The Many Paths to Excellence in Emergency Medicine: Dr. Sharon Bord and Dr. Amelia Pousson, Emergency Medicine Clerkship Leaders at Johns Hopkins University

Shiv Gaglani: Hi, I'm Shiv Gaglani, welcoming you to Raise the Line with Osmosis from Elsevier, an ongoing exploration about how to improve health and health care. 

Today, we're continuing our close look at clerkships and residency programs and what students can do to be successful in them. For that, I'm very happy to welcome Dr. Sharon Bord and Dr. Amelia Pousson, who are both physicians and assistant professors in emergency medicine at Johns Hopkins University, where, as many of you know, I restarted my third year of medical school. 

Dr. Bord serves as the emergency medicine clerkship and sub-internship director and has been integral in developing new curricula and exam material. Outside of her work at Hopkins, she's a member of the Committee of Emergency Medicine Residency Directors and Clerkship Directors in Emergency Medicine.

As for Dr. Pousson, she is deeply involved in global health work with partnerships for teaching and learning in Rwanda, Mozambique, and India. Over the past ten years, she's collaborated on projects with USAID, UN-AIDS, the NIH, and many NGOs and governments in South America, Africa, the Middle East, and elsewhere. 

So, thank you both for taking the time to be here with us. 

Dr. Sharon Bord: Thanks so much. Thanks for having us.

Dr. Amelia Pousson: It's my pleasure. 

Shiv: I'm really looking forward to this conversation and also joining you guys in a couple months on the clerkship. So, we'll start with you, Dr. Bord, with a question we ask every

guest, which is to describe what got you interested in medicine and ultimately a career in emergency medicine?

Dr. Bord: Yeah, great question. I was actually just talking with my kids about this yesterday.

I mean, so what got me interested in medicine? Growing up I was always really very much a science, math, science kind of a person, and also very much a people person. And I felt like medicine very much kind of merged those two things together and was a great fit for a career for me and for my interests in what I like to do. 

I always really liked in medical school learning about that kind of core topics. I was really big into pathology, and thought that was really an interesting class. I got like some nerdy pathology award. I think my friends all thought it was kind of funny. Little known fact about me, I actually got into medical school off the waitlist two weeks before it started and I was really, you know, excited for the opportunity and jumped at it. I always tell students that I think one of the hardest things about medical school is getting in and I still really think that's probably a truth. 

When I first started medical school, I really thought I wanted to be a pediatrician. I had been a camp counselor for many, many years and I loved kids, or at least that's what I thought I loved. And it turns out I really just love braiding hair of like five and six-year-old girls and doing lanyard crafts. After doing my pediatrics rotation, it became clear to me that I didn't want to be a pediatrician and that it wasn't ultimately something that interested me a ton or really like got me going. 

I had structured my whole clerkship calendar about having my pediatrics rotation right in the center of all my clinical rotations where I would be my strongest Then when I did the rotation and I would be in the pediatrics outpatient clinic and they would ask me like, “How much milk does the kid drink?” I was like, I don't care. Like, I just didn't care about a lot of the basic pediatrics things and, you know, it was hard working with some of the parents. Now that I am a parent, I can relate to that a little bit more and the fact that this person is caring for your most precious thing. Then I pondered inpatient pediatrics for a little bit, but I felt like that was going to be like a hard and challenging career emotionally for me in the long term. 

So ultimately halfway through my third year of medical school I had to make a bit of a pivot and rethink what it was that I wanted to do. I was one of those students where -- it's a little cliché -- but I sort of liked everything. I thought about medicine and there were some things about that that appealed to me and some things that didn't, and then I thought a little bit about surgery. When I was on my surgery rotation, I had a very strong female surgeon who encouraged me to potentially pursue a surgical career. 

Then I sort of stumbled upon emergency medicine as an elective in medical school in the summer of my fourth year, essentially. So, it was like right at the cusp between third and fourth year. Now, I would very much be considered a late comer into emergency medicine, but at the time, the timeline was a little bit different. It really just sort of clicked for me. I liked that you could do everything…that you could sew a laceration and resuscitate a patient and there was trauma. I also felt like it really played to my strong suit that I could make people feel comfortable or get to know people quickly. It sort of just felt like a good fit. The rest is kind of history. Again, the timeline was shifted. I was able to schedule an away rotation and apply after doing my rotation in like July of fourth year. And here I am, you know, fifteen-ish years outside of residency working at Hopkins. 

So, that's kind of my history a little bit. 

Shiv: Yeah, that's awesome. I'm really glad you walked us through that because I know a lot of our listeners, myself included, are often confused about what to go into and kind of the zigzags you were going through, both from being really good at pathology to then thinking you were going to do pediatrics to then ultimately winding up in emergency medicine. It's really good for them to hear about because I think a lot of people get pressure to go into something too early and maybe have an identity crises when they thought they wanted to be a surgeon, but then like they're in the OR and they actually don't really like it. So, it's good to hear your story. 

We're going to go to you, Dr. Pousson, because while you guys are both very involved in emergency medicine education, you have very different interests outside of that. I would love to hear your story, Dr. Pousson, of how you got into medicine and then EM, and how you fit in your global health work. 

Dr. Amelia Pousson: Sure. So I think the one thing that's normal in emergency medicine is that a lot of people have a fairly circuitous path to finding out that they love it. I had not considered medicine as a viable career for me. I don't come from a family of physicians and I don't come from a family that has a ton of people who pursued that level of postgraduate education,

meaning none. 

So, when I was in undergrad, I was doing my degree in engineering and I had a female professor who saw in me traits that she thought would make a good physician. It was through her mentorship that I had the confidence even to sit and take the MCAT or apply to medical school Without her diligent mentorship, I wouldn't have even considered that this was a career space that had a place for somebody like me. So, I give great thanks to her because otherwise I think I probably would be in a lab somewhere poking perfectly innocent chondrocytes with a tiny titanium stick over and over again and recording their deformation. So, that was the start of my path. 

After my acceptance to medical school, I actually deferred admission and spent a year and a half doing qualitative research on HIV. The work that I did was around the time that George W. Bush had radically restructured the funding that the United States provided to the global workspace of HIV and AIDS to favor funding faith-based organizations. But at that time there was very little work, essentially no work, on what represented best practice around that.

So, I applied for and received something called the Watson Fellowship and spent a year and a half looking into that in countries outside of the United States and in faith traditions as varied as Candomblé in Brazil to syncreticist work that was happening between traditional faith organizations and evangelical churches in Botswana, to monastery based work that was happening in Thailand and thinking about what unified practices to avoid in the care of people affected by the pandemic at that time, and thinking about how that was actively changing with the rollout of highly effective antiretrovirals. 

After I did that work -- which was incredibly immersive and really did in a very real way, change my life trajectory -- I met my now wife and we've been together ever since. So, in a number of ways that changed my life. I returned to the United States, started medical school at the University of Pittsburgh and going into medical school had a very strong sense that I wanted to be a generalist of some kind…that I wanted to continue to work in the global health space, and that I saw that within the global health space, there was significant damage being done by both the funding and the mechanistic work that made so many things track along a vertical meaning funding for HIV without any health system strengthening. 

I had been a participant, in and developer of that kind of vertical work, so I knew that that was not something that I wanted to continue to do. I wanted to work in a more horizontal way and considered family medicine, considered med-peds, considered emergency medicine, considered emergency medicine pediatrics to the point that I actually ranked several programs in emergency medicine pediatrics on my rank list when it was time to rank for interview and ultimately, I ended up matching into categorical emergency medicine and I'm so, so happy that I did.

I think that for somebody who really enjoys the process of creating some semblance of order out of chaos, emergency medicine is really good for my neurotype and my makeup. I love coming into a really chaotic shift and leaving it a little less chaotic than when I came in and emergency medicine is wonderful for that. It provides a wealth of opportunity to sort little things. It also can be a really challenging career and I think in recent years, we've seen learners have some hesitancy about whether emergency medicine is right for them because of the challenges of the last few years of the pandemic. I think I might have been hesitant to had I been going into emergency medicine at a different time and in a different place.

I feel so lucky that emergency medicine is a specialty that had a place for somebody like me, who's somebody very different than Dr. Bord, but we're tremendous partners. We work together day in and day out on issues of emergency medicine education. My history is working on emergency medicine education in a lot of resource constrained places and now I work on it in a very resource rich place and it's wonderful to have that depth of experience to dig into when we think about how best we can serve the learners that we're tasked with helping learn and love our specialty.

Shiv: Yeah, absolutely. And thanks for taking us through all your thinking as you found your way to EM. You know, for an undifferentiated med student like myself, who's not applying,

you preempted some of the question of EM pros and cons which we'll get into right away. But from my thinking, you know, whether or not I practice full time, part of what appeals to me about EM is the fact that I could be useful to society at large. I was actually on a walk with my friend yesterday and he asked me what I was thinking and although I haven't done the rotation yet, I said, jokingly, “I'd like to leave med school knowing that if there was a zombie apocalypse, I would at least have a place on a team.” And I feel like EM is probably the one specialty that most prepares you -- but correct me if I'm wrong -- to be useful, whether it's someone who has heart issues on a plane or someone giving birth in a mall or something to stabilize people. So, that's a big appeal to me. 

The second appeal is the fact that people are so diverse in their extra medical interests. A lot of entrepreneurs I know, which is my background, go into EM, like my good friend Dr. Robert Lord who I know you guys have mentored over the years. Then Dr. Pousson you're in global health and Dr. Bord you're in education and assessment among other things.

So, those are two of the big appeals to me. Obviously the pandemic and you know, resource constraint and front door being primary care are probably some of the challenges. But let's go right into pros and cons when you talk to students about the choice of EM and maybe we'll start with you, Dr. Bord and then go back to you, Dr. Pousson.

Dr. Bord: I always tell students that there are pros and cons of every specialty, right? Even the ones that are presumably the extra cushy ones like dermatology. You have to look at people's skin all day. Oftentimes you have to manage your own clinical practice. You know, there's good and bad about every single specialty and it's a matter of finding something that you feel like the good outweighs the bad.

I would say some of the good things…you're absolutely right about that zombie apocalypse comment. I mean, we joke around that on my street I am the resource for everyone and particularly during COVID when it was like harder to get in to see people, I diagnosed mallet fingers and told people what to do with it. I diagnosed all sorts of like random things for my neighbors and helped them out. Like, their grandma got a cut on their leg, how should they care for it? All these things, and for me personally, I love being able to be that resource for people and I love being a generalist like what Amelia was saying. 

I love being able to know a little bit about a lot and I also love being able to care for anything that walks through the door in the emergency department, whether it's someone who has had trauma or critical medical illness. We are the people who always have to be like the calmest person in the room. I always say that if I stay calm, everyone else stays calm; if I get anxious, everyone else gets anxious. So, it's very important to kind of keep that level head when you're dealing with that. I love that as time has gone on and my skills have developed, that has been something that has just gotten better and better for me. 

Part of that is also developing a team, and I think one of the things that students really feel when they rotate in the ED is the team based atmosphere more so than any other rotation that people will do for the most part, with the exception of maybe being in the OR. We work just so very closely with our nursing colleagues with our techs…like we are in the room together. I'm always thinking thank goodness we don't have issues with personal space because we are like wrapping ourselves around each other with wires in procedural things. We really have the opportunity to raise each other up and to help each other be the best versions of ourselves that we can be in medicine, and I think that that is something that is really unique. 

I think we can do that also for our students when they rotate with us to really recognize everyone has a role on this team no matter what your job is in the hospital or what you are there to do, and I think that EM is like the ultimate example of that in its finest form. 

What is the bad? The bad is the schedule. I think for me, the schedule is the hardest part. And Dr. Pousson will probably talk with you about the fact that she's a nocturnist, she works only at night, and we're very thankful for the people that work only at night because night shift is one of the hardest things for a lot of other EM people. EM is the specialty where as time goes on,

you don't get rid of your weekend time, your holiday time for the most part, your night shifts, and that can be hard on you as an individual, physically, and can also be hard on the people around you sometimes. I think that that's probably my biggest negative. 

I was telling someone the other day that if I could do my job from eight in the morning till four in the afternoon, it would be the most perfect job. But unfortunately, that's not the nature of our specialty and that's not what we do, and sometimes that involves some sacrifices personally. 

Shiv: That makes sense. And what would you like to add, Dr. Pousson, to any of that?

Dr. Pousson: I would say that one thing, that for many people who love the specialty and have decade long careers in the specialty that is a pro -- but that for some people who are contemplative about the specialty and even some people who don't necessarily thrive in the specialty can be a con -- is that we take care of people on their very worst days, and that often means that people are not their best selves, right? Like, people are generally not based like they're going to a wedding, right? They're generally not in the mood for small talk like they would be at a cocktail party. People don't feel good. They're often under slept, very often in the middle of a family or an emotional crisis, many of them have relatively chaotic or fractured healthcare relationships in general. So your interaction with them may be the first, or only, interaction that they're having with the health system in a while and sometimes that can lead to tension in the therapeutic relationship. 

I thrive on that. I find that that's a very satisfying portion of my clinical work is being able to show up and meet people where they're at. But it can be really demanding and there's some people for whom that is not fulfilling and, and for those people, emergency medicine would be a very challenging career because we see a lot of people on their very worst day.

I would echo something that Dr. Bord said about the schedule with the caveat that this is another one of those funny doubling tricks of emergency medicine. It's a little bit like a fun house mirror, it depends on how tall you stand up into it, whether it's a pro or a con. Certainly it's demanding. Certainly the schedule demands can be brutal and being a nocturnist as I am is not amazing for your health. 

At the same time, being an nocturnist within an academic clinical group affords me immense schedule control and allows me to participate in global projects that I would not be able to participate in because I wouldn't have enough control over my schedule to be able to commit to, for example, a grant funded activity halfway around the world in another time zone where I'm not in as much control of my own schedule as I am. So, with the flexibility comes a real cost,

but that flexibility allows for tremendous diversity in crafting a career that includes niches outside of the delivery of clinical care in the emergency department. So again, it's both a pro and a con, depending on how high you stand in the fun house mirror. 

Dr. Bord: Yeah, I mean, I always say, like, when work is done, work is done for the most part. That's one of the nice things from a clinical perspective. I don't have to follow an inbox. I don't have to do that kind of stuff and that is a potential good thing about the shift work. 

Shiv: Yeah, absolutely. That's something I've heard quite a bit from folks who choose the specialty. One side question…is being a good emergency physician nature or nurture? Like, can you actually train those skills and qualities, or is it kind of a personality attitude? Do you know if someone is going to be good versus someone who won't?

And a corollary to that -- and I ask this kind of facetiously -- have some of the traits or skills you need to have to be a good emergency physician -- like being calm in the face of crisis -- has that translated to other elements of your life? Like, for example, road rage, right? If someone cut you off, are you more generally more calm? 

Dr. Pousson: We're both laughing, which I think might give you a little bit of an answer. 

Dr. Bord: Ifeel like we should do a ‘how well do you know the other person’ thing. I would say Amelia has road rage and I don't, but I don't know. I could be wrong. 

Dr. Pousson: I have a school age daughter who's very down on salty language and salty language is one of my big stress relievers. So now in the car, when someone is driving with…let's call it insufficient caution and regard for the other human beings in the cars around them, we have decided to call them potato drivers to try to cut down on how much I cuss in those moments. Sometimes I do wish for them to be turned into french fry drivers. But other than that, I think I've managed to keep the road rage to a minimum. 

Shiv: That's hilarious. That's really funny. 

Dr. Bord: You know, one thing Dr. Dr. Pousson always says, and I think this is a great thing to say,isthere are so many ways to be good at this job. Can you teach some of these things? Yes. I think you definitely can. I think that over the years,my ability to stay even has definitely improved. I would say the one thing that sort of trickles into my personal life is recognizing this job really makes youhave a greater understanding of the fragility of life. It can really make you be one of those, ‘let's appreciate all of the small things’ person. Not always, 

But sometimes it also has made me a little bit of a nervous nelly in the sense that I'm a very risk averse person and a lot of people in emergency medicine are not that. I think we sort of divide ourselves into two categories: the people who are still like, I'll go ride my motorcycle and skydive and do all those things; and then there's me where I'm like, make sure you wear your helmet. Being more risk preventative is my kind of realm that I take. I think I've definitely gotten that a little bit from my job and have taken that home with me a little bit.

Dr. Pousson:  The only other thing that I would say - and as Dr. Bord mentioned I do say all the time is there's so many ways to be a wonderful emergency physician. There is not one right way. There's lots of ways to sort of peel the orange and get it just right even if the path there looks a little bit different for each emergency physician.

I will say that one of the traits that's really hard to build a good emergency physician without is really rigorous honesty. People have to be really honest with themselves because I think one thing that you're hearing in both how Dr. Bord and I talk about our paths to emergency medicine is a trajectory of incremental improvement and trajectory of like, really rigorous and honest, self-reflection about places that we wanted to grow and then trying to grow into those places. And so that's one realm of honesty. 

Another realm of honesty is being honest about when something doesn't fit. It's an incredibly important part of the diagnostic process in emergency medicine, and then being honest with your supervisors when you're learning in emergency medicine is really the only way to actually learn as opposed to sort of fake your way through. So I would say that when I'm looking for traits among people, I can mold almost anything, but if somebody is fibbing all the time, it's really, really hard to get that person to turn into a really good emergency physician.

Shiv: That's really insightful. All those are very insightful things. You kind of hear a couple of broad strokes about a field, but like, that's why we have people like you on the podcast to talk about the nuances and the color that I think you only get by being in your position. 

So, speaking of the clerkship and the residency program, can you tell us a bit about two things? One is advice you give to students and other trainees in terms of preparing and being successful. What general advice would you want to give them about being successful in emergency medicine? Then, the second is, this is a good chance to sell Hopkins. Like, what do you like about the Hopkins EM programs?

So, we start with you again, Dr. Bord. 

Dr. Bord: Yeah, I think that one of the best things that learners can do, particularly for more novice learners, is to ask lots of questions and to be inquisitive. I think something that can be very hard about our specialty, particularly as students first start, is that it can be very overwhelming. Like, our environment can be chaotic. We're sometimes doing a task, teaching you something, and then the next minute we're like running to a trauma. So, I would say really just kind of understand that you're not going to know everything initially. It's okay to ask thoughtful questions and to really just sort of be inquisitive. 

I would also say that there's a lot of value in learning from those patients on their hardest day and learning how to communicate and talk with people. For some students and learners, that comes very naturally and for some that's a stretch because you feel uncomfortable. Like, this person is not at their best. They're uncomfortable. They're upset. So, really trying to figure out how to best do that. 

The other thing I always tell learners is that everyone on the team is a value add. Whether you're just getting someone a blanket, getting them food, reaching out to their family member, helping communicate with a consultant…like, every single person can make a difference in the trajectory and the care of a patient. I think that's something that you can carry with you through all of your clinical rotations. It's a great mindset to be in. We've had students catch diagnoses. I've had students walk past rooms of patients and they say, “Oh my God, that's a VTAC, right?” All the time we have that happen. Every little bit of knowledge you have is useful and can be applied and is helpful and appreciated. 

I would say definitely for learners, particularly during residency, something that I really value is knowing your limitations and what you know and don't know. When I was a learner, I think that was probably a bit of a struggle for me because through all of medical school and through college, you're used to being the person who gets good grades and who knows everything, who understands everything. And as you enter training, there's just no way to be in that position. 

So, it's okay to not know something and it's okay to say, I just don't know. I don't know how that works. I don't know how to do that procedure. I need help. Residents always do so much better when they come from that place of like a growth mindset, rather than trying to hide it or overcome it with some false confidence. It's okay to not know things and that's why you're in training. You wouldn't need residency training if you knew everything to start out with.

Shiv: Yeah. That aligns really well with what Dr. Pousson was saying about knowing thyself or like not lying to others, but also to yourself about your strengths and weaknesses. Dr. Pousson, anything you want to add to that? And then also I'll turn it back to you to talk about Hopkins specifically.

Dr. Pousson: So I may start with that a little bit. I think that one of the things that allows learners to really thrive -- both visiting learners from outside our institution who come and rotate with us or who come here to train for four years in our residency program, as well as learners who are interested in emergency medicine -- is regarding the ideas that they have about various presentations of illness when they come into the clerkship or when they come into residency as sketches. So, they're doing their paper and the course of training is designed to turn them into like a fully featured oil painting.

Your illness scripts go from sketches where you have this sort of slightly amorphous knowledge. Like, if it's in the right lower quadrant, that certainly could be an appendix, right? They're anorectic, you know, there's a variety of other things that fit into your initial sketchy illness script that you have when you arrive. And then you fill that in with a lot of color. Like, I very rarely see appendicitis with a fever because almost all of them have taken over-the-counter antipyretics. If I’m working in a place that's not part of the culture of self-administered healthcare, maybe more of them would have a fever but that's certainly part of the culture of self-administered healthcare in the United States so very few of them have a fever. So, that gets sort of de-emphasized. It goes into the background of my illness script. Working with learners about how they build in their illness scripts through the diversity of clinical illness that they'll see at our institution is one of the big things that we do over the course of the clerkship. 

In terms of thinking about why this place is a wonderful place to train learners, I think that if somebody were to come in and they were to be like, “Amelia, I am not sure that there's lots of right ways of doing this” working just a handful of shifts with the attendings and senior residents that we have in our emergency department would put the lie to that doubt and they’d be like, “Oh, obviously there's a lot of really good ways to do this.” 

I think we're tremendously blessed with a group of attendings who are really deeply skilled in the practice of emergency medicine, really deeply invested in what does it mean to teach this work in a strategy that actually helps build new emergency physicians who are ready for anything that the world might throw at them and who are prepared for the risk of an emergency.

I think that's a really important thing to think about…the complexities of working in a busy urban emergency department subject to all of the pressures of modern US health care affected by the recent years of pandemic, affected by other threads in US health care including the thread of omnipresent gun violence, including the thread of diminishing access to outpatient psychiatric resources and outpatient primary care resources - all of which ends up landing in the emergency department 

if you're in a system that's less strong than ours, that can often feel like a tsunami that's going to crash over your head, rather than something that the leadership in your in your department is really helping your group navigate in a way that still allows you to provide your mandate for being there which is care for the sickest people, care for those who really don't have minutes to wait. 

That's why I show up to work. It's nice if I can help somebody get a refill of their

anti-hypertensive that they can’t get because they don't have a primary care doctor. I like doing that too, but the reason that I show up to work is for the people who really can't wait and to teach other people how to take care of those kinds of patients as well. 

Dr. Bord:  I just want to add in one other thing. One of the other things that learners can and should do -- and this has been a great change in medicine over the last few years -- is taking care of your own personal wellness. I think for years and years we did not stress that in medicine at all and the fact that we're paying more attention to that is very important and I think that also kind of plays into be being successful within this career, which can otherwise be very, very hard. 

You know, you can't care for other people if you can't care for yourself. That that can be very challenging and I think the fact that we're talking about it more and paying attention to it more is so very important, within emergency medicine in particular, but also within all of health care and education. 

Shiv: Yeah, those are excellent points and I can hear the passion and the inspiration in both those answers about ‘why EM.’ 

I want to open it up now and give you the opportunity to talk about your work outside of clinical emergency medicine because it's diverse, it's very interesting. You could talk about anything. I know you're involved in assessment and curricula, Dr. Bord, and the global health aspects, Dr. Pousson. What's top of mind for you?  

Dr. Bord:  I think that assessment in medical education has also been something that's been in a lot of flux over the last years  I think that with the USMLE initially changing to go to pass/fail…it's funny I was actually in the medical school building the day that announcement went out and there were cheers from the students and everyone was really excited about it. I think that there is a lot of good in changing that assessment. Assessment in those domains can be very debatable about what it actually says about who you will be as a physician and then when COVID happened a lot of medical schools went to pass/fail for their clinical rotation assessments. At Hopkins, this academic year still remains as a pass/fail grading system for a core curriculum. 

Something that I am pretty immersed in is the standardized letter of evaluation, which is the standardized letter that we use in emergency medicine. Emergency medicine was actually a trailblazer in the world of standardized letters for residency applications starting in the late 1990s, actually, which seems like ages ago now. The letter has changed a little bit over the years. The letter, historically, has been a big comparator of you with your peers and we've changed it a bit to reflect some of the EPA-based assessments -- entrustable professional activity assessments -- that the governing bodies for the School of Medicine are encouraging us to use. So, more of a competency-based letter rather than a comparator letter to your peers.

I think that one of the challenges that we all are facing is this handoff from undergraduate medical education to graduate medical education, particularly with there being less discriminating factors between students as they're applying into residency. So, utilizing these standardized letters in emergency medicine, and then a ton of other specialties have kind of jumped on board with that. We need to determine how we can best utilize those letters when we're getting less discriminating factors from the USMLE and from our core clerkship rotations. How can we utilize the standardized letter to be a more discriminating or helpful instrument for students as they apply into residency?

We want that letter to be helpful to students, but also to the people who are taking in that information, because ultimately, our goal is to select the right people for the right residency program. How those letters are kind of like a forward flow for how we can best do that for our learners is the thing I'm sort of working on the most right now as we enter into Match week time and our cycle starts all over with visiting students and so on and so forth.

Shiv: Yeah, that's extremely important work because that's what all my classmates are concerned about right now is, you know, what's going in their evaluations or letters, especially because, as you mentioned, some of the more objective criteria have become pass/fail and so it's very hard to rank. I don't envy residency program directories in terms of how they select at this point.

And then how about you, Dr. Pousson? One quick aside is that one of our strongest collaborations is with Partners in Health. I've worked a lot with the University of Global Health Equity, and I actually went to Butaro, Rwanda last year to visit them. They are one of our favorite partners that we give free access to Osmosis and to other educational resources, too. So, we'd love to hear what your global health interests are and anything else you want to talk about. 

Dr. Pousson:  Well, I'm excited that maybe there's somebody in Butaro who's going to be listening to this podcast. So, “Hi.” But I would say that my interests, whether I'm working in global health or whether I'm working in global health in Baltimore, are actually very similar. I'm really interested in preparation for service. I'm really interested in how we, through the design, construction, and implementation of curricula, prepare learners to make that transition from pre-professional to professional and from professional to somebody who has a long and deeply satisfying career in their chosen profession. 

How do we make sure that that curriculum matches the burden of disease that they're going to see? How do we make sure that it has enough flexibility to account for random respiratory viral pandemics that may emerge during their term of work? How do we make sure that it's robust enough to bear up under the fact that every specialty, emergency medicine included, has things about it that are demanding and incur a cost from the person who's working in that specialty? So, that's my interest, and I'm interested in it kind of no matter who I'm teaching -- whether I'm teaching physicians or non-physicians, whether I'm teaching here in Baltimore City or whether I'm teaching in Kigali City in Rwanda. So, it's broad and deep at the same time. 

Shiv: Yeah, no, that's wonderful. We'll definitely try linking to both your profiles so our learners can maybe reach out if they're interested in these particular areas, even though I know how busy you both probably are. 

I want to be respectful of your time, so I only had two other questions for you. The first is just general advice. I know you've already gone into a lot of advice for learners and what makes people good emergency physicians, but any other advice you want to leave our learners with about approaching their careers? And we'll again start with you, Dr. Bord. 

Dr. Bord: I think an overarching theme, no matter what it is that you choose to do -- and again, it's taken me a while to sort of learn this -- is what makes me happiest when I'm at work clinically, is to be good to your colleagues. Be nice to people. I know that sounds so simple, like that sounds like the most ridiculous advice, right? But, we exist in a very high-stress environment. We exist in a very hierarchical environment, and we do our best when we're nice to each other. 

Like, when the surgery resident comes down and they're like, “Hi, I’m the surgery resident.” I'm like, “Well, you have a name. What's your name?” Like, one time there was a surgery resident that was in the department that had a fever, and they didn't want to tell their attending, but they looked like death. And I was like, you probably shouldn't be working right now. We just have to be good to each other. We do our best by being good to our patients, being good to our staff, being good to each other. I think that's really important, rather than bringing each other down. There's no need to have a fight about a patient. We're there to take good care of patients. 

And it translates also into the education world and all the things that we do. Just be good to each other. It will make your life just so much better because ultimately we all have the same goal. We all want to have a job and career fulfillment. We all want to take good care of patients. So, we do our best with that by just being kind to each other, whether or not it's something small -- like offering a patient a snack or their family member a coffee if they've been up all night or offering the surgery resident a thing of Oreos -- like, you just need to be good to each other to sort of keep the day going. There's going to be days that you need your cup filled, and then there's going to be days that other people need their cup filled and if you're good to each other, everything will be sort of okay. 

Shiv: I love that advice. It reminds me of one of these quotes, I forgot where it came from, but it said in a world where you can be anything, be kind. So, that's really good. 

Dr. Bord: Yeah. I mean in medicine, the culture historically has been that we're at odds with one another, but it doesn't need to be that way.

Shiv: It's true. It's true. How about you Dr. Pousson? Other advice you want to leave our learners with? 

Dr. Pousson: The only other thing that I would say as learners enter a season of beginning the cycle all over again, but coming as fresh, wide-eyed learners to the clinical environment, is to be open to falling in love with something that you didn't expect and be open to being honest with yourself if something does not make you happy. A career in medicine can and should be pretty long, but that means that it should be something that you're excited to do. The grass isn't greener in some other specialty. Every specialty has its challenges, and just reinforcing what Dr. Bord said earlier, which is that if you find something where the things that are challenging about the specialty don't bring you down, and the things that are delightful about the specialty really bring you up, you may be in the right place. Don't be scared if that's some place that you've never considered before.

Shiv: That's great. That's great. I mean, radical candor and then the self-awareness is so important. I think we learn it too much through experience, too late in a lot of cases and people are afraid to switch paths when they do learn it.

So, okay, the last question for you all is to share a favorite patient story or a situation you were in that you think EM really helped you prepare for. Or, just open mic…share anything else you want to share with our learners. So, again, Dr. Bord. 

Dr. Bord: All right. Patient story. I always struggle with this question. I'll be honest with you.

I feel like this is the question that you get asked at a cocktail party. “Tell me about a cool case you saw.” Right? And people want you to tell you about someone that put something up their butt, to be perfectly honest. You can edit that out if you need to. 

Shiv: Not at all, that’s fine. 

Dr. Bord: I think it’s what people want to hear about for some reason. I don't even know why people want to hear about that. I feel like the cases that stick with me the most are not cases that are cocktail party cases, right? They are cases that oftentimes were really hard emotionally for me, or a case that was really hard in a way that it was intellectually stimulating. It was like a tough medical case and it sticks with me in that way.

I don't want to tell any depressing stories, but for kind of a fun, uplifting story, I remember I was working the night shift and this older guy -- he was probably in his sixties -- came in and he was altered and it turns out he was super intoxicated. His alcohol level was very high and, you know, those cases are a dime a dozen, right? We don't normally think about them after the fact because we see people who come in intoxicated all the time. A few weeks later I got a thank you note in the mail, and we have very few thank you notes. That's the other thing… don't go into the specialty if you want thank you notes, or like patients to bake you brownies. 

The note said thank you so much for caring for me. I'm so embarrassed. I haven't been that intoxicated since college. It was totally from left field. I was not at all expecting to ever hear from that patient ever again, because patients come in intoxicated and they sleep it off and then we discharge them. Again, it's a dime a dozen case. So, that sort of has stuck with me and I keep that thank you note with me because, again, there are few in emergency medicine and it kind of was one of those things that made me smile and laugh a bit. 

Shiv: That's awesome. And that person probably follows the advice you shared with our learners to be kind, right?

Dr. Bord: Yeah. It was funny. I was like, who do I get a thank you note from? 

Shiv: How about you Dr. Pousson last words on this? 

Dr. Pousson: Similar to Dr. Bord, I sort of dread this question when it comes up in social occasions, because many of the cases that are most deeply meaningful to me either would be too individually identifiable to share and I think are sacred in a way that sort of surpasses HIPAA. The only people who I would tell that story to are people who are there already. 

So in lieu of that, I'll share something that is one of my favorite stories of teaching emergency medicine. Elbow dislocations are kind of notorious in emergency medicine. Little kids, when they put their elbow out, it tends to be actually a subluxation instead of a dislocation. They're really, really easy to put back in, so much so that you can actually usually do it just by distracting them with some Bluey or something on their smartphone, and then just taking their hand and bending their elbow. 

Grownup elbow dislocations are a totally different story. They tend to be very, very challenging to put back in. And a trainee of mine, in Rwanda actually, had been struggling with putting elbows back in. He had been on a run of them and we had talked about a variety of strategies to help make this learner more successful with them that did not mandate brute strength because I'm a fairly petite human being who doesn't have a lot of brute strength in my corner to make something go the right way. 

Then, they ended up in a total drought of additional elbows throughout the rest of my time working with them, and they sent me a text on WhatsApp a couple of years ago, saying that now they are ‘the elbow whisperer’ at their hospital and that many years later, they've been able to take those techniques and put them into practice. And now baby elbows, which are easy and deeply satisfying, and grown up elbows, which are tough, but can also be deeply satisfying, represent something that even specialists in other departments in orthopedics and other things will come to them for assistance with because they're known to be really good at it.

For me, that's the takeaway story that helps fill my cup when I think about, like, why do I keep doing this? Why do I stay in a career in academic emergency medicine? And it's about stuff like that. It's really hard to see the ripples of the stones that you throw in the pond. Sometimes you get to find out about them, but often not so when you do it's really treasured for me. So, a little story about elbows. 

Shiv: That's a great one. That's thanks for sharing that. One reason we love education and one reason we invite clerkship directors like yourself on the podcast is because of that scale, right? You obviously help patients one-on-one, but then when you help a trainee become an elbow whisperer, you know, while you're sleeping, they're fixing elbows in Rwanda day in day out. 

So with that, thank you both so much for taking the time to be with us on the Raise the Line podcast. We really appreciate it. 

Dr. Pousson: Thank you. 

Dr. Bord: Yeah. Thanks for having us. 

Shiv: And with that, I'm Shiv Gaglani. Thank you to our audience for checking out today's show and remember to do your part to raise line and strengthen our healthcare system. We're all in this together. Take care.