Medicine and residency program have helped those cultures come together. “The two hospitals have been a tremendous support for our programs,” Dr. Griffen says. “Through our joint effort with the hospitals, we are world-class in door-to-profusion cardiac time. We want to design systems and processes that effectively treat sick patients who come to the emergency department.”

The new residency program reflects the School’s awareness of preparing its graduates for the shifting demands of future health care. “People want access to care immediately when they need it,” Dr. McDowell observes. “Urgent care centers have helped address that need, but it’s in conflict with the medical home concept and primary care physicians. Emergency medicine will play an integral role in the future of health care.”

“We are the safety net, and we’re here 24 hours a day,” Dr. Nordeman says. “Our job is to provide the care.”

Dr. Griffen advocates a shift in the public’s perception of EM. “The Emergency Department is a natural intake site for patients who don’t have a physician and also for those who do. We are the clearinghouse of medicine. We shouldn’t be trying to keep people out of the emergency department,” he says. “Emergency Medicine is a vital component in system of medicine dealing with trauma and complex problems. The big
diagnoses in medicine are often best cared for when they go through the ED.” Emergency Medicine accounts for only 2 percent of health-care expenditures, according to the ACEP.

As the residency program enters its second year, the new EM interns include five women, two of which are alumni of SIU School of Medicine. The growing division will emerge as its own department in the next few years. “We have a supportive environment among the schools and the hospitals, and we want to return the favor by growing into a strong department that offers fantastic patient care, great education for residents, and provides service to the community,” says Dr. McDowell. He envisions working with EMS providers to develop a curriculum for better patient care that will benefit the community as a whole beyond Springfield to the entire service area.

With supportive faculty and team solidarity, the residents are gaining a distinctive residency experience. “We’re doing more procedures in the first year than in many cases what’s required to graduate after three years,” Dr. Cummings says. “The autonomy is fantastic. Our rate of learning is accelerated because of the experience we’re getting.”