Wednesday, October 22, 2014

Failure in medicine

Medicine doesn’t take failure well. In high-risk areas of patient care and safety, when the cost of failure is a life, that obviously makes sense. But do failures necessarily have to be that large?
I’ve spent a lot of time over the past few months talking to people at Penn’s Innovation Center. Their job is, as you might expect, to bring innovation into the UPenn health system. Here’s what I’ve learned. Medicine has long been thought of a field entrenched in its own traditions, one that has a lot of institutional memory. Changes are slow and incremental to be proposed, let alone adapted. I was immersed in an entrepreneurial ecosystem in college where I learned to rapidly iterate and learn from mistakes, and then just iterate again. I learned to think at the scope of microchanges, so no one mistake cripples me, but over time the sum of these microchanges would completely change the outcome. With this particular way of thinking, failure never seemed all that scary. From what I’ve seen, this doesn’t happen too often in medicine. I’ve asked those far more powerful than I, and they agree. Some of them take it a step further and say it’s not feasible, and this is where I disagree. From a policy level, I’ve noticed the prevailing opinion is that the healthcare system is so broken that nothing short of an overhaul will be acceptable. From EHR to universal access, all of the issues in the current healthcare system are purported to be too complicated and intertwined for any one measure to solve. This might explain why the Affordable Care Act (ACA) seemed so disparate and overwhelming (read into what the actual articles of the ACA are – very few deal with access to healthcare). Even in medical education, medical schools very rarely change their curricula – we’re still effectively using a model developed decades ago despite the field’s rapid evolution.

At my vantage point, two things have to happen: those who have been in the field for decades have to be willing to test new ideas, and healthcare needs to accept failure. The former means that doctors, nurses, staff, etc. have to buy into the idea that small changes can be impactful and are worth making. Not every issue is going to be fixed with one catch-all solution. The latter means that in areas where medicine can afford to innovate, it should. Failure will always be a statistically necessary byproduct of frequent iteration, but if the iteration is done with intention and care, there’s no reason to be afraid of it. The Innovation Center is doing exactly that – looking at implementing projects that doctors and staff want to see happen and helping them navigate the red tape. (One of the most frequent answers I’ve received in response to a question about implementing something new is red tape. Red tape is entirely the invention of a bureaucracy, and if the very institutions that complain about it simply choose to ignore it, the red tape magically vanishes). It’s a good start, but I don’t think it’s enough. There’s still this institutionally ingrained hesitation when it comes to trying new things.

I have a hard time believing iterating with microchanges wouldn’t work – it’s especially because healthcare often has to avoid large failures that the start-up way of thinking ­should work. There is great evidence of this already with the Intermountain Healthcare System in Utah and Idaho. But it’s not enough. Those of the philosophy that healthcare is vast and complicated and failing grossly are all correct – but I see that not as a paralytic, but as a call to action. I want to get in the habit of thinking like an innovator now, when the risk is relatively low (all I really do right now is a bit of armchair-philosophizing). But on a larger scale, more hospitals, more schools, more companies have to start innovating to disrupt within the confines of the medical system. It doesn’t have to be large. A new checklist here, a new curricular initiative there, and we might be able to (slowly, but surely) create a new medical system someday.

Friday, September 26, 2014

Movin’ On Up to the East Side

Last spring, I was trying to decide between Perelman and several other top medical schools. Like a typical type-A, wannabe medical student, I searched for any differentiating factor between the schools. Which city was more fun? Whose students were happier? Who had the funnier student YouTube spoof videos? As someone interested in orthopaedic surgery, I resorted to looking at the websites of top ortho hospitals, trying to gauge how many Penn students had gone to such places in the past. My dear friend Google helped me find an institution called The Hospital for Special Surgery (HSS) in Manhattan, New York City that seemed to be perennially ranked #1 or #2 for ortho. On a promising note, I found that several Perelman students had matched there over the years. Indeed, it seemed that Penn was perhaps the perfect place to help me get to the next step. 

Less than one year after first putting on my white coat in the Annenberg Center, I found myself staring at a large white and blue HSS sign in the Upper East Side of Manhattan. I had been selected to the hospital’s Medical Student Summer Research Fellowship program and was set to spend about 9 weeks working with some of the most renowned orthopaedic surgeons in the US. With only one year of medical training under my belt, one of my top priorities was to not look too dumb around the great minds at HSS. It was evident from the first meeting that the hospital was a special place. When the first day finally slowed down, I almost had to laugh at my own serendipitous path to, first Philadelphia, and then New York City. A year earlier, I had stared at my computer screen thinking, “Wow. Manhattan. HSS. That’d be a great place to train.” Now I was scrubbed into surgery at the hospital and assisting a surgeon that (literally) wrote the textbook on hand surgery.

I spent July and August working on projects with the attending surgeons, residents, and other researchers, learning their work habits, schedules, and personalities. I rose before the sun and ran for exercise around the city, getting to know the East River Esplanade, Central Park, the Upper West Side, Midtown, Yorkville, and of course my home, the Upper East Side. Afterwards, my morning at the hospital would start with the residents’ conference. Topics here ranged from in-depth anatomy reviews to avoiding bias in research to diagnostic radiology for orthopaedics. After this meeting (and the all-important free bagels), I would trail to the operating room or head to the motion analysis lab, where my background in engineering and data analysis helped me contribute to projects. This blog doesn’t have enough lines for me to adequately describe how much I learned, so suffice it to say that it was an amazing academic training experience that I was blessed to have.

Sunrise from the East River Esplanade at 77th Street
Van Cortlandt Park in the Bronx, NYC

The academic rigor of the weekdays was rivaled only by the fun of the weekends. My girlfriend, a fellow student at Perelman, typically arrived via the $1 bus on Friday night, leaving two whole days for us to explore the city before she had to return to her own research in Philadelphia. We ran, we ate, we saw shows on- and off-Broadway. We navigated the city on foot and via train, walked the High Line, toured the Brooklyn Brewery, gawked at animals in the Bronx Zoo, watched “Frozen” in the park, and spent way too many hours debating which Upper East Side dogs were the cutest (the English and French bulldogs get my vote). Each weekend went too quickly, and each weekday brought new awe-inspiring lessons in medicine. 

Morning View Looking South over the Central Park Reservoir
For the person out there considering the Perelman School of Medicine, I won’t tell you that this is the perfect place for you. To be perfectly honest, the idea that a perfect place for you exists is a myth. Each school excels in many things while lagging a bit behind with regards to other things. But, in Philadelphia, I have found a school – No, I have a found a home, where I know the administrators and professors look out for the students, and the curriculum gets us ready  to excel at actually being doctors, not merely at passing tests.  It is at Perelman that I have met some of the most amazing people, had some of the most humbling experiences, cried, laughed, held up intramural champion shirts, learned great lessons in medicine, and never regretted my decision on where to attend medical school.
Sunset from the Entrance to HSS

Thursday, June 5, 2014

Inspiration and the Medical Student

My last post started with the idea of finding Inspiration, of the sort that drives one to create, to achieve, to question, to learn. The natural next question is what I plan to do with that Inspiration.
We’re told as children to dream big, that the world is ours for the taking. It’s no less true now—I’d be hard-pressed to find a better and richer environment in which to learn—but things have changed. As a high school or college student, I had the bandwidth to pursue those dreams. Sure, I still wanted to do more than I was able, but my internal checks and oft-waning interest for my latest obsession set up a sustainable way to balance my time against my passions. But as a medical student, it’s simply no longer possible to operate the same way. I realized this a few weeks ago as I found myself having ten conversations a day with my classmates commiserating about how 24 hours in a day is just too little, but it’s only starting to strike me now. 
I’ve certainly tried to do it all by going the extra mile to free up my time. But somehow, days blend into weeks, weeks to months, and I’m still sitting on that to-do list that’s gotten only marginally shorter. I want to be clear: I’m not saying that medical students don’t have the ability to pursue anything outside of their classes. Looking at the amazing things medical students are doing every day across the country would disabuse anyone of that notion. What I’m saying is that for very disparate career interests, even within the field of medicine, it’s exceedingly difficult to build solid skill sets as a student. For example, I have a strong interest in the innovation happening in the healthtech start-up world, I love writing and medical journalism, I’d like to pursue pharmaceuticals and drug engineering, and I want to do some academic research as well. These aren’t just passing interests; I would commit to doing all of these things as a career to better inform the way I care for patients and approach medicine.
To those reading, it would seem that I’m complaining about growing up. After all, it’s universally true that with adulthood come responsibilities and a narrowing of horizons. First with a college degree, then a focused graduate degree, and then often a more focused job.  I’m not presumptuous enough to think these issues are limited to medical students, or even students. But it’s a little different for us as medical students: we spend those formative 20s (and sometimes 30s), when much of our generation is exploring and trying and doing, in school and in training. Our capacity to extend and challenge ourselves becomes greatly diminished simply because our road consumes so many hours of our days and years of our lives. None of this is new, I realize. And none of this was new to me when I applied straight from college. I’m proud of my decision and excited for the future, but I need to have those difficult conversations with myself now. What do I want to do? Where do I want to make an impact? And as negative as it sounds, what doors am I willing to shut? Since I can’t both invent a device and revamp Medicare (I’m sure someone has, but c’mon, I have to play the odds), what next?  So I’m not complaining about growing up. Instead I’m realizing I can’t so easily take on the world anymore.
So to answer my first question: my Inspiration is being put to use leaving ajar as many doors and creating as many windows as I can. It’s far too easy to get bogged down by grades, and classes, and The Next Step. It’s even easier to shrug off goals because school is just too busy. To all my friends and peers with whom I’ve sympathized about running out of time, I get it. I don’t have the time either. But we have to make the time. We can’t sell ourselves short—the world is ours for the taking, remember?

To read more of my musings, follow my personal blog.

Wednesday, April 9, 2014

5 Reasons I'm Glad I'm a (Penn) Medical Student

1. I can find Inspiration on short notice

In the past few months, I've become increasingly focused on classes and getting through the day with the same routine. Exercise (sometimes), food, sleep, a semblance of a social life, studying, rinse, repeat. I was never someone who operated with such mental blinders on. In college I was the girl who had her mind in about a hundred places at once. I was the girl who wanted to blog, start some company, make new friends, find mentors, take more classes, invent a drug, and change the world all at the same time; I would lie awake at night thinking of everything I wanted to do and how I could make my mark on the people around me.

Since coming to medical school, it's admittedly been hard to find motivation within me, and that girl took a break. But a couple days ago, I realized I needed some big-time Inspiration. I looked up the events the school was having, and one of the events that evening was Penn Pearls, Penn Med's annual teaching awards ceremony. I went and listened to residents, fellows, and attendings impart their wisdom on the next crop of graduating medical students and my mind woke up from its hibernation. I could hardly wait to get home to start emailing, writing, thinking, and doing. It only took 30 minutes of being around the wonderful mentors at Penn Medicine to find the drive in me to start creating again. If I weren't here, that couldn't have happened.

2. People tell you to laugh (actual medical school-sanctioned advice)

This was by far my favorite Pearl from the ceremony I mentioned. Turns out, courtesy of Dr. Andrew Baum, laughter is a great medicine.

Things laughter can do for you (if a doctor tells you it must be true right?--there are actual studies, though)
  • Reduces stress (and may play a role in boosting your immunity)
  • Helps you with pain management because it releases endorphins
  • Plays a role in lowering your blood sugar
  • Improves your blood pressure
  • Acts as a burst of exercise for your body each time you laugh (and cleans up your respiration too!)
I might be speaking for Dr. Baum here, but I think his advice goes beyond the physical act of laughing or finding things funny. To me, reminding myself to laugh means reminding myself to be happy and to find joy in what I do. And in life, a school that reminds you to laugh is a good place to be.

3. Emailing anyone and getting a response

Definitely not to be taken for granted in a powerhouse like Penn. It gives me a warm, fuzzy feeling when I email the director of some big center here at Penn with a life question and they get back to me. It shows me that I'm valued as an individual and as an intellectual. On a larger level, it speaks to the philosophy of Penn Med. Lecturers have constantly told us that they love learning from medical students, and every lecturer we've had has welcomed shadowing. The flat structure of the medical school and the enthusiasm with which faculty here approach their jobs is rare and a great honor.

4. Penn really cares about its students

Nowhere else have I seen weekly meetings between students and curriculum directors. And it's not just empty promises. If the student body has a complaint, it gets implemented the next week. We all have to fill our course evaluations on every. single. professor. to get our grades. Annoying, at times, but that means the course directors get some hundreds of pages of student feedback every year. Right now I'm sitting on a focus group to revamp one of our classes. Our team (composed entirely of students) is responsible for sifting through those evaluations, polling our students, and presenting a huge report on our recommendations for the course next year. The best part? The faculty members implore us to participate in these groups because it really matters to them. Medical education has historically been based on the tradition of generations before. Our curriculum is so dynamic it changes every week based on our needs.

5. Respecting the human body

Something I've learned in medical school is that the human body is an awe-inspiring machine. The things it is capable of minute to minute astound me. I remember one day, while sitting in biochemistry, I was struck with the thought -- gosh, I'm so lucky more things aren't wrong with me. That feeling's only been compounded. We're now in neurology, and I'm seriously considering the social acceptability of walking around all the time wearing a helmet. In the midst of stress, studying, and lectures, it's hard to take care of myself. It's hard to eat well and sleep enough or pass on that last slice of free pizza. But one of the great privileges and powers of medicine and the holistic teaching at Penn Med is knowledge. And before I start caring for other people with that knowledge, I have to start with myself.

About me: I'm Sneha Kannan, a current MS1. I hail from Potomac, MD and graduated from MIT in 2013 with a degree in Bioengineering. The next question I'm often asked is, "so what do you want to go into?" (which, by the way, is just the grown-up-medical version of "what do you want to be when you grow up"). To be honest, I don't know. Every day I discover some new interest of mine and I'm loath to try and pare that down so soon. I know I can't do it all but a girl can dream, can't she? The really important things, though: I'm inspired by people around me, probably addicted to chocolate, love tennis, and spend quite a bit of my time reading, traveling, singing, and crossword puzzling.

Wednesday, April 17, 2013

10 Reasons to Come to Penn

Now that it's almost Penn Preview, here are 10 some-typical-and-some-slightly-more-atypical reasons why Penn is the best med school on the planet and Philly is a great place to live, in no particular order except #1 (at the end):

10. The city—it's pretty! This one is not because I'm running out of reasons already. This is what I see on my way home from school every day:
A little bit of extra happiness every day adds up to a lot over four (or eight) years!

9. The second anatomy exam. Which is the only way to take an anatomy exam, as far as I'm concerned. It's taken in learning teams, and each learning team dresses up to a theme.

We had a Pac-Man team,
Photo by Dr. Rubinstein

a Sesamoid (Sesame) Street team,
Photo by Dr. Rubinstein

and an Avengers team,
Photo by Dr. Rubinstein
among others.

Our team dressed up as Dr. Fisher! He's one of the anatomy professors, and he wears black scrubs and black gloves every day. He even took a picture with us :)
Photo by Dr. Rubinstein
(The rest of the pictures, taken by Dr. Rubinstein, the Mod I director, are here.)

8. Learning teams. I'll be really honest here: I don't think anyone starts out loving their learning team. Well, actually, maybe some people do, but I think for most people (myself included), there's an adjustment. When you randomly put seven people in a group, there will probably be some people who wouldn't normally interact much with each other. But, I also don't think there's anyone who doesn't end up loving their learning team, and that's the important part. 
Photo courtesy of Winnie Lin

7. Everyone in Suite 100 is super nice and wants to help you. Suite 100 also has everything from mailboxes to tissues to candy.

6. Every student gets an iPad. Because we can download lecture slides onto our iPads and take notes from there, (nearly) everything is electronic. I mean, seriously, you decide:

5. All the med buildings are connected, and mostly above ground—that means avoiding the elements when it’s raining/snowing/too hot/too cold, without giving up the benefit of sunlight. Here’s one indoor trip I took with Rebekah, who is on my learning team, with a detour to show off how pretty the buildings are (apologies if anyone gets dizzy/sick):

No sound, because played at 5x recording speed, we sound like chipmunks. Literally.

Here’s a rough map of where we went. Green rectangles are elevators.

4. SPOOF! Spoof happens every spring, and it is basically what it sounds like. It’s always hilarious, and also always includes a “first-year skit,” which is written, directed, and performed by first years. This year, the first-year skit was “Perelman Avengers.” This is Casey, one of our classmates, demonstrating Perelman Avenger Dr. White’s power stance (Dr. White teaches anatomy and writes the USMLE review book for anatomy, and is awesome!):

3. VC2000. I know I’ve written about this before, but it is really convenient if you ever need to miss class for anything, or just to review lectures afterward—for example, I’ve used VC to catch up when I missed class because I was shadowing at HUP, and Rebekah used VC to stay up-to-date with the lectures last time she was at a conference. Many people also VC because they just prefer to watch lectures at home. It has lots of useful features:

2. Three free classes in whatever you want. Mine this semester is ESE603, Simulation Modeling and Analysis, and I'm enjoying it, but there is definitely the option to take classes that probably sound more fun to everyone else. For example, my roommate took a Wharton class last semester, and one of my learning team-mates is taking a bioethics class. All of Penn is also on one continuous campus, which means getting to class isn’t a problem!

1. The students. This time last year, I was mostly choosing between two places. When I came to Preview, I had so much fun that I ended up missing my train back to school and booking a last-minute bus ticket on a friend's phone instead. I decided that was a pretty good indication that I should come here, and it's been one of the best decisions I've ever made. I guess what I learned is that some things, like the atmosphere at a school, are hard to quantify. But, it's those un-quantifiable things that make a decision which might seem whimsical at first the right one in the end.

Thursday, March 14, 2013

[Penn]WikiHow: How to Dissect an Eye

WE DISSECT EYES IN BRAIN AND BEHAVIOR!!! We also dissect brains, but I’m not sure if there are rules against taking pictures of them, whereas I’m pretty sure HIPAA doesn’t apply to cows’ eyes, so it seemed safer to skip the brains and go with the eyes for posting pictures on the Internet. I also didn’t want to get any of my camera-containing devices dripping in formaldehyde, since the brains are preserved.

Here’s how to dissect a cow’s eye in five easy steps, learning team-style:

Warning: This post is full of potentially graphic pictures.
Disclaimer/anti-warning: However, they were taken with my silly-phone (i.e., not smartphone), since I forgot to charge my iPad that day, so they might actually just be too blurry to see.
Plug for Penn, since it’s getting to be recruitment time: Every student gets an iPad! We take notes on them, instead of lugging huge stacks of paper around.
  1. Three eyes per learning team magically appear in the first-floor Stemmler lab rooms.
    Eyes in a bowl
  2. Find the optic nerve and the extra-ocular muscles (muscles around the eye that control eye movement), and cut off the muscles.
    Cleaning an eye
  3. Cut away the front part of the eye. Now you can see the lens (that round blob in the middle), and the vitreous humor behind it. The retina, which contains the photoreceptors that allow us to see, is in the wall around the vitreous humor.
    Inside of eye
  4. Play with the vitreous humor. It’s surprisingly jello-like—on a scale of 1 to 10 where 1 is water and 10 is jello, I’d probably give it a 6.5. If you look through the vitreous at the lens from the other side, you can see a shape exactly like the Mercedes-Benz logo on the back of the lens. Nature’s form of product placement?
  5. Look at the rest of the eye, without the vitreous humor. It’s blue in cows, which helps collect light that isn’t absorbed by the photoreceptors the first time around. That’s why they can see better in the dark than we can. However, it also means that their vision is kind of blurry. (Wikipedia has a better picture)

Ta-da! Basically, Brain and Behavior is super cool.

Wednesday, February 13, 2013

A VC Day

PennInTouch with a
slightly depressingly-
far-away graduation
Hi everyone! My name is Jessica, and I’m a first year MD-PhD student. I’m from Centreville, Virginia, which is about 20 minutes outside D.C. I did my undergrad at MIT, where I majored in bioengineering and minored in music, and just graduated in June 2012. I’m interested in a bunch of things, both on the research (tissue engineering, microfluidics, computational biology…) and medical (peds, cardiology, neurology…) sides, so I’m not quite (read: not at all) sure what I “want to do” yet, but my expected graduation date is apparently Spring 2020—see screen capture from PennInTouch—so I guess I still have plenty of time to figure it out. This is also my first blog post, so I’m kind of nervous, but here goes:

You may have heard that Penn has something called VC2000, which is like Reunion Hall CSPAN (Reunion Hall is where we have lecture). All of our lectures are recorded and put on VC, so that those who can't attend a lecture in person can watch them from home later. It’s pretty popular!

Anyway, I took advantage of VC recently too, but not to sleep in (although some do); instead, I shadowed at HUP’s electrophysiology lab! It was amazing. The backstory is that we have a project for our Mod 6 Doctoring class called ITAP (Interprofessional Team Assessment Project), where we’re supposed to observe a medical team in action and analyze how they work together. So Thursday morning, Russell (who is on my learning team) and I went up to the 9th floor of Founders in HUP to watch the electrophysiology team do their daily morning meeting. We watched how the team members interacted as they discussed the patients they’d be seeing that day, determined what procedures they’d be doing, and made some decisions as to how certain patients should be cared for. After we’d fulfilled the bulk of our ITAP responsibilities, we stuck around to talk to/do some short interviews with some of the team members (also for ITAP), and of course, to watch the procedures.

First, I went to see an ICD replacement, while Russell headed off to watch an atrial flutter ablation. ICDs (Implantable Cardioversion Defibrillators) are about half-cell-phone-sized, battery-powered generators that use electricity to effectively shock the heart back into normal rhythm when the patient has dangerous irregular heartbeats. Here’s a Youtube video of one in action: 

And here's the corresponding article in Sports Illustrated:

ICDs have a limited lifespan, though, so they need to be replaced every so often. The procedure for replacement was very different from what I expected—only a local anesthetic is used, the incision to take out the old ICD and put in the new one is just a few inches long, and the entire process took about half an hour. Only the generator—not the wires that connect it to the heart—get replaced, and a lot of double- and triple- and quadruple-checking goes on to make sure the wires are reconnected correctly. I didn’t understand much, and it didn’t seem like a good time to interrupt with a million questions, but it looked and sounded like each wire is color-coded, labeled with what part of the heart it’s coming from, and labeled with a serial number to make sure that it connects to the right place in the generator. The patient was actually awake until the very end, when the electrophysiologists induced an irregular rhythm in order to test the new device.

Since the ICD replacement went so smoothly and quickly, I went to find Russell, who was watching an atrial flutter ablation, after it was done. The setup for the atrial flutter ablation reminded me of an airport control tower. Since the ablation done by inserting a catheter into the femoral vein and guiding it up into the heart, X-rays are used for imaging throughout the process. In order to minimize X-ray exposure for the doctors who are doing these procedures every day, one of them is in the room with the patient doing the ablation while another one is in a “control room,” watching and guiding. Everyone inside the procedure room is wearing lead jackets to protect themselves from the X-rays, and the control and procedure rooms communicate via headset.

On every monitor in the control room, a large number of indecipherable squiggles were running across the screen. Luckily for us though, it turns out the ablation procedure includes a 30-minute wait, so during the waiting period the attending paused to explain these squiggles, and what on earth an atrial flutter ablation is anyway.

Image adapted from the National Heart, Lung
and Blood Institute. Original image here:
Heart muscles contract when they are stimulated by electricity, which is made in some special heart cells and is sent throughout the muscles. Normally, the electrical current passes through the atria in the upper part of the heart once, causing them to contract and pump blood into the ventricles, which then pump blood into the body. However, in atrial flutter, the electricity keeps on going around and around the atrium instead of disappearing. As a result, even though the atria contract more often, each contraction is less efficient, and this can cause all sorts of problems, including blood clots. To fix the problem, electrophysiologists can make a series of tiny burns in the wall of the atrium; this is called ablation. Then in the future, if the current tries to go around the atrium instead of stopping like it should, the electricity will get stuck where the burns were placed, and the atria will continue to contract normally.

When the half-hour wait was over, it was time to see whether the ablation had worked. To do this, the doctors stimulated the heart muscle with electricity in one location, and then measured how long it took to get to two other places in the atria. Based on which of these two places “felt” the electricity first, they could tell whether current was still passing through the area they had intended to ablate. To give an idea of the level of precision involved, they were looking at differences on the order of tens of milliseconds—for comparison, test your reaction time here: (average appears to be ~215ms. Guess I'm way below average!). Fortunately, the equipment being used could detect time differences that are much shorter than human reaction times, and they saw the stimulation pattern they expected, which meant that the procedure had worked.

After watching the ablation, we decided it was time to end our brief foray into real life after med school, and headed back to the biomed library to catch up on some rheumatology lectures. Shadowing was great, though; and we learned so much! I loved shadowing in the EP lab, but for those who aren’t as interested in cardiology, Penn also has many other shadowing opportunities, both at HUP and at CHOP—in fact, shadowing in the emergency departments at both hospitals is an established "thing" and is fairly common among our classmates. Some people also just set up shadowing times outside of the emergency departments, with small group preceptors, for example. Whatever your interests, shadowing opportunities are fairly easy to come by here, and definitely worth missing lecture for once in a while!