#66 – How to be a Good Student on Emergency Medicine Rotation


Guest for the Episode

John B. Hurt, MPAS, PA-C

Assistant Professor and Director of Academics and Curriculum – Samford University – Department of Physician Assistant Studies

My 10 Rules

  1. Be on time
    • On-time = early
  2. Introduce yourself to the team
    • Preceptor and/or supervising physician
    • Charge nurse
    • Secretary or unit clerk
  3. Be Goal Oriented
    • Shift
      • Have 1-2 objectives for every shift you work
    • Rotation
      • Talk with your preceptor about what you want to see/do/experience
        • Actively seek out these experience
  4. Always Be Doing Something
    • Checking labs/images
    • Ask to draw blood for techs
    • Ask if you can get anything for your preceptor/staff
    • Review cases
      • There is something to be learned about every case we see in the ED
      • Look them up, write them down
      • Ask your preceptor what their decision making looks like
  5. Develop an algorithmic approach to common ED presentations
    • Chest pain, abdominal pain, AMS, fever, dyspnea, back pain, nausea/vomiting, trauma
      • Fast the providers what they do
      • Write these out to reference in the future
      • Get familiar with clinical decision instruments
        • Ottawa Rules, NEXUS, PERC, Canadian C-Spine
  6. 1-minute Presentations are an absolutely must
    • Have your diagnosis and plan ready
    • Differential diagnosis
      • Life threats, most likely, plausible, Zebras
  7. Disposition is the end decision in EM
    • Every patient either gets admitted or discharged
    • Before your preceptor makes the decision, make your own and see if your right
  8. See every type of patient that walks through the door
    • Don’t cherry pick (unless it is on your bucket list)
    • This will help you immensely throughout your career
  9. Go up and see the patients you admit before you leave the hospital after a shift
    • It will benefit your decision in the long run if you see what the inpatient team is doing
    • Your patients will also appreciate you checking on them
  10. Get feedback after every shift (if possible)
    • Plus-Delta approach
      • Things you do well (plus)
      • Things you can change (delta)

Congratulations to the UAB PA Program Class of 2016



You guys made it…….2.5 years.

2.5 years of blood, sweat, tears, late nights, early mornings, angry attendings, sweet patients, amazing staff, and lots and lots of coffee…..but you made it.  I am sure it feels like both an eternity and a blink of an eye.


You have made life long friends through this journey and now, you gain 9 faculty members as new colleagues.


As you are standing in the processional line on Friday awaiting your diploma and you are reflecting over your time in PA school, I want you to think back to 2013.


The hardest part of the CASPA application is the personal statement.  Think about the self-reflection you did as you struggled to put into words the feelings you had about wanting to become a PA.  Think about all your personal, professional, and academic trials and tribulations that led you to the moment that you decided to click on the “Begin a New Application” on the CASPA website.  Think about all the medical professionals you encountered, both good and bad, and how you said to yourself “when I am a PA, I will definitely do or not do that”.  Remember what that future PA looked like?


That is you now.

My request is simple….be the PA you said you wanted to be in your personal statement 3 years ago.

Don’t let you down.


You certainly have not let me down.  There was reason I did not include your class on my “Open Letter to My Students” blog post a few weeks ago.  You deserved your own recognition.  I am proud of each and everyone of you  and I am even prouder to call you all colleagues.  You will make great PAs and will make an indelible mark on the world of medicine wherever you practice.



Interview Game

So we have interviews all this week for the PA program at UAB and I want to play a little game.


I am curious to see how many applicants follow me on the blog/Twitter/Facebook and rather than flat out ask, I want you to do the following:

Make it a point to come up to me and say “butterscotch“……or tell another faculty member you are interviewing with that you wanted to tell Mr. Maday that “you love Cocoa Puffs, too“.

This should be fun………………


2016 White Coat Ceremony Keynote Address



This is a video of my keynote address to the UAB PA Program Class of 2018.  Of all the lectures/courses/talks I have given, this one is my near and dear to my heart.  The white coat ceremony at UAB is my baby and I take great pride in bringing this tradition to my alma mater.  It is also an homage to Sir William Osler, who has inspired me not only in clinical practice, but also in academia.


How To Write A Personal Statement


This is a lecture I gave to a group of biomedical science students on how to write a personal statement for graduate professional programs.  It is directed towards medical professions (PA, MD, DO, DMD, etc.), but the basic tenets are the same.  By following a few basic rules and sprinkling in your unique experiences, your narrative will win over the selection committee.

To watch the video, click here


Why Do I Do This……

“A person who feels appreciated will always do more than what is expected.” (Author unknown)

This quote I came across many moons ago has been ringing in my head for the past few days.  Even though I am still considered a “young” professional at 36 and I was born in the transition years between Generation X and Millennials, I still feel I have an old-school professional ethos.

Do your job…work hard…do what is asked…don’t ask for anything….let your work speak for itself.

I know this blog is meant to be educational and to teach you something about medicine so you can better take care of patients in the clinical setting.  But…one of the more selfish reason I created it was because I wanted to see the fruits of my labor and feel like I accomplished something important.  Academic publishing has always been a fickle beast.  You spend weeks to months writing a manuscript and submit it to a journal, only to be judged by a select few that will decide the fate of your work.  Sometimes it is accepted….sometimes it is rejected…and sometimes it hangs out in limbo accepted but not published for years (I have 2 papers that I wrote in 2014 that have yet to be published).  This is why I started the blog and podcast.  I have control over what I do and when it gets out for people to read and listen to.

I think it more important to disseminate information and teach to whoever wants to learn, than to write for journals (that nobody reads) just because “this is what we do in academia”.  My hope is this paradigm will shift in the future as more and more people see the benefit non-traditional educational activities and how it can be used as scholarly work.  But unfortunately….this is not the day.

I never fancied myself as a writer, but I am starting to have that cathartic feeling that so many writers have.  For the 5 or 6 of you that read this blog, thank you.  The PAINE Podcast and Blog is the single most important professional endeavor I have ever done because it benefits only you, me, and patients.  No journals…no professional societies…no third parties.  The feedback I get from my students, the social media universe, and other professionals I work with tells me what I am doing means something and for that, I will always be grateful.  To me, that is more important than publications, grant funding, or research.

I leave you with “The Man in The Arena” by Theodore Roosevelt that really sums up how I have been feeling of late.


“The Man in the Arena” by Theodore Roosevelt

Memory and Learning

This is my post for The American Academy of Physician Assistants Blog “PAs Connect” in a recurring series called “Professor’s Corner”.

School is all about memory.  You are presented information in class and you try to remember everything the professor is saying in order to transcribe what you think is important on your notes.  Then you go home and study these notes, textbook chapters, and journal articles to help try to make sense of the material. This is where our cognitive weapons of choice come out: different colored highlighters, index cards, sticky notes….all in the hopes that it is processed into neat little compartments in your brain so you can recall them for the exam.  Rinse…wash…repeat for 2.5 years of PA school.  But what is the science behind memory and why do somethings work better than others?

Most people think of memory as just short term and long term, but depending on which psychologic theory of memory you prescribe to, there can be many more.  I, personally and professionally, like the three-tiered, information processing model to memory: sensory, working, and long-term.

Memory Graphic

Sensory Memory

The first step in memory involves the processing of sensory stimuli that are introduced in the learning environment.  The brain uses three main senses (sight, sound, touch) to get as much information brought in as possible.  Now, if you had to process every single sensory stimulus into your working memory, your brain would get overloaded in a matter of seconds.  To avoid this, you use sensory memory as the environmental buffer to pick and choose what you think is the most important……this is where attention comes in.  Attention is the filter from the sensory memory system into the working memory system and allows us to focus on smaller, more important sensory stimuli.

Attention is the bodyguard outside of Club Working Memory.  He will pick and choose what information gets through for further processing to make sure the club isn’t overcrowded.

Working Memory

Once the sensory information is attended to, we can store it in a temporary cognitive sandbox where we can actually work with it.  This is your working memory.  It is short (15-30s) and the information stored here only stays if the learner is actually doing something with it (rehearsal).  There are 3 main components of working memory:  central executive (supervisor), the phonological loop (language storage), the visuospatial sketchpad (visual storage).  As you hear and see things over and over again, you start to make connections and correlation between the information and begin to encode it all into neat data packages.  Each system is different and the cognitive load when using both systems is only slightly higher than using them individually.  Cognitive psychologists recommend using this to your advantage while studying.  For example, assign each class a room in your house and only study in this room.  It will increase the likelihood of correctly recalling the information when you can get your cognitive bearings straight on the location you learned the information.  You can incorporate similar strategies such as listening to different music or artists for different subjects.

The more you rehearse this information in working memory, the greater the cognitive load….but the higher likelihood it will make it to long-term memory.

Working Memory Graphic

Long-term Memory

Due to this increased cognitive load of working memory, it is not possible to keep information in working memory indefinitely.  This is where long-term memory comes into play.  We try to categorize this information into packages for easy storage and recall in long-term memory.  There are 3 steps to this process:  encoding, storage, and retrieval/rehearsal.  The majority of the energy used when studying is trying to encode the information in working memory so it can be efficiently and effortless recalled when needed.  This is why mnemonics, acronyms, and all the other things we do as students help process and package new information so we can remember them later.  “Oh Oh Oh To Touch And Feel Very Good Velvet, Ahhhh” may mean nothing to you, but it is how I can still recall all 12 cranial nerves to this day.

Loss of Memory

Even with all these sophisticated and complicated cognitive pathways that our brains have developed to retain information, we still forget and lose information.  There are many theories behind this, but the 2 main ones I like are:  information decay (the less you use it, the less you can recall) and interference (learning new information inhibits recall of old information).

To limit interference when I am teaching, I try not to overload the senses with extraneous stimuli.  If I stand up and just read the powerpoint (which is not teaching by the way), you (the student) can’t listen to what I am saying when you are being bombarded with paragraphs of text that you feel compelled to read. This leads to overload of the sensory and working memory as you are trying to listen, read, and process everything that is being thrown at you.

To limit long-term memory decay, I utilize spaced repetition.  When I am teaching, I like to bring up old information (last exam, least semester, etc…) to re-introduce to it to my students.  It is also why I believe in comprehensive final examinations.  It gives them an opportunity to dust off the stored information in long-term memory and play with it again in the sandbox of working memory.  This strategy has been shown to improve retention and efficiency of recall when you need it the most…..when taking care of patients.

SPaced Repitition

Wolf G. Want to Remember Everything You’ll Ever Learn? http://www.wired.com/2008/04/ff-wozniak/?currentpage=all



1)  Anderson JR.  Cognitive psychology and its implications.  7th ed.  Worth Publishers. 2009

2) McLeod SA. Working Memory | Simply Psychology. Available at: http://www.simplypsychology.org/working memory.html. Accessed February 15, 2016.

3) Cognition (Sensory memory). Introduction to Instructional Design. Available at: http://byuipt.net/564/2013/08/23/cognition-sensory-memory/. Accessed February 15, 2016

4)  Baddeley AD.  Working memory.  Science.  1992;255:556-559.

5) Cognition (Long-term memory). Introduction to Instructional Design. Available at: http://byuipt.net/564/2013/08/23/cognition-long-term-memory/. Accessed February 15, 2016.

6) Wolf G. Want to Remember Everything You’ll Ever Learn? Surrender to This Algorithm. Wired.com. Available at: http://www.wired.com/2008/04/ff-wozniak/?currentpage=all. Accessed February 15, 2016.

7) Nickson C. Learning by Spaced Repetition. Life in the Fast Lane Medical Blog 2011. Available at: http://lifeinthefastlane.com/learning-by-spaced-repetition/. Accessed February 15, 2016

Fear and Education

This was my first blog post for The American Academy of Physician Assistants PA Blog in a recurring series called “Professor’s Corner”. 


           Fear is good.  It is a strong statement and is bound to invoke certain emotional feelings, which may not always be positive in nature.  Think back to the last time you were truly scared.  Chances are you can remember more than you think about the event in question.  Cognitive psychologists have studied the effect of fear on attention, as well as retention, and shows there may be a “sweet spot” for a “healthy amount” of stress that is beneficial to learners.  The trick is not only finding that perfect zone for each student, but also adjusting it throughout the 2.5 years of school. 

            The fear and stress at the beginning of the didactic phase of PA education is most commonly caused by grades and doing well on exams.  Many of you may have gone through undergraduate studies with very high marks, and maybe even didn’t have to study all that hard.  Then PA school hits you like a freight train.  So what happens?  You commit “academic bulimia”……binging on large amount of information for exams and then completely purging it from memory to make space for the next exam.  Very little retention takes place, but the fear of doing well in school is tempered.  Compare this to the end of the didactic year when you have your studying methods down, but you are preparing for clinical rotations and suddenly you think you “can’t remember anything”.  Now the fear is shifted from grades, to trying to remember as much as possible to take care of actual patients.  While on clinical rotations, your fear is redirected once again to trying to recall any information from your didactic year so you don’t look incompetent in front of your patients or preceptors.

            Our jobs as professors in PA programs is to instilling aliquots of fear in safe environments to get you ready to practice medicine.  Maybe it is using more simulation in a group setting.  Maybe it is calling on you in class.  Maybe it is pop quizzes.  Maybe it is comprehensive final exams.  The method to our madness……stress inoculation.  By doing small stressful tasks throughout your classroom instruction, we are trying to prepare you for learning in the clinical environment.  Simulation prepares you to make clinical decisions in low-stakes environments.  Calling on you in class prepares you for the Socratic method of teaching that permeates the halls of the hospitals.  Pop quizzes and comprehensive finals teaches you to be self-directed, intrinsic learners that will persist for your entire medical career.

              Fear is good.  No other profession has the life or death struggle that medicine embraces.  The moment you do not fear taking care of patients is the moment you may cause someone harm.  Part of the educational process of PA school is to teach you how to manage this fear.  Every time you overcome fear, you become stronger.  Suddenly, thinking about getting called out in class by a professor in a class of your peers is nothing compared to getting called on by your attending in front a group of strangers….or telling a patient they have terminal cancer.  Harnessing this fear and helping you focus it will not only help you be the best clinician possible, but it will indirectly help every one of your patients you take care for the rest of your career.


1)  Vermeulen N, Godefroid J, Mermillod M (2009) Emotional Modulation of Attention: Fear Increases but Disgust Reduces the Attentional Blink. PLoS ONE 4(11): e7924.

2)  Schwabe L, Joels M, Roozendaal B, Wolf OT, Oitzl MS.  Stress effects on memory:  An update and integration.  Neuroscience and Biobehavioral Reviews.  2012;36:1740-1749.

3)  Susskind JM, Lee DH, Cusi A, Feiman, Grabski W, Anderson AK.  Expressing fear enhances sensory acquisition.  Nature Neuroscience.  2008;11(7):843-850.

4)  Perry B.  Fear and Learning: Trauma-Related Factors in Adult Education Process.  New Directions for Adult and Continuing Education.  2006;110:21-27.