Saturday, August 26, 2023

A Tale of Two Coconuts

A Tale of Two Coconuts

Phil and Tony live on a small island in the middle of the ocean with a population of 2. The nation state of Islandia. There is a coconut tree on the island. In 2020, it produced 1 coconut. Hence, the gross domestic product (GDP) of the island was one coconut. There are 10 Island Dollars in circulation. In 2021, the the tree also produced 1 coconut (valued at $10 dollars). Unlike 2020, this 1 coconut was picked up by Tony, who sold it to Phil, who then sold it back to Tony. Hurrah, Tony declared. "The GDP of our island went up by 100% in 2021, our GDP was $20". As a result, Phil, who also coincidentally runs the central bank, was in structed to print more money to prevent deflation - as a rule of thumb, the money supply has to match economic output, or else money becomes more valuable. Money becoming more valuable/scarce is the real definition of deflation.

Gross Domestic Product is useful for comparing economic output over the years, but it can very easily be manipulated to give the impression of economic growth when in reality there wasnt any.

The value of the Islandia Dollar is ultimately determined by the number of coconuts produced. If the coconut is transferred back and forth between Phil and Tony, GDP can rise by a few hundred percent - but it still doesnt change the fact that only one coconut was produced.

Now a Mexian beer themed virus hit the shores of Islandia. In a panic, there were lockdowns and the economy was disrupted. No coconuts this year. To maintain spending, Phil increases the money supply by encouraging people to take loans - because money is spawned into existance when people take loans (this is the objective reality of the fractional reserve system used in modern banking). Ultimately the money supply grew by 30%.

Over the coming years, the virus is but a distant memory, and coconut production has resumed. Tony says "Yay! The GDP grew by 10% this year", after noticing that the coconut was sold once for $11, instead of $10 before the Mexican Beer Virus.

The economy still ultimately makes one coconut a year - but because Phil expanded the money supply, there is now 1.30 times the number of dollars per coconut. There are 13 dollars in circulation.

Yup. Money just became 30% more worthless because of money printing. This, people, is the true definition of INFLATION. It is the devaluation of every dollar in existance. By definition, if you print more money you are devaluing money itself. Think of it as a tax on every dollar in your savings account, because that's what it really is.

Why Australia is a nice place to live.

In a very literal sense - Australia makes stuff, and has a small population relative to the amount of stuff it makes. Iron ore, natural gas, agricultural produce, and services that are exported (education / software / consulting) for foreign currency. Australia has a lot of coconuts for relatively few people. That's the bottom line.

Despite all this, if the money supply goes up by 30% - it's guaranteed that it will be felt by everyone, as things will become 30% more expensive by definition. This is true inflation.

Ezradamus predicts the future

Petrol used to cost around AUD $1.20 per litre before the pandemic. It now costs about $1.89. While it is true that there was genuinely a hydrocarbon shortage due to supply disruptions in early 2023 (war in Ukraine etc), those disruptions are now over, and prices have returned to pre-pandemic levels.

Keep in mind the American Dollar also devalued due to money printing in the past three years by around 20% (Look up USD M1/2/3 money supply statistics). Around $60USD per barrel 2020 to $80USD per barrel now.

Oil prices ($USD/barrel)

The Reserve Bank Does The Right Thing

There is another country that starts with the letter "A" - Argentina - that has experienced hyperinflation despite making lots of coconuts. They were the number 1 beef exporter in the world for decades and was a one point predicted to outpace Singapore and Europe in growth. Then their central bank (with lots of corruption and political influence) devalued their currency to peanuts and caused hyperinflation - now they are stuck in a debt trap and are financial pariahs on the world stage.

RBA - M1 money supply

Kudos to Reserve Bank of Australia govenor Phillip Lowe for doing the right thing.
Interest rates are now in the 4pc range. Money supply is now starting to shrink. Realistically, it will need to shrink further - or else, inflation will 'stick'. This will no doubt be a politically unpopular move, and I can already see lots of political pressure to stop the interest rate rises.

Absolute Legend.

In my opinion, interest rates should be closer to 7-8 percent (the decades long average). There will be blood - people will default. Anthony Albanese (The current elected PM) will no doubt face a lot of pressure to lower interest rates from stressed mortgage holders - and even homeowners keen on seeing their property prices keep on rising. But in return, retirees with savings will have the value of their savings protected, and young people will find housing much more affordable. This is much more sustainable in the long term. The problem is that 'long term' = decades, and election cycles are much shorter than that. I am writing this to improve general knowledge on this topic for this reason. IMHO voters are too shortsighted to see the bigger picture - everyone wants handouts and tax cuts. But monetary policy is ultimately what is making your payslip more worthless every year - as it's a tax on money itself.

My message to people who own property keen on seeing prices rise - The value of the house you stay in is meaningless unless you are planning to sell. If your home doubles in price, but the value of the money it is being sold for halves in value, you have not turned a profit - only hedged against inflation. The property price increases (much more than inflation) over the past two decades was from genuine population and economic growth - something that may not necessarily repeat in the coming decades as birth rates fall: You will be proverbially shafted by a demographic buttplug. Ask all the Tokyo homeowners that were once told Tokyo house prices will never fall. A single detached home only costs USD$300k in Tokyo (LINK: Life From Where Im From (Youtube)). Also note Australian coconut production is pretty stable after the mining growth spurt.

Thoughts / Comments
I would like to invite comments from readers on this topic.
  • Has your household spending risen by 20% in the last 3 years?
  • Will a rise of 3-4% to interest rates cause mortgage stress?

Saturday, August 05, 2023

The Long Climb Up Mt FACEM


              1) Prelude
              2) The Long Climb Up Mt FACEM
              3) The Exit Exam (Fellowship OSCEs)
              4) What was the Emergency Medicine Training program like?
              5) Special Thanks

1) Prelude

              Specialist training is a bit different in Australia compared to many other countries - becoming a specialist does not involve universities or masters programs. So unlike universities with an impetus to have high pass rates and good reviews, the opposite is true. Becoming a specialist is like joining a club of enthusiasts who are interested in a particular field. They dont do this for the money - it's a passion for them, especially the examiners and senior college members. The ones holding the keys to the gates are taking a pay cut to be involved in the examination process - setting the standard is a responsibility they take very seriously. It's a lifestyle. A vocation. The training program ultimately answers four questions:

1) Are you a safe doctor that meets the current standard of care? (medical expertise)
2) Will I be happy for you to look after my mother? (empathy)
3) Can you lead a department? (leadership, prioritisation)
4) Will you make the department/world a better place? (health advocacy / systems / processes)

              The above takes time. The ED Training program can technically be passed in 5 years. I took 9. The college requires you to pass within 12 years. It sounds like alot, but trust me the years will fly, and many people take time off for other things (parenting etc).

              Above all else, ED Training is an apprenticeship with exams. You will work as a registrar with consultant oversight, and be gradually given more responsibilities and key decision making roles. The ED tier-list is roughly as follows:

Intern / PGY 1- All patients discussed and seen in person by a senior.
PGY 2 - All patients discussed with a senior.
PGY 3 - Most straightforward bog standard presentations managed independantly.
Junior Registrar - Straightforward presentations managed independantly. Others discussed.
Senior Registrar - Complex presentations managed independantly. Can run department when required; especially at night, but requires consultant advice and support occasionally.
Principal Registrar - Able to run department at the level of a consultant, with other consultants available for mentoring.
Fellow – You have joined the college, but yet to sign your fat juicy consultant contract.
Consultant - The buck stops with you. Google and Bing maybe? I heard AskJeeves is no longer used. I might just crack open the textbook. Or perhaps use that jedi-mindforce gestalt from years of experience.

              There are a total of 4 exams. Keep in mind the doctors sitting these exams have been working for many years and have a keen interest in emergency medicine. They were all > 97th centile in highschool/college. Then after finishing medschool and proving themselves on the ED floor, they were all deemed fit for entry into the training program by two senior emergency consultants. Despite this, roughly one third will fail every exam. When i sat the Fellowship Writtens, the pass rate was only 59%. Fail 3x (primary) or 4x (fellowship) and it's THE END (you will be removed from the training program). The stakes are very high. I failed OSCEs on my first attempt - and the preparation for round 2 nearly broke me.

The Primary Writtens: It's like med-school, but with a much lower pass rate and a focus on ED relevant anatomy, physiology, pharmacology and pathology. Also, unlike med-school, you will be working full time while preparing for this. Enjoy =)

The Primary Vivas: A bit more clinical. Can you talk about the above topics coherently?

The Fellowship Writtens: It gets real. Real life medicine. Application of knowledge.

The Fellowship OSCE: Dials realism up a notch. Actual on the floor performance is assessed. Paid actors will be in tears if needed. Challenging complex presentations. Boring mundane things you are expected to do very well. Are you performing at the level of a consultant? There are no tricks. They are not trying to fail you. You need to be quick, adapt, and apply consultant level knowledge/heuristics on the fly. 7 minutes per station. 12 stations. I was almost in tears when it was over. The preparation for this exam almost broke me. The sound of the end-station bell triggers PTSD in many consultants for a reason. This exam is unlike any other. It is ultimately a consultant level benchmarking exam.

              A particularly time consuming part of the training program is the research requirement. Regulation 4.10 it's called. You can either do a statistics course from a recognized university, or publish as first author in a reputable journal. I was very fortunate to have contacts from my Monash days and published an article in the Annals of Emergency Medicine. Research is hard. I do not recommend this route - the biostatistics course is probably much easier. On the plus side I now know how to use basic statistical analysis tools. In addition to the above, there are other requirements at various stages of training just to spice things up a bit. 

2) The long climb up Mt FACEM.

              2003 - Finished Highschool
              2005 - International Baccalaureate Diploma
              2007 - 2011 Monash MBBS (Selection ATAR / Centile > 97%)
              2012 – Internship
              2013 - Hospital Medical Officer
              2014 - Start of Emergency Medicine Training
              2015 - Year off as unaccredited Intensive Care Registrar
              2016 - Decided ED training is more exciting. So back to ED Training.
              2017 - ACEM Primary Writtens and Primary VIVAs
              2018 - 6 months in a Rural ED (3 hours from melbourne)
              2019 - Research Requirement. Published paper in a high impact journal.
              2020 - Advanced Training time. Certificate of Clinician Performed Ultrasound (CCPU)
              2021 - ACEM Fellowship Written Exam (59% pass rate)
              2022 - Start working true in-charge shifts; running the floor/department.
              2023 - ACEM Fellowship Clinical Exam (67% pass rate)

              I graduated third in my highschool. Being thrown into the Monash MBBS cohort was quite a departure from what I was used to. I have never felt more average. Every one in the room was from the top of their class.

              In medicine, you will be exposed to various departments as a junior medical officer. Time seemed to pass quickly in Emergency, so I thought - why not. I joined the college of emergency medicine in 2014 and spent a year at Clayton hospital (Tertiary referral) and Dandenong hospital (Urban district). I was probably a bit too green for the job at that point. Reviews were less than stellar. I was considering switching course.

              Took a year off to try my hand at Intensive Care - I was only four years out, and probably a bit too green for that job as well, but it was a very good learning experience. This was when I started to really develop key procedural skills and become comfortable looking after sick patients.

              2016 was the year ED training really began in ernest, and my first taste of failure. I failed the Primary Viva that year. I was quite unprepared. You need about 500-1000 hours of preparation for both the primaries and fellowship writtens. But at least you could study/prepare for it. The OSCEs are a totally different ballgame. Studying for the OSCE is moot.

3) Exit Exam - The Fellowship OSCE

              It is a true exit exam, unlike other colleges whereby you sit for exams in the third year, and 'do your time' so to speak apprenticing on the job for the next three years. The ACEM Fellowship OSCE is a consultant level benchmarking exam, whereby you are tested against real emergency consultants as well as the rest of your cohort. The test is thorougly curated. A bunch of blinded consultants will sit the exam and a benchmark score will be created for each station. Could you perform at the level of a junior consultant? That is what is assessed. Roughly 2/3rd of those sitting will pass, but this includes those sitting for the 2nd, 3rd and 4th (final) time. Realistically (and anecdotally from my study groups), roughly half of those sitting for the first time will pass.

              Everyone sitting this exam has had 4-11 years of ED experience at the registrar level, and had passed both the primaries and fellowship writtens. Knowledge is a given - this is not a test of knowledge. In my first attempt I made this mistake. I studied for this exam - I went through the entirety of the syllabus and my exam resources. I failed.

              The preparation for my second attempt took a full year. It required a complete change in my thinking, and ironed out alot of the idiosyncrasies and bad habits you tend to accumulate over the years - and made me a much better doctor as a result.

              In my time of need, the esteemed members of the college came to my aid, and polished my practice of medicine to the level of a FACEM. I did not pay them anything for this - their only request is that I pay it forward - which I will. FACEMs with decades of experience sat down with me 1:1 and went through OSCE scenarios - and helped polish my responses. This is the real GOLD of the FACEM training program. It is not in any official document or rulebook. It’s the intangible benefit of mentoring and support from members of the club.

              The OSCE process was life and practice changing. It really took me up a notch in the way I interact and conduct myself in real life and on the floor. This is what makes the ACEM Fellowship quite special. This is not an exam that could be studied for. There is no textbook. Knowledge is a given. It is about you, as a person, dealing with real life situations – all stations are based on real life. You cannot fake it. You cannot script your answers. It is about how you process information. Synthesis. Third order thinking, as my mentor puts it. You then need to be able to communicate that information appropriately to other consultants, nursing staff, students, and the average layperson. Demonstrating medical knowledge is the bare minimum required, and you will still fail if you do not address the human factors, health advocacy, leadership, prioritization and other domains assessed.

              After many years of real world clinical practice, the OSCE will make sense. If you have qualified to sit the OSCE, I have some tips below. 


How I got through the OSCE.

The advice below is my experience from having failed the OSCE once.

Do not study for the OSCE. *practice* for the OSCE.

              Leading up to the OSCE, you should be practicing every single day you are not working on the floor, and on every day you are working on the floor. This is harder than it seems because of the shift work, and everyone having different schedules. Also remember that every single real-life interaction at work is effectively an OSCE – think about how the domains apply to your everyday practice and polish your performance to give off that consultant vibe.

              In the months prior to the OSCEs, I was eventually having sessions 4-5 times per week, in addition to working full time doing shift work. This is a life-stopping soul crushing amount of work. Keep in mind a lot of time goes into logistics, travel and planning as well. You will need an OSCE buddy as many OSCE scenarios utilize a confederate. I had Kevin, who joined many of the sessions, and we grew together through the OSCE learning process. He passed too.

              Practically, what you need is a forward rolling availability calendar, then every time you have a session with someone – make sure to book in the next session!. That way you can slowly build up a schedule and fill up all slots.

              For example, this was my actual real life schedule in the 4 weeks leading up to the exam. This went on for two months and damn well near broke me.

   Monday              Ruth 9am, Ben 12pm
   Tuesday              Garry 7pm
   Wednesday        Work 2.30pm to midnight.
   Thursday            Mohan 10am, Work 2.30pm to midnight.
   Friday                 Cabrini Trial Exam
   Saturday             Work 2.30pm to midnight.
   Sunday               Work 2.30pm to midnight.

   Monday              Darsim 2pm, Mohan 10pm
   Tuesday              Mohan 10am, Darsim 3pm, Garry 7pm
   Wednesday        Monash Trial OSCE morning. Then Work PM Shift 2.30pm to midnight.
   Thursday            Mohan 1pm. Work Night Shift 11pm to 8.30am.
   Friday                 Imran 9am. Work Night Shift 11pm to 8.30am.
   Saturday             Mohan 9pm. Work Night Shift 11pm to 8.30am.
   Sunday               Mohan 9pm.

   Monday              Garry 7pm, Mohan 9pm
   Tuesday              Jo Dalgleish 1pm, Work PM Shift 2.30pm to midnight
   Wednesday        SIM TEACHING SESSION morning, then Work PM Shift 2.30pm to midnight.
   Thursday            Abrar 10am, Mohan 12pm, Work PM Shift 2.30pm to midnight
   Friday                 Jo Dalgleish 10am, Darsim 12pm, Work PM Shift 2.30pm to midnight
   Saturday             Mohan 10pm
   Sunday               Mohan 10pm

   Monday              Start Planned Annual Leave. Mohan 9pm
   Tuesday              Jo Dalgleish 12pm, Garry 7pm
   Wednesday        Frankston OSCE trial, Ruth Hew 3pm
   Thursday            ECG/VBG/Xray refresher
   Friday                 Toxicology refresher
   Saturday             Shayaman session.
   Sunday               Frankston OSCE trial 2 by Mohan and Abrar 1:1 face to face.

Correct Circadian Rhythm

              Align circadian rhythm and set up a routine whereby I would have a cup of chamomile tea, and sleep as much as possible every night. It will be very difficult to sleep the night before the OSCE – this is quite possibly the single most important thing in preparation that few people realize. Nobody sleeps well before the OSCE. If you are interstate, fly in two days earlier and get used to the hotel/bed. Hotel too noisy? Switch hotels. I took annual leave before the exams so I could set up my circadian routine.

Know the uncommon but important to know stuff

              An exciting aspect of emergency is that we deal with rare presentations, and are expected to know how to deal with them reasonably well. Think methaemoglobinaemia from nangs/poppers, variants of ACLS (pregnancy, hypothermia, TCA OD), toxinology (snake bites), thyroid storm, the RBBB STEMI, and all the random critical things you may (or may not) have seen in your ~10 years of being a doctor. And know how to do them well.

This is where your OSCE practice comes in. You would have at least been in a OSCE practice scenario involving a rare but not to miss condition that you may not have encountered in real life. I failed the toxicology station in my first attempt because I wasn’t polished enough about organophosphate poisoning. I knew the basics, but knowledge alone will not guarantee a pass.

There Are No Tricks

              The examiners are not trying to fail you. You just need to demonstrate what you already do every day at work on the floor. For example, the ECG station in my first attempt was that of a young 9yo girl with chest pain. I was interacting with an intern who has come to me with that ECG. My opening words were “Well they are obviously juvenile T waves and nothing to worry about”. But as the intern discussed the case, she started asking about other things, and I eventually asked her to get a paediatric cardiology opinion – that’s a fail. Stand your ground. Have faith. Use the force. My second time around the ECG station was a boring bog standard pericarditis, and a HMO who is worried about ischaemia. Nailed it. How you describe your reasoning in a way that is understandable to your target audience is important. If it quacks like a duck, it’s a duck. You don’t need to consult a professor of Ornithology to confirm your convictions is not a chicken. You would however describe a duck differently to a kindergardener and a university student of biology, which brings me to my next point:

The Special Sauce.

              Always ask yourself – why is this in a consultant level exam? The exam board is transparent in that the domains are always given, so you know what you are being examined on. Teaching? Leadership? Medical expertise? If it says 60% teaching for a boring bronchiolitis baby case, then be sure to place emphasis on your delivery of content attenuated to the level of the person you are teaching – blurting out the entire RCH guideline on bronchiolitis to a doe-in-headlights intern will be a clear fail. The station tests if you have tought and supervised interns before. Medical knowledge is a given at this point. If the case is very straight forward, there is always some special sauce somewhere that will give you a chance to demonstrate your consultant level responses.

              All answers need to be clinically relevant and demonstrate breadth of knowledge that is prioritized due to the fast paced nature of emergency medicine. This is not a physicians exam. There are no long cases. For example, in a bog standard presentation of an elderly person with abdominal pain, mentioning porphorya, retroperitoneal fibrosis, pancreatitis from scorpion venom, and epiploic appendagitis will not win you any points. ED exists ultimately to exclude red flags and make appropriate referrals in these situations. Think broad. Take one step back. Vascular catastrophe (TAD / AAA), Endocrine (DKA), Visceral (PUD / Pancreatitis), Surgical (SBO/LBO, diverticulitis, appendicitis, hernias), Cardiac (atypical MI). Focusing on just surgical causes for example will be a fail for that question. What would you do in real life? Do that. You cannot fake it. It is about you, as a clinician.

The Feels.

              It is easier to do something than to do nothing. Any registrar can correctly treat an infective exacerbation of COPD, but a consultant knows when to stop and switch to comfort focused care (palliation), and how to break the news to the patient and family. You would have likely been a part of these types of discussions in real life at some point prior to the OSCE, but you will need to polish it to sound like a consultant and develop rapport and trust with patients/families. Sure you can make the correct decision to palliate, but the situation may involve you breaking the news to a relative. The paid actor will be in tears in the real exam.


4) What was it like being an Emergency Medicine Trainee?

it is a full time 86hr/fortnight job
1/3rd of all shifts are night shifts (11pm to 8.30am).
1/3rd are morning (8am to 5pm), 1/3rd are afternoon (2.30pm to midnight)
It's a 5-12 year commitment depending on how fast you progress.
You will do a rural/remote term (6 months) in a far out place. The META of a rural ED is quite different and is an invaluable experience to have.
You will do a minimum of 6 months of combined ICU/Anaesthethics (I did 18 months total as an ICU registrar, and 6 months of Anaesthethics)
College fees are about AUD $2k per year. Each exam is about AUD $3k.
Mentoring at least 1-2x a month (workplace assessments)
At least 48 months of working in ED.
See at least 400 sick kids. (I saw closer to 1200 by the time I reached fellowship)
Some non-ED time doing non-ED things. (I did ultrasound)

10000 hours?

              It is said you need 10000 hours to become good at something. Well, working 47 weeks a year (5 weeks annual leave) for 9 years = 18189 hours. Each exam took 300-500 hours of preparation, or about 1500 hours total. Then add a few hundred hours for research, courses, presentations and workplace based assessments. It took about 20,000 hours for me to reach this point. Im a slow learner.

Why did I do it?

              Because ultimately it's fun. I dont find the job onerous and look forward to going to work despite the high stress nature of the job. Time passes quickly and I find myself staying back to get stuff done instead of dreading every minute at work looking forward to go home. I've called in sick once in the last three years and that was because of PCR confirmed COVID and I was kinda forced to do so. I have *never* called in sick on a night shift.

If you find yourself dreading to go to work, this is not for you.

5) Special Thanks

The Family

Peggy - My wife. The rock that keeps me grounded through very tough times. She shared the stress of the exams and was there for me in times of need. This exam damn well near broke me. I could not have done it without you.
Mum and Dad – for the encouragement and support over the years.

The Senior Emergency Consultants

Mohan Kamalanathan - The Mentor. Who had seen me through the past 7 years of training and spent so, so much time with me to polish my performance, both in exams and in real life. A very senior examiner. Sometimes when im stuck i'll go - hmm, what would Mohan do? A true mentor. Yoda, he is.

Abrar Waliuddin - The OSCE nerd. Tons of simulated OSCE practice, including the two mock OSCEs and many many in person sessions. This guy went out of his way to design OSCEs and run the fellowship training program in Frankston hospital. He wrote the Frankston OSCE guidebook.

Garry Wilkes - The Examiner of Examiners. How to deal with very difficult leadership and empathy scenarios. He trains the new first time examiners. His advice on dealing with difficult scenarios is practice changing. Not just in exams but in real life.

Jo Dalgleish - The Lead Examiner. The literal chair of the ACEM examinations committee. For helping me brush up my performance and thought processes for the OSCE. How to think like a FACEM.

Imran Chanth Basha - The Contact. I've only known Imran for a year, but he got me in touch with Jo and Ruth. Absolutely priceless. Legend.

Shayaman Menon - The Director of Directors. An Emergency Physician who has risen to become the overarching Director of Medical Services. Also an examiner. Had a few sessions with useful feedback and confidence building.

Ruth Hew - The Oracle. Tells you exactly what *you* need to hear. Her feedback was invaluable. A very, very, senior examiner (Turns out she was Shayaman’s mentor back in the day). Lives in a house full of character. Gives you baked goods. Motherly vibes. Here, have a cookie.

Darsim Haji - The POCUS Guru. An examiner, who is very adept in ultrasound. Helpful sessions and feedback on the floor. Well respected examiner and mentor from my ultrasound rotation days, who spent some time polishing OSCEs with me.

Jon Dowling - The Trainee Whisperer. The nudge in the right direction to not sit 6 months later and to properly prepare was gold. Looking back there is no way I would have passed if I had just gone straight for the next exam sitting. Jon is very good at clinical processess and leadership - when encountering a leadership situation I find myself asking 'what would Jon do?'

Gabriel Blecher - The Director. He is the current director of my department. I was feeling quite low after failing my first attempt. His positive feedback was invaluable in rebuilding my confidence. Sometimes you forget about the things that do go well and dwell on things that dont.

Diana Egerton-Warburton - The Researcher. Last but not least, the Professor who helped me get published for the fellowship research requirement. She is the most accomplished researcher I know in person. Holds an Order of Australia (OAM).

What Happens Next?

              You look in the mirror, notice some grey hairs, and come to the stark realization that you are now the pointy haired boss. You have a director and executives above you, but you are running the floor. The juniors have to (at least pretend to) like you for good term assessments and feedback. You have earnt the title of Fellow of The Australasian College of Emergency Medicine, and can get your fancy FACEM self-inking stamp.

Welcome to middle management.

Monday, August 22, 2022

Ikigai and What It Means To Be An Expert

Lost and Afraid
I was feeling lost for quite awhile. The frightening thing of not knowing what else can be done. I had studied to the point of burnout and revised the entirety of the syllabus before attempting the OSCE – and still failed. Studying harder is not the solution.

But I think im starting to get the idea of what this exam is all about.

After gaining the necessary book knowledge (passing the primaries, and fellowship writtens), the final textbook/syllabus is REAL LIFE, with the development of structure in active working memory and heuristics to respond to unique circumstances.

It sounds impossible. But put it this way: It cannot break the rules of real life. There is only so much that can be examined realistically in an OSCE scenario.

How do you prepare for an exam that doesnt really have a textbook or syllabus?
An exam that tests if you are functioning at the level of a consultant. Looking back, my approach was completely wrong – book knowledge will not get you past this exam. You could say all the right things, yet lose marks in Prioritization, Leadership and Communication. 

One revelation came when I got a zoom account and recorded some practice OSCE sessions. It’s hard to describe, but I was speaking like a registrar – not a consultant. Rewiring my brain will take time and practice.

Standing in front of each OSCE station, there is a stem. A spiel. A clinical situation. An expert knows the meta/background of the clinical situation, and will be thinking three steps ahead – what needs to happen, what to look for, and important organizational minutae that needs to happen.

A second revelation came from a very senior, recently retired, ED consultant (James Taylor) who gave the following words of wisdom:
It is a Specialist Level Expert Exam. It is designed to blow gaps in knowledge apart, and assess your response to very specific scenarios that require expert level knowledge and input. 
- Contents unchanged for past 30 years.
- Ask how am I going to be an expert at: (insert oddly specific thing here)?
- budget 20hr/week for 50 weeks.
- Take time. Read your books. Know the drills.

You will know you are ready when you can confidently answer the following questions:
- Am I functioning at a registrar level or expert level?
- Are there clear improvements in Markers of progress?
- Am I Well prepared – 1000 hours, courses, and trial exams?
- Do my mentors think I am at expert level?


How I Failed?
Change in hospital. Lost touch with mentors. Lost sleep / circadian rhythm. Slept for two hours the night before the exam (anxiety). I did not have enough practice, and only found out about the old SCEs four weeks out to the exam. Completely wrong study approach. Going through the entirety of a syllabus did not help me prepare for this exam. Studying harder is not the solution.

SWOT analysis
Discipline and work ethic.
Experience of real exam, and multiple trial exams and many months of practice with mentors. I am starting to get the vibe of what I need to to – develop expert level heuristics.
Stacked repetition of previous experiences will make learning a whole lot meaningful.

Near zero empathy and low emotional intelligence.
Writtens in March 2021 – need to refresh knowledge.

There is time to organize and structure approach. 
Time to attend more courses.
Need to pass by 2026. There is time.

Failing kills confidence – second attempts have a lower success rate.


What It Means To Be An Expert.
(link to Veritasium’s video here)

TL;DR - Expertise = Recognition = Intuition.

There are two memory systems that we use daily: System 1 (fast, subconscious) and System 2 (conscious slow effortful). Think riding a bicycle vs carefully considering which stock to pick.

Better working memory for specific situations that occur in real life. With full pattern recognition / chunking - making sense of complex situations quickly and seamlessly.

Having highly structured information stored in long term memory. 
Need to be able to quickly assess a clinical situation (or OSCE stem!).

1. Many repeated attempts with feedback - This is the osce process, which is why it is a finishing school of sorts for consultants.

2. A Valid Environment - Immerse self in an environment where the specific situations can occur. Where feedback actually means something on a deep level. This means working full time, and having lots of interaction with senior mentors who have a wealth of practical knowledge not in any textbook. 

3. Timely feedback - real life feedback is ideal, but rarely happens on the floor. The OSCE training process is essentially a virtualization of clinical encounters with timely feedback.

4. Deliberate practice in challenging situations. Dont get comfortable - I have become competent in most clinical situations. That does not make me an expert. It causes stagnation and prevents that extra learning that is required to become an expert. I need to immerse myself in to complex clinical situations until it becomes second nature to sort them out.

It is pointless to 'study' for the OSCE. The key to passing is not in any textbook or reference manual. I need to meet the four criteria above to develop a structure for approaching common and uncommon (oddly specific) situations that I may have never seen in real life.

Common situations would be things like:
- a pediatric elbow injury
- diabetic complications (HHS / DKA).
- a myocardial infarct.

Uncommon situations that I may have never practiced in real life such as:
- managing a priapism
- system crisis (external emergencies / fire / access block)
- managing a smallpox/contagion outbreak
- dealing with workplace interpersonal conflicts.


Learning 2.0 
– In my 36 years of life. This is what I think works best.

1) A Healthy State of Mind
- Enough sleep. At least 7 hours a day.
- Enough exercise. For enhancing neuroplasticity.
- Enough nutrients. Fish twice a week at least.
- Enough social contact. I must not neglect my friends.

2) Stacked repetition
- The single most important thing to ingrain things to long term memory. Repetition at intervals.
- Perform. Polish. Perform again. Polish. Until second nature.
- Think Karate Kid.

3) Reliable Sources of Wisdom
- Wisdom, not just knowledge. Structured. Curated. Distilled.
- The structure that has been developed in senior consultants
- Templates from which I can grow my own structure.
- Regular meetings with my mentors, consultant examiners, and peers.

wax on, wax off.


Great. So how is this going to work in real life?

1) Consistency / Advanced Scheduling
- Two week forward planning availability schedule. 
- Goal to arrange at least two sessions per week for OSCE practice / mentoring consistently.
- Schedule protected study time – with a target of 20 hours per week total.

2) Full Immersion
- Work full time. Live it. Breathe it.
- Slow the fuck down. Debrief. Ruminate. Reflect. Marinate in thoughts. Develop structure.
- I need to sit down for half an hour a day to ruminate and reflect.
- Regular debriefs/meetings with the senior consultants who have graciously offered to help.

3) Focus on themes and structure.
- Need to collate and compile feedback from various trials into themes.
- Develop structure to approach broad range of situations
--- What to do if a pt with XYZ is in front of you
--- How to deal with challenging communication/interpersonal scenarios
--- Describing procedures at an expert level
--- The oddly focused examinations (eg. neuro in spinal trauma) to be expert/slick at.

4) Avoid being in my comfort zone
- I have reached a stage in my career where I can confidently manage most things without too much mental effort. This is bad in a way. Why are we doing X? Is Z really the right option?
- I need to consciously focus on what can be done better.
- I need to actively seek feedback and critique or will never grow. As I have become more senior, this negative feedback is extremely hard to come by.
- ... to continue actual learning. Bit by bit. Every day.

5) Knowledge Refresher
- Spend about 30mins a day flipping through, and ruminating on trial written exam papers.
- (instead of reading textbooks, that does not help in developing heuristics / situational structure)



Sounds simple. Yet it’s going to need real focus. Here is where Ikigai comes in.
I enjoy what I do and look forward to going to work. The world needs emergency physicians. Im paid for it. Im good at it. And I freaking love it!

It shouldn’t be arduous. Annoying maybe (having to set up zoom meetings and lots of scheduling)… but enjoyable at the end of the day.