About
JETem is an online, open access, journal-repository for EM educators in all major topic areas. We focus on active learning and technology. Submissions include team-based learning (modified and classic), small group learning, simulation, podcasts, workshops, lectures, curricula, innovations and submissions to our image and video bank. For our fully searchable site, and details regarding submissions please go to www.JETem.org
Volume 10, Issue 5, 2025
Special Issue: Certifying Exam Practice Cases
Certifying Exam Practice
- Clinical Decision-Making Case: Intussusception
Audience: This clinical decision making case is intended for emergency medicine residents of all levels.
Introduction/Background:
To become board certified in emergency medicine, graduates must pass both a qualifying exam and an oral exam. In 2026, the American Board of Emergency Medicine (ABEM) is transitioning to a Certifying Exam. Historically, the oral exam included two structured interview (now retitled clinical decision making [CDM]) cases and one pediatric case. Vomiting and abdominal pain are two of the top five reasons pediatric patients present to the emergency department. Being able to take a complete history and exam, regardless of age, and form an appropriate differential diagnosis is a critical skill for emergency physicians. There are many resources available to prepare for standardized single patient encounters, but there are very few resources available for candidates to prepare for the CDM cases. Here we present a CDM case of irritability and vomiting in an 18-month-old for learners to familiarize themselves with the CDM format and to demonstrate management of a pediatric patient.
Educational Objectives:
By the end of this mock oral boards session, learners will (1) demonstrate familiarity with the CDM case format and case play, (2) model a problem-based history and physical exam, (3) generate a differential diagnosis for pediatric abdominal pain, and (4) demonstrate the ability to manage intussusception.
Educational Methods:
This CDM case is based on the sample script available on the ABEM website. Individual residents were tested by a faculty member virtually via Zoom. After all residents completed the case, a group debrief was held virtually on Zoom.
Research Methods:
This case was originally tested with a pilot group of five learners who provided verbal feedback following the case. Adjustments were made to the case based on that feedback. The case was then tested with 36 second- and third-year emergency medicine residents from two residency programs. At the completion of each case, a faculty examiner scored each resident’s performance based on a standardized scoresheet. Residents received one-point for completing each task and the overall score was calculated out of 25 possible points. Residents were surveyed on prior experience with the CDM format and the educational value of this oral boards session. Educational value was evaluated on a 5-point Likert scale with 5 being excellent.
Results:
In total, 36 residents completed this mock CDM case. The average score was 20.3/25. All examinees performed palpation on abdominal exam, ordered and provided justification for an abdominal ultrasound, ordered and provided justification for an air contrast enema, and stated the correct diagnosis of intussusception. Nearly all examinees provided an appropriate differential diagnosis for the patient. The most common items that examinees missed included asking about surgical history, asking about blood in the patient’s stool, listening for bowel sounds on exam, and providing at least one vital sign when the inpatient team was called for admission.
Twenty residents responded to the post-case survey (55.6%). When asked if they had previous knowledge of the CDM format, only 30% of respondents were aware of this case format, and only 10% of respondents had previously participated in a CDM practice case. The learners rated the educational value of this case a 4.7/5 with 95% “agreeing” or “strongly agreeing” that the case was helpful in preparing for their oral board exam and 90% feeling like the educational value was “very good” or “excellent.”
Discussion:
We present a CDM case of intussusception that allows the resident to become familiar with this type of case while demonstrating their ability to obtain a history from, examine, and treat a pediatric patient. Through this case, residents are asked specific questions about the thought process behind the history and physical exam they perform. They are also required to provide a differential diagnosis, treatment plan, and disposition for the patient. Through this clinical decision-making process, our residents felt that the case was of high educational value and was helpful in preparing for the certifying exam.
- Clinical Decision-Making Case: Pediatric Sexually Transmitted Infections and Consent
Audience: This clinical decision-making case for the Certifying Board Exam is designed for emergency medicine residents at all training levels (PGY1 through PGY4).
Introduction: Navigating consent for pediatric patients in the emergency department (ED) presents unique ethical and legal challenges. Physicians must understand parental consent requirements and the relevant exceptions that apply in the ED. Studies indicate that residents may lack confidence or knowledge in handling complex or nuanced consent scenarios, particularly regarding adolescents. We aimed to develop a structured educational intervention to address this gap. This clinical decision-making case aims to improve resident competency and comfort in managing these situations.
Educational Objectives: By the end of this case the learner will be able to: 1) demonstrate competency with the new ABEM Certifying Exam Clinical Decision-Making Case format, 2) manage a simulated pediatric care encounter that requires navigating the details of pediatric consent, 3) explain common exceptions to requiring parental consent in emergency situations according to established guidelines as well as state and local laws, 4) report increased comfort managing ethical dilemmas related to pediatric consent in the ED.
Educational Methods: This educational activity utilizes the new Clinical Decision-Making Case format for the American Board of Emergency Medicine Certifying Board Exam. This method simulates realistic ED encounters where residents must gather information, apply ethical and legal principles, and make decisions regarding pediatric consent under time constraints, similar to the new structure used in the board certification process for emergency medicine physicians. Additionally, a short presentation accompanied the debrief of this session to highlight the relevant clinical learning points.
Research Methods: We administered pre- and post-intervention surveys assessing self-perceived comfort (using Likert scales) and objective knowledge (using multiple-choice questions) regarding pediatric consent, as well as comparing audience vs. participants experience. This study was approved by the Baylor Research Institute Institutional Review Board, approval number 025-322. Informed consent was obtained from all participants electronically.
Results: Thirteen EM residents (PGY1-PGY3) participated in this activity. In the presurvey, only 30.8% of residents reported to be somewhat or very comfortable, while in the post survey, 100% reported to be somewhat or very comfortable with pediatric consenting. When asked to evaluate the learning value of the case, 76.9% selected very valuable and 15.4% selected valuable.
Discussion: This clinical decision-making case provides a standardized, active learning method to address emergency medicine residency training regarding pediatric consent, which has previously been identified as an area of difficulty for EM trainees. 1 The format allows for assessment of not just knowledge, but also application, communication, and ethical reasoning. Providing specific, constructive feedback immediately following the session is crucial for maximizing educational benefit.
Topics: Clinical decision-making case, board certification, pediatrics, ethics, legal.
- Clinical Decision-Making Case: Seizing the Diagnosis: Eclampsia
Audience: This practice certifying exam case is intended for emergency medicine residents.
Introduction: The American Board of Emergency Medicine (ABEM) certification process is currently undergoing a significant transformation, with the new ABEM Certifying Exam replacing the long-standing ABEM Oral Exam, which has been in place since 1980. The Certifying Exam will utilize a new exam format to evaluate different competencies compared to the Oral Exam, including high-stakes communication, managing difficult conversations, patient-centered communication, clinical decision-making, team management, leadership, procedural skills, ultrasound skills, reassessment, troubleshooting, task switching, and prioritization. This shift has understandably generated a degree of apprehension among Emergency Medicine (EM) residents preparing for their board exams. The new exam emphasizes several new cases and scenarios, including Clinical Decision-Making (CDM) cases. These structured discussions require residents to articulate their thought processes and justify their clinical choices while navigating simulated Emergency Department (ED) encounters with undifferentiated patients.
Although the CDM cases are similar in length (15 minutes) and format to the Structured Interview cases from the prior Oral Exam (structured discussion eliciting the steps necessary to diagnose and treat a patient with an undifferentiated presentation), ABEM has established new scoring criteria and objectives for the CDM cases. Therefore, to effectively prepare residents for this evolving assessment landscape, relevant and challenging example CDM case scenarios are essential. This CDM case focuses on eclampsia, defined as seizures occurring in a woman with pre-eclampsia or gestational hypertension during the peripartum period. This condition is a relatively rare, yet critical, emergency at the intersection of obstetrics and neurology that carries significant maternal and fetal risk and demands prompt recognition and decisive management. This case aligns directly with the exam's emphasis on high-acuity, low-occurrence presentations and provides a realistic and challenging opportunity to hone crucial clinical decision-making skills. It ensures that residents are not only well-prepared for the high-stakes Certifying Exam but are also capable of effectively managing this critical obstetric emergency in actual clinical practice.
Educational Objectives: By the end of this Mock Certifying Exam session, learners should be able to: 1) demonstrate familiarity with the Clinical Decision-Making case format and structure, 2) elicit relevant historical information and connect that information to the diagnosis of eclampsia, 3) describe and interpret physical exam findings and their significance in establishing a pertinent differential diagnosis, which includes eclampsia, 4) initiate appropriate diagnostic testing, interpret results accurately, and formulate a stabilization and treatment plan for a patient with eclamptic seizures, and 5) reassess the patient's condition, modify the management plan as needed, provide relevant anticipatory guidance for disposition, and articulate the clinical decision-making rationale at each stage of the encounter.
Educational Methods: This educational intervention employed a simulated ABEM Certifying Examination case. The initial case, focusing on the critical presentation of eclampsia, was developed collaboratively by a team of Emergency Medicine education faculty at a large, urban, three-year EM residency program. The structure and format were modeled after examples of the new CDM cases provided on the ABEM website. The CDM format involves a dynamic patient encounter in which the learner progresses through different phases of care, making diagnostic and therapeutic decisions and justifying their rationale to an examiner.
A pilot phase was conducted to ensure realism, educational value, and appropriate timing for the examination format. Four recent graduates of the EM residency program participated in this pilot: two fellows (in Emergency Medical Services and Medical Education, respectively) and two actively practicing attending physicians in community Emergency Department settings. These individuals engaged with the case as if they were taking the actual Certifying Examination, providing detailed feedback on the clarity of the scenario, the appropriateness of the clinical challenges presented, and the overall flow and timing of the case. Based on the insights gained from pilot testing, the case underwent refinement and adjustments to optimize its effectiveness as an assessment and learning tool.
The finalized eclampsia CDM case was then implemented in a testing phase involving eighteen PGY-3 (Post Graduate Year-3) EM residents. These residents participated in a simulated certifying examination experience, with two faculty members acting as examiners for each resident physician in individual exam rooms, closely resembling the actual testing environment. The examiners sat across a table from the examinee, and a separate screen was utilized to display the case stimuli and task sheet during the case. The case sessions were limited to a maximum of 15 minutes. While this CDM case was incorporated into a Mock Certifying Exam session with multiple other cases and scenarios, it could also be employed in isolation using a virtual or in-person format. Following the Mock Certifying Exam, a group debrief was conducted in-person. This session provided collective feedback to resident examinees and faculty examiners regarding the eclampsia case, the CDM case format, and key clinical learning points.
Research Methods: Following each simulated case encounter, faculty examiners evaluated resident performance using a standardized scoresheet. The scoresheet, derived from ABEM Certifying Exam Score Guidelines, assessed nine domains: focused history, physical exam interpretation, differential diagnosis, diagnostics, patient stabilization, reassessment, disposition, clinical reasoning, and pathophysiology.
These nine domains were collated into the standard JETem scoring rubric, which includes 25 points spread among categories associated with the CDM format. In addition to the faculty assessment, residents anonymously completed a two-question post-case evaluation. This evaluation employed a 5-point Likert scale (1 = poor, 5 = excellent) to assess the overall quality of the case, characterized by how well the session met educational objectives and resident expectations, and the degree to which the case enhanced understanding of the certifying exam format (1 = strongly disagree, 5 = strongly agree).
Results: In total, 18 residents completed the case, and 17/18 residents (94.4%) completed the post-case evaluation. All residents identified eclampsia as one of the top three relevant differential diagnoses, administered intravenous magnesium as part of the treatment, and appropriately admitted the patient. However, antihypertensive medications were the most overlooked treatment modality.
The mean quality rating of the case was 4.94/5, and 100% of resident respondents rated the overall quality of the case as “very good” or “excellent” on a 5-point Likert scale. Furthermore, 100% of respondents agreed or strongly agreed that the case enhanced their understanding of the certifying exam format.
Discussion: The implementation of this CDM case proved highly effective in preparing EM residents for the complexities of clinical practice and the new challenge of understanding the Certifying Exam CDM format. The case was exceptionally well received, with a mean quality rating of 4.94 out of 5, and 100% of resident respondents rating its overall quality as "very good" or "excellent." Furthermore, 100% of examinees agreed or strongly agreed that the case significantly enhanced their understanding of the certifying exam format, underscoring its utility as a preparatory tool for the newly formatted ABEM Certifying Exam.
From its implementation, we learned that high-fidelity mock cases, particularly those involving critical scenarios like eclampsia, are invaluable for assessing and refining clinical decision-making skills. Eclampsia is a high-yield case due to its critical nature, requiring a wide differential diagnosis for seizures, a deep understanding of pathophysiology, and the rapid initiation of diagnostic workup and treatment to mitigate significant morbidity and mortality. This type of simulation-based training provides a safe but realistic testing environment for residents to gain experience with rare or high-acuity situations they may not frequently encounter in clinical practice.
The main takeaway from this experience is the critical importance of proactive, targeted preparation for the evolving ABEM Certifying Exam. The overwhelmingly positive resident feedback and performance scores demonstrate that such simulated experiences are highly effective in enhancing understanding of the exam format. By providing a realistic, low-stakes environment for decision-making and targeted feedback, these mock cases directly contribute to residents' preparedness for board certification and, more importantly, for safe, high-quality independent practice in emergency medicine.
- Clinical Decision-Making Case: Pulmonary Embolism
Audience: Emergency medicine residents and medical students on emergency medicine rotations.
Introduction: Pulmonary embolism (PE) is a common diagnosis with an annual incidence of approximately one in 1000 persons.1,2,3 There is a wide variety of clinical presentations, ranging from the asymptomatic patient to shock and cardiac arrest. Most patients have chest pain and shortness of breath (SOB), but PE may also present with mild or nonspecific symptoms, such as dizziness, cough, wheezing, syncope and hemoptysis. These patients have risk for clinical decompensation.4,5 It is therefore critical to maintain a high level of suspicion because misdiagnosis is common. There are risks attributable to the diagnostic evaluation and treatment, including radiation exposure, contrast reactions and complications related to anticoagulant therapy. Work up requires an understanding of clinical pretest probability, diagnostic algorithms such as the modified Wells scoring system and the revised Geneva scoring system, the pulmonary embolism rule-out criteria (PERC), and interpretation of D-dimer testing and diagnostic imaging.6,7 Management requires anticoagulation, but for the unstable patient may also require respiratory and hemodynamic support, systemic or catheter-directed thrombolysis, catheter or surgical embolectomy, or extracorporeal membrane oxygenation (ECMO) if available. Understanding the diagnostic evaluation and management of pulmonary embolism is essential for the practicing emergency medicine physician.
Educational Objectives: By the end of the clinical decision-making case, the learner will: 1) gain familiarity with clinical decision-making (CDM) case format to be used in the new American Board of Emergency Medicine (ABEM) certification examination starting in 2026, 2) demonstrate the ability to obtain a focused history and physical examination and develop appropriate differential diagnoses for chest pain and dyspnea, 3) demonstrate understanding of clinical decisions rules to estimate the pre-test probability for pulmonary embolism and the application of rules to guide appropriate diagnostic testing, 4) recognize high clinical suspicion for pulmonary embolism and indication for empirical treatment, 5) recognize the unstable patient and provide appropriate hemodynamic and respiratory support, 6) understand indications for thrombolytic therapy or embolectomy in unstable pulmonary embolism, 7) demonstrate communication skills with patients and specialists across the health care spectrum, and 8) arrange appropriate disposition for the unstable patient with a pulmonary embolism.
Educational Methods: This session is based on the clinical decision-making (CDM) case format introduced by ABEM to be used in the oral certification examination starting in 2026.8 The materials were modeled after the samples provided in the instructional videos on the ABEM Qualifying Exam Part 2 released in December 2024. Slides were provided to the instructor concerning clinical presentation, differential diagnosis, and management for the debrief following the session. This case was tested using 18 resident volunteers ranging from PGY 1-2 in an Accreditation Council for Graduate Medical Education (ACGME) accredited emergency medicine residency program. This was our first mock board session using the CDM format.
Research Methods: Prior to the session, the learner was asked to complete a pre-survey to see if the learner had previously reviewed the ABEM instructional video demonstrating a CDM case. Immediate feedback was then solicited both from the learners and from the evaluators following the debriefing session. Residents were asked to evaluate the educational value of the case using a 1-5 Likert scale (5 being excellent). Evaluators were asked to score the residents by designating whether the learner was able to provide the correct responses concerning required appropriate historical information, physical examination findings, diagnostic testing needed, differential diagnoses, interpretation of diagnostic results, reaching the correct diagnosis, management and disposition of the patient and coordinating transition of care. The examiner would mark the evaluation form with either a yes or no for each response.
Results: Eighteen residents (nine PGY1 residents and nine PGY2 residents) completed the case. We were a new residency program at the time and did not yet have any PGY3 residents. The average score was 28.9 out of 29 points. The pre-survey revealed that only two of the nine EM PGY1 and four of the nine EM PGY2 had reviewed the ABEM video. Eighteen residents completed the post-survey which was done immediately after the simulation. The learners rated the educational value of the case 4.9/5 (5.0/5 for PGY1, 4.9/5 for PGY2). Fifteen residents (8/9 PGY1, 7/9 PGY2) stated that the case increased their understanding of key concepts about the disease process “somewhat,” while three responded that they have had similar patients and did not learn anything new. Thirteen residents (8/9 PGY1, 5/9 PGY2) said that the experience made them more comfortable with the new testing process but that they needed more practice, while only two residents (both PGY2) responded that they were very comfortable with the process.
Discussion: The objective of this oral boards case was two-fold: to give residents experience with the new CDM case format of the ABEM certifying exam and to reinforce the work-up and management of pulmonary embolism.
This simulation was an effective educational tool for residents to gain familiarity with the CDM case portion of the ABEM certifying exam. Only a minority (6/18, 33%) of the residents were familiar with the new testing format prior to the case. This session was the first mock oral board session using a CDM case. Post survey results revealed that 72% of the residents (13/18) said that the experience made them more comfortable with the new testing method but that they needed more practice, while only two residents (11%) stated that they were very comfortable with the process.
This was also a learning opportunity for the examiner in this new CDM case format. The evaluation form used a dichotomous yes/no format which likely contributed to excessive prompting which inflated scoring. This may not accurately reflect the experience at the certifying exam. In response, more specific criteria regarding the degree of prompting and timing of case were added to the script. Repetition of testing in this format should be helpful for residents and educators as preparation for the ABEM certifying exam.
The initial evaluation of pulmonary embolism is a topic with which most residents are comfortable. Residents scored well on testing, suggesting an understanding of the work-up for chest pain and routine management for pulmonary embolism. They had less familiarity with management of the high-acuity, unstable presentation.
This case was not tested on medical students, but we anticipate that this would be an appropriate learning experience for the medical student on an emergency medicine rotation, without need for modification.
This case was designed to introduce residents to the CDM case format. There is limited existing training material for the new oral board exam, and we feel this simulation case is valuable for residents to gain familiarity with the new ABEM certifying exam format through a comfortable topic and a “low pressure” setting.
- Clinical Decision-Making Case: A Giant Headache
Audience: This certifying exam practice case is intended for emergency medicine residents and medical students rotating through emergency medicine.
Introduction: Giant cell arteritis (also known as GCA, temporal arteritis, cranial arteritis, or Horton’s disease) is the most common systemic vasculitis.1 Patients commonly present with a new and unique headache, often with tenderness in the temporal region. Patients may present with associated jaw claudication and transient visual loss. Constitutional symptoms such as fever and fatigue are common and proximal muscle weakness may be present with concurrent polymyalgia rheumatica.1 These symptoms are thought to be a result of an exaggerated immune response to vascular injury with lymphocyte proliferation and giant cell formation which can lead to luminal narrowing and even ischemia.2
The incidence varies among various demographics. It is highest in Scandinavia (21 per 100,000) and lowest in East Asia (less than one per 100,000). Globally, it is estimated to be 10 per 100,000 and in the US roughly 19 per 100,000.2,3 Recent studies have shown increasing incidence in Hispanic and African American populations while showing it to still be rare in Middle Eastern and Asian populations.4 It is most common in patients who are 70-79 years old and almost never presents in those under 50.1
Left untreated, GCA can result in significant morbidity – vision loss.4 Treatment is not benign – there are adverse effects of long-term glucocorticoid therapy. The cost to the healthcare system in the US is expected to increase dramatically by 2050 due to the aging population and cost of treatment.3Given its relatively low incidence but high morbidity, giant cell arteritis is a rare diagnosis that Emergency Medicine residents may not encounter in training but is an important differential diagnosis to consider in the appropriate clinical context.
Educational Objectives: By the end of this clinical decision-making case, learners will be able to: 1) demonstrate increased knowledge pertaining to ABEM’s clinical decision-making case, 2) communicate the differential diagnosis of a new acute onset headache in patients over the age of 50 and the importance of giant cell arteritis in that differential, 3) acquire an appropriate history and physical exam in this clinical setting, 4) verbalize, interpret, and justify the appropriate diagnostic testing for this clinical case (at minimum CT head, complete blood count (CBC), basic metabolic panel (BMP), comprehensive metabolic panel (CMP), erythrocyte sedimentation rate (ESR), and 5) explain the appropriate treatment and disposition of a patient with temporal arteritis.
Educational Methods: This session was structured after the clinical decision-making case that was introduced by the American Board of Emergency Medicine (ABEM) in the instructional videos on the ABEM Qualifying Exam Part 2 released in December 2024. The materials used were modeled after the samples that were provided in the supplemental material for the clinical decision-making case. Slides were provided to the instructor concerning clinical presentation, differential diagnosis, and management for the debriefing following the session. This case was tested using 18 resident volunteers PGY 1-2 in an ACGME (Accreditation Council for Graduate Medical Education) accredited emergency medicine residency program.
Research Methods: Using a score sheet, evaluators assessed the residents’ performance in acquiring appropriate clinical information, interpreting diagnostic tests, providing a differential, and justifying their management. Residents were asked to evaluate the educational value of the case.
Results: Nine PGY1 residents and nine PGY2 residents completed the case, scoring 19.7/25 with four failures and 21.4/25 with three failures, respectively. Reasons for failing included scoring less than 19/25 or missing a critical action. Of the 17 residents that completed the post-survey, the educational value was reported to be 4.7/5 with all residents stating it increased their medical knowledge. Almost all of those residents stated that this experience made them more comfortable with the new ABEM clinical decision-making case.
Discussion: This educational case focusing on giant cell arteritis (GCA) was effective in enhancing resident knowledge and clinical skills. All participating residents reported increased knowledge following the exercise and rated the case highly in terms of educational value. Performance outcomes further supported the case’s efficacy. All residents successfully completed critical actions related to obtaining an adequate history, performing a focused physical exam, and ordering appropriate diagnostic tests. The only resident who failed the critical action of starting steroids was also the only resident to miss the critical action of diagnosis, which supports the close association of these two critical actions. This positive feedback supports the use of this case to expose learners to a rare but high-risk diagnose which they are unlikely to encounter during clinical training.
- Clinical Decision-Making Case: Thyroid Storm
Audience: This clinical decision-making case is intended for all emergency physicians (EP) in training.
Introduction: Thyroid storm (TS) is a rare but life-threatening endocrine emergency that represents the most severe form of thyrotoxicosis. If not promptly recognized and appropriately managed, TS carries a mortality rate of up to 25%.¹ However, with timely and aggressive treatment, mortality can be significantly reduced to 1.2–3.6% in the United States.² Due to its rarity and often nonspecific presentation, early diagnosis and intervention in the emergency department are essential to improving patient outcomes. Recognizing its critical nature, the American Board of Emergency Medicine (ABEM) identifies thyroid storm as a core emergency condition that emergency physicians (EPs) must be trained to manage.³ Additionally, recent updates to the ABEM certifying examination emphasize the importance of clinical decision-making and the ability to verbalize diagnostic reasoning and management plans. This case has been designed to help learners practice and demonstrate these skills in the context of a high-stakes, time-sensitive clinical scenario involving thyroid storm.
Educational Objectives: By the end of the session, learners will be able to: 1) verbalize key pertinent historical and physical exam findings in a young female patient presenting with altered mental status; 2) formulate a prioritized differential diagnosis based on the history and physical exam; 3) order appropriate diagnostic studies and recognize abnormalities suggesting thyroid storm; 4) describe pathophysiology, management and rationale of sequential pharmacologic therapy in thyroid storm; 5) communicate patient’s medical care and course to family; and 6) review essential disposition actions including consultations and level of care for admission.
Educational Methods: We implemented a certifying exam board format case aligned with the ABEM’s updated certifying exam board examination. The case was co-developed by experts in simulation-based education and emergency medicine and underwent external peer review, which focused on the accuracy of the clinical context, clarity of scenario instructions, and educational value.
Research Methods: The case was iteratively developed and refined through multi-site piloting. Initial design was completed by three faculty with emergency medicine and simulation backgrounds, followed by external review using the Simulation Scenario Evaluation Tool (SSET). Feedback focused on case progression, realism, alignment with objectives, and consistency with assessment standards.
The case was then piloted at two academic training sites and at the Society for Academic Emergency Medicine (SAEM) Annual Meeting. Participants included faculty facilitators and EM residents. Residents and faculty completed a modified usability survey incorporating Likert-scale items (1 = strongly disagree to 5 = strongly agree) and open-ended comments. Data was collected in Qualtrics® and analyzed in Excel®. Revisions were made after each iteration to improve clarity, usability, and educational impact.
Results: The simulation scenario evaluation tool (SSET) evaluations were strongly positive. Facilitators (n = 3) consistently rated the case objectives, critical actions, and supporting materials as clear. They agreed or strongly agreed that the case was appropriate for the learner level, that the clinical course adhered to the ABEM format, and that the critical actions supported the stated objectives. Mean ratings ranged from 4 to 5 for ease of use, and facilitators noted that their colleagues would also find the materials accessible. They described the case as well-integrated, expressed confidence in facilitation, and endorsed its utility for ABEM certifying exam preparation.
Resident feedback was similarly supportive. Three learners unanimously agreed that the case provided helpful practice for the ABEM exam and reported that both the written and verbal instructions were clear.
Discussion: The thyroid storm clinical decision-making case proved to be an effective educational tool, meeting its intended objectives and offering meaningful preparation for emergency medicine residents facing the new ABEM certifying examination. Facilitators consistently reported that the case objectives, critical actions, and supporting materials were clear and aligned with the targeted level of learner training. Similarly, both facilitators and residents found the case to be a valuable exercise, providing relevant and realistic practice in the style of the certifying exam.
While early results are encouraging, future challenges and opportunities remain. In particular, the evolving structure and scoring approach of the new ABEM certifying examination introduces areas where additional refinement may be needed. As more information becomes available regarding the exam’s evaluation metrics, this case can be further tailored to enhance alignment and maximize its educational impact. Continued iterative development will ensure the case remains a practical and high-yield resource for residents as they prepare for certification.
Topics: Hyperthyroidism, communication, clinical decision-making case, certifying exam, thyroid storm, endocrinology.
- Clinical Decision-Making Case: Non-Accidental Trauma
Audience: This clinical decision-making (CDM) case is intended for emergency medicine (EM) residents of all levels.
Introduction: Non-accidental trauma (NAT) is a leading cause of morbidity and mortality in pediatrics. Every year in the United States, more than 656,000 children are found to be victims of NAT, causing over 1,800 deaths annually.1 Subtle abusive injuries are frequently missed in medical settings,1-3 and children may subsequently experience escalating or life-threatening abuse if interventions do not occur.2 Timely identification of abusive injuries in acute care settings is crucial to provide appropriate and potentially life-saving care.
Educational Objectives: By the end of this clinical decision-making case, learners will be able to: 1) demonstrate familiarity with the CDM case format and case play, 2) describe important historical information to obtain when suspecting non-accidental trauma, 3) recognize potential physical exam findings in non-accidental trauma, 4) justify appropriate diagnostic studies based on clinical findings and current evidence on occult injury in suspected pediatric abuse, and 5) propose an appropriate disposition plan for patients with non-accidental trauma.
Educational Methods: This is a clinical decision-making boards case as outlined by the American Board of Emergency Medicine (ABEM). Each learner was paired with one instructor for the case, a scoring checklist by the instructor was used, and learners were given the opportunity to provide feedback after the case.
Research Methods: Each CDM case session lasted approximately 20 minutes, with 15 minutes for the case and 5 minutes for debriefing and feedback. A 25-point critical action checklist was developed to evaluate each learner’s performance. Learners then provided verbal feedback on the cases to the examiners at the conclusion of their assessments.
Results: Thirty-nine emergency medicine residents participated as learners for this clinical decision-making session, including 10 third-year residents, 12 second-year residents, and 17 first-year residents. Scoring checklists had a possible score of 25 points, with each point reflecting an equally weighted item. The average overall score was 16.85 of 25 possible points. Performance with respect to post-graduate year (PGY) is as follows: 18.0 for PGY-3s, 18.9 for PGY-2s, and 14.7 for PGY-1s. One resident had a perfect score of 25/25. There was no threshold passing score; therefore, no one resident “failed” this mock structured interview.
Discussion: Performance of our learners varied and unexpectedly, our second-year residents outperformed our third-year residents. We believe this is due to our PGY-2 learners being responsible for the primary care of stroke patients in our department, which makes their identification of head bleed likely more recently retrievable. We reviewed outlier items (where residents all scored very high or if the score was lower compared to other items) to determine if this is an appropriately written item, and if so, we will use lower-scoring items as learning opportunities to emphasize within future didactics sessions. One of these items involved asking who the patients’ caregivers were, which may be attributed to being unaware of the relevance of this question to NAT, or, more likely, that NAT was not a top differential diagnosis in the early aspects of the case.
Verbal feedback from our learners primarily focused on widening our accepted differential diagnoses for future iterations. We believe that this case is appropriate for all levels of learning, particularly when a formative approach (assessment for learning) is used. Given the feedback learners and instructors provided, we believe this case has high value impact in reviewing high-risk or high-acuity pediatric pathology.
Topics: Emergency medicine, pediatrics, non-accidental trauma, pediatric head trauma, head bleed.
- Prioritization: Run This Board: Septic Shock, Acute Coronary Syndrome, Small Bowel Obstruction, and Penetrating Chest Trauma
Audience: This case was specifically designed for senior emergency medicine (EM) resident physicians as a preparatory tool for the American Board of Emergency Medicine (ABEM) Certifying Exam. However, it is applicable for EM residents at all levels of training.
Introduction: “A hallmark of emergency medicine is the ability to triage or prioritize care. This case will require the physician to evaluate and treat multiple patients while ensuring those who require immediate care receive it quickly. The physician may face the arrival of additional patients, the deterioration of existing patients, and realistic workflow interruptions during the case. A successful candidate will identify and stabilize high acuity patients.”1 With the introduction of the new Certifying Exam by ABEM and the current lack of resources to practice prioritization in an assessment setting, resident physicians will need practice material in order to adequately prepare for their board examination.
Educational Objectives: By the end of this case learners will be able to: 1) Become familiar with format of a prioritization case (a component of the ABEM Certifying Exam), 2) Practice their ability to prioritize multiple patients and provide stabilizing care, 3) Consider changes in status/patient acuity/new cases as presented, 4) Understand how to utilize team resources appropriately.
Educational Methods: This encounter is a structured, oral simulation case designed as a prioritization exercise for emergency medicine resident trainees. It follows an interview-based format in which an examiner presents evolving patient information in a time-limited scenario, and the examinee responds in real time with clinical reasoning, prioritization of care, and management decisions. The case mimics the structure of the Prioritization Case in the ABEM Certifying Exam, allowing the examinee to verbalize thought processes while receiving updated clinical data from the examiner. This format emphasizes critical thinking, triage under pressure, and the delegation of tasks within a simulated emergency department environment.
Research Methods: We first alpha-tested the case with board-certified emergency medicine physicians, who evaluated both the facilitator and learner aspects of the simulation. Their feedback was used to refine the structure, flow, and clinical realism of the case. Following these edits, the revised case was implemented with emergency medicine residents across varying levels of training. This staged approach allowed us to ensure educational fidelity and enhance realism, while also confirming that the case structure aligned with ABEM exam standards and expectations.
Results: We conducted multi-site alpha and beta testing of a novel ABEM-style prioritization case with a total of 18 emergency medicine residents (eight individual residents and two 5-person PGY2 teams) and three facilitators. Surveys were completed by two facilitators (Simulation Scenario Evaluation Tool, SSET) and eight resident participants or teams (modified usability survey). Facilitators rated the case highly, with an average global score of 87.5/100, and learners reported strong overall quality (4.4/5) and exceptional educational value (4.9/5), though clarity of instructions was rated lower (3.6/5). Participants were predominantly senior residents (62.5% PGY-3, 25.0% PGY-2, and 12.5% PGY-4). Qualitative comments emphasized the usefulness of practicing the new case format and highlighted a need for clearer explanations of structure and rules.
These results suggest the case was well-received across training levels, with iterative revisions improving clarity and usability. Based on preliminary beta testing, a Total Score of 70-75% indicates passing for this case.
Discussion: This oral board-style prioritization case offers learners the opportunity to practice essential but often underemphasized skills, including rapid prioritization, task switching, and real-time decision-making. The case format reinforces critical concepts such as situational awareness and resource management within the dynamic environment of the emergency department. During initial implementation, participants reported strong engagement and found the exercise particularly valuable in preparing for the ABEM Certifying Exam. Many noted that the structure and expectations closely mirrored those of the actual prioritization station based on the example video provided by ABEM.
From the instructor perspective, the standardized format promotes consistent delivery and assessment. To minimize examiner cognitive load during this high-complexity simulation, we developed a modular toolkit including a structured script, stimuli slides, and an automated scoring sheet, modeled in part after ABEM’s dual-examiner approach. A suite of Appendices supports both digital and paper-based use, allowing flexibility across educational settings.
To further support formative practice, we created a scoring rubric to guide examiner feedback and learner self-assessment. However, as ABEM has not released its internal scoring criteria, this rubric is unofficial and should be interpreted with caution. It is intended for educational use only and is not designed to predict performance on the actual certification exam.
- Prioritization: Intracranial Hemorrhage, Testicular Torsion, and Tricyclic Antidepressant Department
Audience: This case is designed for emergency medicine residents preparing for the American Board of Emergency Medicine Certifying Exam (ABEM). While we tested the case with third year emergency medicine residents, it could also be used with first- and second-year residents to develop complex decision-making and prioritization skills in a simulated environment.
Introduction: Emergency medicine requires physicians to rapidly prioritize care, stabilize critically ill patients, adapt to changing clinical circumstances, and delegate tasks and resources. Traditional oral board cases emphasize single-patient encounters rather than multitasking or task-switching. This prioritization case better aligns with the clinical workflow of a shift in the emergency department, including triage, teamwork, and flexibility. This case forces learners to make timely decisions with incomplete information, giving examiners insight into how the examinee performs in the clinical environment.
Educational Objectives: By the end of this case learners should: 1) Become familiar with the format of a prioritization case (a component of the ABEM Certifying Exam), 2) demonstrate their ability to prioritize multiple patients and provide stabilizing care, 3) consider changes in status/patient acuity/new cases as presented, 4) understand how to utilize team resources appropriately.
Educational Methods: A group of five emergency medicine faculty with experience in simulation and oral board case design created a 15-minute practice prioritization case. This case is based on information provided by ABEM on the prioritization case format from the ABEM Certifying Exam. Learners are presented with evolving patient scenarios via tracking boards and prompted to prioritize, stabilize, task switch, and delegate as they manage multiple patients. The case is intended to be administered with two examiners and one examinee at a time. We used a group debrief structure, but this case can also be debriefed with each individual learner.
Research Methods: This case was tested on 18 third-year emergency medicine residents. Following the case, each resident completed an anonymous two-item evaluation. The first item, “This case increased my understanding of the certifying exam format,” was scored on a 5-point Likert scale from “strongly disagree” to “strongly agree.” The second item, “How would you rate the overall quality of this case?” was scored on a 5-point Likert scale from “poor” to “excellent.”
Results: Sixteen of eighteen (89%) examinees completed the post-case evaluation. All respondents (100%) “agreed” or “strongly agreed” that the case improved their understanding of the ABEM Certifying Exam format. Overall case quality was rated 4.88/5, and all learners rated the case “very good” or “excellent.”
Discussion: This case was effective in simulating the competing demands of the clinical environment while also preparing learners for a new exam format. During the group debrief session, learners appreciated the pace, needing to stabilize multiple patients, and reacting to new information as it was presented. This case significantly improved residents’ understanding of the prioritization case type that will be tested on the ABEM Certifying Exam. It also provides a controlled environment for program faculty to observe how residents perform managing multiple sick patients simultaneously.