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SGEM: Did You Know? Headache: Not Just Migraine
continuously face. I am hopeful that post-pandemic life may compel the distillation of American ideals and the restructuring of systems of power that have abandoned our communities at their most vulnerable. As we emerge into a brave new world of our own devising, may we always remember la familia.
The initial stages of mandatory quarantine are where I first noted despair and social disconnect brewing in my community. People were glued to their televisions and struggling to decipher a barrage of information. They were severely isolated, especially young adults and recent immigrants who had not yet built family structures or robust support systems. Without such networks in place, stay-at-home orders became challenging, and those with relatives abroad were forced to weather the pandemic alone.
In the best of times, mental health often receives little attention in immigrant communities. When compounded with the pandemic, mental health vulnerabilities were exacerbated. New immigrants tend to have limited support, insufficient health care access and cultural barriers that limit them from developing mental health coping skills. As a result, many suffered from unrecognized health issues ranging from depression to panic attacks and major psychotic breaks.
Mass vaccination is nearly within reach to help mitigate this crisis, yet health providers must now find empathetic ways to tackle a new challenge: vaccine hesitancy. I have witnessed
Latinx (predominantly Catholic) and African (predominantly of strong faith backgrounds) community members defer this decision to religious leaders because of historical mistrust of medicine in SGEM: DID YOU KNOW? American underserved communities. Just as we began to see hope on the horizon with the release of vaccines distrust has been fueled by religious leaders claiming the vaccines are “anti-Christ”, “mark of the devil” or unethical. All untrue assertions by trusted sources in immigrant communities. Well-informed community and health leaders committed to evidence have large roles in rebuilding trust while showing empathy to address misinformation for the sake of public health Duty Calls As physicians, our voices have to be louder than the megaphones of those who are spreading misinformation or disinformation. It is our duty to ensure people make informed decisions rooted in evidence. It is imperative to seek to understand the communities we serve — underserved and immigrant alike — to provide better equitable care which will be the beginning steps to address the health disparities that have long plagued medical communities with distrust and fear from our patients .
ABOUT THE AUTHORSHeadache: Not Just Migraine Dr. Shafer is an assistant By Soumitri Barua and Alyson McGregor, MD, on behalf of professor of emergency SAEM’s Sex and Gender Interest Group medicine physician and A seemingly simple headache may mask a more medical toxicology at Baylor sinister process such as ischemic stroke, especially College of Medicine. in women. While women have a higher lifetime risk of primary headache syndromes like migraines and Dr. Bicette is an assistant tension headaches, chronic headache syndromes put professor of emergency people at higher risk for major cardiovascular events, medicine at Baylor College including ischemic stroke, myocardial infarction, and of Medicine and a medical cardiovascular disease-related deaths. A study found director in the Baylor St. Luke's that women with migraine with aura had double the healthcare system. @DrRichiMD prevalence rate of an ischemic stroke than women without a migraine disorder; however, a similar Dr. Turner is an education association was not found in male participants. and administration fellow at
It is important to have a low threshold to evaluate Baylor College of Medicine. for stroke, even when a patient presents with a non- anisha.turner@bcm.edu specific neurologic complaint such as headache. A @DestinedDoc prior diagnosis of a migraine syndrome does not mean the patient is having another episode. On the contrary, a migraine that “feels like the other ones” could mean a woman is in the early hours of a stroke. As in acute coronary syndrome, women with underlying ischemic stroke are more likely to have nontraditional symptoms such as pain (including headache), change in level of consciousness, or even non-neurologic symptoms. SGEM "Did You Know?" is a recurring SAEM Pulse submission designed to represent concise facts that demonstrate how patient sex and gender effect emergency care. We welcome submissions. Please send contributions to the coeditors Lauren Walter and Alyson J. McGregor at sgem@lifespan.org.
Differentiating possible strokes from stroke mimics is only possible when one knows how to identify symptoms from red herrings.
Migraine and stroke have some overlapping presentations that warrant keeping both on the list of differential diagnoses at initial evaluation. For example, a hemiplegic migraine, a rare type of migraine, involves weakness on one side of the body (face, arm, and/or leg) and can resolve spontaneously before presenting at an emergency department. Resolved weakness may also be a sign of transient ischemic attack, and persistent weakness would warrant a stroke workup.
Women are more likely to have a migraine and report longer headaches and have a higher lifetime risk of an ischemic event compared to women without migraines or men in general. Women also have a higher lifetime risk of stroke. Emergency medicine physicians should continue to be aware that headache can be an important sign of stroke, especially for women. ABOUT THE AUTHORS Soumitri Barua is an MS4 at The Warren Alpert Medical School of Brown University. Dr. McGregor is an associate professor of emergency medicine, The Warren Alpert Medical School of Brown University.
Telehealth + Education: Identifying the Needs and Building the Programs
Meeting at the Crossroads is a column dedicated to bringing members of various SAEM interest groups and academies together to explore the areas where they intersect. In this column, Erica Olsen, MD, director of virtual health services in the department of emergency medicine at Columbia University Irving Medical Center and immediate past chair of the SAEM Telehealth Interest Group talks with Peter Greenwald, MD, director of telemedicine in the department of emergency medicine at Weill Cornell Medicine; Thomas Bennett, MD, senior resident, New York Presbyterian Emergency Medicine Residency; and Neel Naik, MD, director of emergency medicine simulation education, associate medical director at the WCM NYP Simulation Center and simulation fellowship director for emergency medicine at NewYork-Presbyterian Hospital/ /Weill Cornell Medicine.
Dr. Olsen: Thanks for taking some time out today to talk about telehealth education. This is an exciting time for this topic. Just last fall, as part of the SAEM20 consensus conference, an agenda was set for research priorities in telehealth education; more recently the AAMC proposed clinical competencies in telehealth medical education. On a personal level, based on the experience that we have all had over the past several years as physicians working telehealth shifts, administering telehealth programs and using telehealth to assist in the recent public health emergency, we are at a point where we can identify the major needs, gaps, and pitfalls in telehealth training and then build educational programs to target those needs.
Dr. Greenwald: When we started doing telemedicine in 2016, we wanted to get our providers educated in how to conduct a visit virtually, at the time there weren’t many resources dedicated to telehealth. We ended up hiring a media consultant to help us with “telepresence,” but that was the extent of it. In subsequent years, our idea that education is important in this space has been reinforced. Especially in the last year we have all picked up examples of suboptimal telehealth visits — for example someone on screen with an unmade bed behind them, or someone failing to do a physical exam when that exam would provide valuable information for the patient’s care, and so on. I think it is very important that providers be trained in how to project a professional appearance in telemedicine, how to conduct virtual exams, including in some cases informing providers that exams are possible, and the basics of medical-legal awareness, especially the non-intuitive stuff like location and controlled substance considerations. As educators, it’s really our job to build that necessary education and set the agenda.
Dr. Bennett: Dr. Greenwald and I have discussed telemedicine in the past, but I don’t think it was really until the COVID-19 pandemic hit that it piqued my interest because the emergency department (ED) patient volume didn’t return to pre-COVID levels after the surge was over. I knew that these patients were going somewhere, but they weren’t walking into the ED. Then I had the realization that many were being seen through telehealth (a space where the residents weren’t getting much experience). I knew that we had a robust telemedicine program within our own system and that as residents we would likely need these skills someday as the landscape of medicine changed, yet we weren’t yet exposed to this in training.
Dr. Olsen: That’s a great observation you made and you’re right — we were very busy with one of our programs, the Virtual Urgent Care program, which is a direct-to-consumer platform whereby patients use their devices to connect with our emergency medicine (EM) providers directly from anywhere. For patients with non-COVID-19 concerns, there was tremendous trepidation about returning to the physical ED for fear of contracting the virus, and for those who did have COVID19-related concerns, there was fear of being admitted to the hospital without having any family support, as no-visitor policies were enforced to limit spread. Having a program in place where patients could call from the comfort of their own homes proved to be a preferred model of patient care for many. To your point about formal education, when we faced a surge and the need to onboard more providers to meet volume demands, we did provide expedited education to many providers around things like professional presence and physical exam skills, including a dedicated module to assess respiratory status virtually for those with
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COVID illness. Dr. Naik can elaborate on the educational programs at the NYP Center for Virtual Care.
Dr. Naik: I think one of the things we need to keep in mind about education is that as telemedicine was becoming a way of taking care of patients out of necessity, a lot of people were trying to take the skills they had from years of experience in person and apply it to the telemedicine. If we consider how much time we spend working on bedside manner and learning the art of medicine, both in medical school and then in residency and later in our own practice, those sets of skills over telemedicine are different and that’s what we focused our education on. How do we provide good medical care over telemedicine? It dives into some of the things Dr. Greenwald mentioned earlier: How do you do a good physical exam? How do you get the information you need? How do you set up your space so that your patient feels comfortable and keeping in mind some of the medical-legal things like patient privacy and confidentiality, how do we incorporate that into your visit in a seamless way? Ultimately it comes down to this: if we are not comfortable in that space and communicating and caring for our patients, then we can’t make our patients comfortable in that virtual exam room. We need to know those basics, along with some troubleshooting tips and dos and don’ts to navigate it.
The approach that we use is the hybrid model; we provide some knowledge content, such as what kind of bandwidth you need to get started to some of the medical-legal pitfalls, and we provide them in an online module. So first, we provide basic knowledge, but this is the point where a lot of telemedicine education stops. As we know from education in general, experiential learning is a great way to develop skills, so in our training program we include a simulation component as well. We have our learners go through a telemedicine case with standardized patients, so they must put these skills into practice. We record it so that we can play it back for the learners and so they can see what they look like on camera as uncomfortable as that is.
But by seeing themselves on camera and seeing what their facial expressions are and how they communicate over camera, they started to feel more comfortable and understood how they could practice that art of medicine in the telemedicine space.
One of the greatest aspects of using simulation, as we are doing now at the center, is that the program evolves as learners improve, and as learners improve, we can move into more advanced topics such as how bias plays a role in our decisions over telemedicine. I think this simulation system is a model for how we should develop medical education for telehealth going forward.
Dr. Greenwald: One of the things we noticed during the pandemic is the value of having a learner and a supervisor on the same visit. Having video platforms with the ability for multiple people to join the video lets us do that. A learner could start by observing a case, then do a case with supervision and ultimately see their own cases alone. A similar program for residents could be conceived where the resident learner can receive feedback. Dr. Bennett, you and I have done some work in that way, I’m curious about your thoughts on that.
Dr. Bennett: I thought that it was one of the best ways to learn because doing the video visit myself with the attending in the background, observing and then interjecting when needed, allowed me to use all the skills from the module with guardrails around me to make sure I was doing things correctly.
Dr. Naik: I think one of the things to keep in mind in that resident supervision model is really making sure you take that into account when you’re introducing yourself to the patient, and how the visit is going to be conducted, making sure that everyone in the virtual room is comfortable with that arrangement. We want to make sure that these resident supervisory visits are still a safe space in which to provide medical care, and that includes knowing everyone who is in the room both on the provider end and patient end.
Dr. Greenwald: Neel, I totally agree, one thing that is very important when teaching people to do visits in this space is build the “room” and know who’s in it. If the patient finds out there is someone else in the room that they did not know about, you will lose all trust; if the provider doesn’t know who’s in the room, you set the stage for privacy violations or potentially even threatening someone’s safety.
Dr. Naik: To take that a step further, this is the beginning of telemedicine becoming an integral part of medical care; if we lose that kind of trust with our patients early on we could lose trust for all future telemedicine visits going forward; it’s a field we don’t want to sow with patients. As we embark on doing telemedicine we need to make sure we are training our current providers as well as future providers on how to do this well; what we teach will evolve as telemedicine itself evolves and we use it in new ways we haven’t even thought of yet, so we need to make sure that our educational systems for teaching telemedicine have that ability to evolve. Creating systems that have both a knowledge education component and then experiential learning component are key.
Dr. Bennett: I’m happy to say that our residency program will be starting to incorporate telehealth in the resident curriculum starting this year. All PGY years will have exposure and education each year. I think the publication of the AAMC competencies in telehealth medical education helped to facilitate that decision. I think it is really going to help our residents in their future careers.
Dr. Olsen: I agree, and I think that emphasizes the need for our involvement at all levels including regulatory bodies. As Dr. Greenwald mentioned earlier — it is up to us to set the agenda.
BIOGRAPHIES
Dr. Olsen is the director of virtual health services, in the department of emergency medicine at Columbia University Irving Medical Center.
Dr. Greenwald is the director of telemedicine in the department of emergency medicine at Weill Cornell Medicine.
Dr. Bennett is a senior resident at New York Presbyterian Emergency Medicine Residency.
Dr. Naik is the director of emergency medicine simulation education, associate medical director at the WCM NYP Simulation Center and simulation fellowship director for emergency medicine at NewYork-Presbyterian Hospital/Weill Cornell Medicine.
