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eScholarship
Open Access Publications from the University of California

Volume 18, Issue 1, 2017

Special Issue in Educational Research and Practice from CDEM and CORD

Brief Educational Advances

52 Procedures in 52 Weeks: An innovative curriculum for emergency medicine residents

The specialty of Emergency Medicine (EM) requires that providers are as competent in rare procedures as they are in common ones.  This creates a challenge for EM educators, who are charged with graduating competent physicians who have the mental and technical expertise to perform such a breadth of procedures.  To facilitate this instruction, we have created a weekly procedure curriculum that utilizes videos coupled with hands on instruction to teach 52 EM procedures.  We have found this curriculum to be very effective and easy to implement into our residency training schedule.

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Brief Research Report

A Needs Assessment for a Longitudinal Emergency Medicine Intern Curriculum

Introduction

A key task of emergency medicine (EM) training programs is to develop a consistent knowledge of core content in recruits with heterogeneous training backgrounds. The traditional model for delivering core content is lecture-based weekly conference, however a growing body of literature finds this format less effective and less appealing than alternatives. We sought to address this challenge by conducting a needs assessment for a novel longitudinal intern curriculum for millennial learners.

Methods

We surveyed all residents from the six emergency medicine programs in the Chicago area regarding the concept, format, and scope of a longitudinal intern curriculum. Results were analyzed both in total and by a subgroup of interns.

Results

We received 153 responses from the 300 residents surveyed (51% response rate). The majority of residents (80%, interns: 82%) agreed or strongly agreed that a dedicated intern curriculum would add value to residency education. The most positively rated teaching method was simulation sessions (91%, interns: 91%) followed by dedicated weekly conference time (75%, interns: 84%) and dedicated asynchronous resources (71%, interns: 69%). Less than half of residents (47%, interns: 26%) supported use of textbook readings in the curriculum.

Conclusion

There is strong learner interest in a longitudinal intern curriculum. This needs assessment can serve to inform the development of a universal intern curriculum targeting the millennial generation.

What do they want from us? A survey of EM Program Directors on EM application criteria.

ABSTRACT

Introduction Although a relatively young specialty, emergency medicine (EM) is quite popular among medical students and is one of the most competitive large specialties.  Consequently, students increasingly seek more opportunity to differentiate themselves from their colleagues by pursuing more clerkships at the cost of taking out additional loans.  This despite the fact that those who match in emergency medicine typically do so in their top three choices.  We sought to ascertain what factors EM program directors seek in their typical candidate.  Methods Emergency Medicine program directors were recruited via the Council of Residency Directors email listserv to participate in an anonymous survey regarding the United States Medical Licensing Examination (USMLE), the number of Standard Letters of Evaluation (SLOE), and the number of EM rotations during the fourth year.  Results 135 respondents completed the anonymous survey.  59% of respondents stated their program did not have a minimum USMLE Step 1 score, but 39% reported a minimum score of 210 or higher. 95% of programs do not require Step 2 to grant an interview, but 46% require it to place the student on the rank list.  80% require only one EM rotation to grant an interview and none require more than 2.  95% of programs will accept 2 SLOEs for both application and rank list placement.  Conclusion For the typical emergency medicine applicant, there is likely little benefit to performing more than two rotations and obtaining more than two SLOEs. Students can defer USMLE Step 2 but must complete it by the time rank lists are due. Our study was limited by the anonymity of the survey and comments by the respondents revealed the questions did not account for some nuances programs apply to their application review process.

Medical Student Documentation in the Electronic Medical Record:  Patterns of Use and Barriers

INTRODUCTION: The Association of American Medical Colleges and the Liaison Committee for Medical Education have identified documentation in the electronic health record (EHR) as a key communication skill for students to master prior to graduation. We aimed to better understand the frequency with which students in Emergency Medicine (EM) clerkships document in the EHR, faculty review of these notes, and perceived barriers to student documentation.

 

METHODS: We conducted a cross-sectional electronic survey of EM clerkships identified through membership in the Clerkship Directors in Emergency Medicine between March and May of 2016.

 

RESULTS: Surveys were received from 100 clerkships, representing a completion rate of 86%. 63% of institutions allow students to document in the EHR, 95% of which have a process of note-review and student feedback. The most commonly cited reasons for not allowing student documentation were medical school or hospital policy (80%) and fear of litigation (60%).  Other reasons related to billing and clinical productivity, workspace limitations, educational resources and learning objectives.

 

DISCUSSION:  Student documentation in the EHR is common but far from universal in EM clerkships.  Though national medical education organizations have prioritized documentation in the medical record as a key skill, institutional policies and concerns related to medical liability appear to play a significant factor in limiting more widespread use.  This is despite a lack of evidence that medical student EHR documentation poses an increased medical liability risk.  While there are certainly difficult barriers to overcome related to student documentation in the EHR, EM educators should investigate opportunities within their departments and advocate for students at an institutional level.

 

Demographics and Fellowship Training of Residency Leadership in EM: A Descriptive Analysis

INTRODUCTION

Emergency Medicine (EM) fellowships are becoming increasingly numerous and there is a growing trend among EM residents to pursue postgraduate fellowship training. There is scant data published on the prevalence of postgraduate training amongst EM physicians. We aim to describe the prevalence and regional variation of fellowships amongst EM residency leadership

METHODS

We conducted an online anonymous survey which was sent to the EM Council of Residency Directors (CORD) membership in October 2014. The survey was a brief questionnaire, which inquired about fellowship, secondary board certification, gender, and length in a leadership position of each member of its residency leadership.  Responses to the survey were separated into four different geographic regions. The geographic regions were defined by the same classification used by the National Resident Matching  Program (NRMP).  Residency leadership was defined as program director (PD), associate PD and assistant PD.  Residencies who did not complete the survey were then individually contacted to encourage completion. The survey was initially piloted for ease of use and understanding of the questions with a select few EM PDs.

RESULTS

Responses were obtained from 145 out of the 164 ACGME accredited EM residencies (88%). The fellowship prevalence amongst PD, Associate PD, and Assistant PDs was 21.4%, 20.3%, and 24.9% respectively. The most common fellowship completed was a fellowship in toxicology. Secondary board certification among PD, associate PD, and assistant PD was 9.7%, 4.8%, and 2.9% respectively. 82% of PDs have at least five years in residency leadership. 76% of PDs were male, and there was a near even split of gender amongst associate PDs and assistant PDs. The Western region had the highest percentage of fellowship and or secondary board certification amongst all levels of residency leadership.

 

Conclusions: There is a low prevalence of fellowship training and secondary board certification amongst EM residency leadership with the most common being toxicology. Assistant PD’s who the majority had less than 5 years residency leadership experience had the highest percentage of fellowship training. There is a regional variation in the percentage of residency leadership completing postgraduate training.

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Educational Advances

A Novel Curriculum to Optimize Emergency Medicine Residents’ Exposure to Pediatrics

Recognizing the profound impact that emergency medicine residency graduates have on the quality of the emergency care of children, residency training programs must provide a broad clinical experience and training in pediatric care. Traditionally, part of this training has included a hospital ward rotation in inpatient pediatrics. However, these experiences may be perceived by learners as being educationally low-yield in terms of direct applicability to the practice of emergency medicine. This educational innovation describes the development of a novel curriculum for teaching pediatrics to emergency medicine residents. Rather than focusing on tasks disconnected from emergency medicine practice, residents provide the initial clinical care for patients in the emergency department in a professional setting situated to mirror their ultimate professional practice. The innovation involves longitudinal patient follow-up, with mentored supervision and discussion to reinforce learning. The curriculum includes dedicated Pediatric ED time, deliberate inpatient and phone follow-up, ward rounds, focused pediatric topics, and direct observation assessment and feedback on pediatric clinical skills.  This novel curriculum emphasizes the importance of situated learning, and is one component of a longitudinal teaching plan for pediatrics within an emergency medicine residency.

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The Council of Emergency Medicine Residency Directors’ (CORD) Academy for Scholarship in Education in Emergency Medicine: A Five-Year Update

The Council of Emergency Medicine Residency Directors’ (CORD) Academy for Scholarship in Education in Emergency Medicine was founded in 2010 to support emergency medicine educators, advance educational methods and scholarship in Emergency Medicine, and foster collaboration among members. As one of the first academies housed in a specialty organization, the CORD Academy concept has been successfully implemented, and has now grown to thirty members in the categories of Distinguished Educator, Academy Scholar, and Academy Member in four focus areas (Teaching and Evaluation; Enduring Educational Materials, Educational Leadership, and Education Research). In this update, the Academy leadership describes the revised academy structure, evolution of the application, and reports the activities of the three Academy pillars – membership/awards/recognition; faculty development and structured programs; and education research and scholarship – in the first five years of the Academy.

Transition of Care Practices from Emergency Department to Inpatient: Survey Data and Development of Algorithm

Introduction

We aimed to assess the current scope of handoff education and practice among resident physicians in academic centers, and to propose a standardized handoff algorithm for the transition of care from the emergency department (ED) to an inpatient setting.

 

Methods

This was a cross-sectional survey targeted at emergency medicine residency programs in the United States (US). The Web-based survey consisted of multiple choice, completion, and Likert scale items and was distributed to potential subjects through a listserv. A panel of experts used a modified Delphi approach to develop a standardized algorithm for ED to inpatient handoff.

 

Results

121 of 172 allopathic and osteopathic programs responded to the survey, for an overall response rate of 70.3%. Our survey showed that most EM programs in the US have some form of handoff training, and the majority of them occur either during orientation or in the clinical setting. The handoff structure from ED to inpatient is not well standardized, and in those places with a formalized handoff system over seventy percent of residents do not uniformly follow it. Approximately half of responding programs felt that their current handoff system was safe and effective. About half of the programs did not formally assess handoff proficiency of trainees.  Handoffs most commonly take place over the phone, though respondents disagreed about the ideal place for a handoff to occur with nearly equivalent responses between programs favoring the bedside, over the phone, or face to face at a computer station. Approximately 2/3 of responding programs reported that their residents were competent in performing ED to inpatient handoffs. Based on this survey and review of the literature, we developed a five-step algorithm for the transition of care from the ED to an inpatient setting.

 

Conclusion

Our results identified current trends of education and practice in transitions of care from the ED to inpatient setting among US academic medical centers. An algorithm to guide this process is proposed to address the current gap in a standardized approach to ED to inpatient handoffs identified from the surveyed needs assessment.

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Student Advising Recommendations from the Council of Residency Directors Student Advising Task Force

Emergency Medicine (EM) has become more competitive in recent years with a marked increase in the number of applications per student, raising costs for students and programs. Disseminating accurate advising information to applicants and programs could reduce excessive applying. Advising students applying to EM is a critical role for educators, clerkship directors, and program leaders. There are a variety of advising resources available through social media and individual organizations, however currently there are no consensus recommendations that bridge these resources.  The Council of Residency Directors (CORD) Student Advising Task Force (SATF) was initiated in 2013 to improve medical student advising.  The SATF developed best-practice consensus recommendations and resources for student advising.   Four documents (Medical Student Planner, EM Applicant’s Frequency Asked Questions, EM Applying Guide, EM Medical Student Advisor Resource List) were developed and are intended to support prospective applicants and their advisors. The recommendations are designed for the mid-range EM applicant and will need to be tailored based on students’ individual needs.

Emergency Medicine Resident Orientation: How Training Programs Get their Residents Started

ABSTRACT Introduction. The first formal orientation program for incoming emergency medicine (EM) residents was started in 1976. The last attempt to describe the nature of orientation programs was by Brillman in 1995. Now almost all residencies offer orientation to incoming residents, but little is known about the curricular content or structure of these programs. The purpose of this project was to describe the current composition and purpose of EM resident orientation programs in the United States (U.S.). Methods. In autumn of 2014, we surveyed all U.S. emergency medicine residency program directors (n=167). We adapted our survey instrument from one used by Brillman (1995). The survey was designed to assess the orientation program’s purpose, structure, content, and teaching methods. Results. The survey return rate was 63% (105 of 167). Most respondents (77%) directed 3-year residencies, and all but one program offered intern orientation. Orientations lasted an average of nine clinical (Std. Dev.=7.3) and 13 non-clinical days (Std. Dev. =9.3). The prototypical breakdown of program activities was 27% lectures, 23% clinical work, 16% skills training, 10% administrative activities, 9% socialization and 15% other activities. Most orientations included activities to promote socialization among interns (98%) and with other members of the department (91%). Many programs (87%) included special certification courses (ACLS, ATLS, PALS, NRP). Course content included: use of electronic medical records (90%), physician wellness (75%), and chief complaint-based lectures (72%). Procedural skill sessions covered: ultrasound (94%), airway management (91%), vascular access (90%), wound management (77%), splinting (67%), and trauma skills (62%). Conclusion. Compared to Brillman (1995), we found that more programs (99%) are offering formal orientation and allocating more time to them. Lectures remain the most educational common activity. We found increases in the use of skills labs and specialty certifications. We also observed increases in time dedicated to clinical work during orientation. Only a few programs reported engaging in baseline or milestone assessments, an activity that could offer significant benefits to the residency program.

Trends in NRMP Data from 2007-2014 for US Seniors Matching into Emergency Medicine

Introduction

Since 1978, the NRMP has published data demonstrating characteristics of applicants that have matched into their preferred specialty in the NRMP main residency match. This data has been published approximately every two years. There is limited information about trends within this published data for students matching into emergency medicine (EM). Our objective was to investigate and describe trends in NRMP data to include the ratio of applicants to available EM positions, USMLE Step 1 and Step 2 scores (compared to the national means), number of programs ranked, and AOA membership among US seniors matching into EM.

Methods

This was a retrospective observational review of NRMP data published between 2007 and 2016. The data was analyzed using ANOVA and Fischer’s exact to determine statistical significance.

Results

The ratio of applicants to available EM positions remained essentially stable from 2007 to 2014, but did increase slightly in 2016. A net upward trend in overall Step 1 and Step 2 scores for EM applicants was observed. However, this did not outpace the national trend increase in Step 1 and 2 scores overall. There was no statistical difference in the mean number of programs ranked by EM applicants among the years studied (p=0.93). Among time intervals, there was a difference in the number of EM applicants with AOA membership (p=0.043) due to a drop in the number of AOA students in 2011. No sustained statistical trend was identified over the 7-year period studied.

Conclusion

NRMP data demonstrate trends among EM applicants that are similar to national trends in other specialties for USMLE board scores, and stability in number of programs ranked and AOA membership. EM does not appear to have become more competitive relative to other specialties or previous years in these categories.

Defining uniform processes for remediation, probation, and termination in residency training

ABSTRACT

It is important that residency programs identify trainees who progress appropriately as well as identify residents who fail to achieve Milestones as expected so they may be remediated. The process of remediation varies greatly across training programs, due in part to the lack of standardized definitions for good standing, remediation, probation, and termination. The purpose of this educational advancement is to propose a clear remediation framework including definitions, management processes, documentation expectations and appropriate notifications.

Informal remediation is initiated when a resident’s performance is deficient in one or more Milestones but not significant enough to trigger formal remediation. Formal Remediation is when deficiencies are significant enough to warrant formal documentation because informal remediation failed or because issues are substantial. The process includes documentation in the resident’s file and notification of the Graduate Medical Education office, however, the documentation is not disclosed if the resident successfully remediates. Probation is when a resident is unsuccessful in meeting the terms of formal remediation or if initial problems are so significant to warrant immediate probation. The process is similar to formal remediation but also includes documentation extending to the final verification of training and employment letters. Termination involves other stakeholders and is when a resident is unsuccessful in meeting the terms of probation or if initial problems are so significant to warrant immediate termination.

Adapting Gel-Wax into an Ultrasound Guided Pericardiocentesis Model at Low Cost

Cardiac tamponade is a life-threatening emergency for which pericardiocentesis may be required. Real-time bedside ultrasound has obviated the need for routine blind procedures in cardiac arrest and the number of pericardiocenteses being performed has declined. Despite this fact, pericardiocentesis remains an essential skill in emergency medicine. While commercially available training models exist, cost, durability, and lack of anatomical landmarks limit their usefulness. We sought to create a pericardiocentesis model that is realistic, simple to build, reusable, and cost efficient. The model was constructed utilizing a red dye filled ping-pong ball (simulating the left ventricle) and a 250cc NS bag (simulating the effusion) encased in an artificial rib cage and held in place by gel-wax.  The inner saline bag was connected to a 1L saline bag outside of the main assembly to act as a fluid reservoir for repeat uses. The entire construction process takes approximately 16-20 hours, most of which is attributed to cooling of the gel-wax. Actual construction time is approximately 4 hours at a cost of less than $200. The model was introduced to Emergency Medicine residents and medical students during a procedure simulation lab and compared to a model previously described by dell’Orto1. The learners performed ultrasound guided pericardiocentesis using both models.  Learners were given a survey comparing realism of the two models.  Learners felt our model was more realistic than the previously described model.  On a scale of 1-9 with 9 being very realistic, the previous model was rated a 4.5.  Our model was rated a 7.8.  There was also a marked improvement in the perceived recognition of the pericardium, the heart, and the pericardial sac. Additionally, 100% of the students were successful at performing the procedure using our model. In simulation, our model provided both palpable and ultrasound landmarks and held up to several months of repeated use. It was less expensive than commercial models ($200 vs upto $16,500) while being more realistic in simulation than other described “DIY models”.  This model can be easily replicated to teach the necessary skill of pericardiocentesis.

Creation of a realistic model for removal of a metallic corneal foreign body for less than $75.

Metallic corneal foreign bodies (MCFBs) are one of the most common causes of ocular injury presenting to the emergency department. Delays in removal, or forceful attempts to remove the MCFB can lead to infection, further injury to the eye, and worsening of vision. In order to prevent these underlying complications, it is imperative for the medical provider to properly master this technique. As current trends in simulation become more focused on patient safety, task-trainers can provide an invaluable learning experience for residents, medical students and physicians. Models made from bovine eyes, agar plates, gelatin, and corneas created from glass and paraffin wax have been previously been created. One study also used a rubber glove filled with water to simulate intraocular measurement with a Tonopen. However the use of corneas created from ballistics gel for MCFB removal and intraocular pressure measurement has not been studied. We propose a realistic, sustainable, cost-effective MCFB task-trainer to introduce the fundamental skills required for MCFB removal and measurement of intraocular pressure with a Tonopen.  A pilot survey study performed on medical students and emergency medicine resident physicians showed an increase in comfort levels performing both MCFB removal and measurement of intraocular pressure with a Tonopen after using this task-trainer.

Novel Airway Training Tool that Simulates Vomiting: Suction-Assisted Laryngoscopy Assisted Decontamination (SALAD) System

Objective: We present a novel airway simulation tool which recreates the dynamic challenges associated with emergency airways. The Suction-Assisted Laryngoscopy Assisted Decontamination (SALAD) simulation system trains providers to use suction to manage emesis and bleeding complicating intubation.

 

Methods: A standard difficult airway mannequin head (Nasco, Ft. Atkinson, WI) was modified with hardware store equipment to enable simulation of vomiting or hemorrhage during intubation. A pre- and post-survey was used to assess the effectiveness of the SALAD simulator. A 1-5 Likert scale was utilized to assess confidence in managing the airway of a vomiting patient and comfort with suction techniques before and after the training exercise.

 

Results: Forty learners participated in the simulation, including emergency physicians, anesthesiologists, paramedics, respiratory therapists, and registered nurses. The average Likert score of confidence in managing the airway of a vomiting or hemorrhaging patient pre-session was 3.10±0.49, and post-session 4.13±0.22 (p<0.00001).  The average score of self-perceived skill with suction techniques in the airway scenario pre-session was 3.30±0.43, and post-session 4.03±0.26 (p<0.0005). The average score for usefulness of the session was 4.68±0.15, and the score for realism of the simulator was 4.65±0.17.

 

Conclusion: A training session with the SALAD simulator improved trainee’s confidence in managing the airway of a vomiting or hemorrhaging patient.  We feel the SALAD simulation system recreates the dynamic challenges associated with emergency airways and has the potential to transform airway training.

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Original Research

Development of an assessment for Entrustable Professional Activity (EPA) 10: Emergent patient management

ABSTRACT: Introduction. Medical schools in the United States are encouraged to prepare and certify the entrustment of medical students to perform 13 core entrustable professional activities (EPAs) prior to graduation. Entrustment is defined as the informed belief that the learner is qualified to autonomously perform specific patient care activities. Core EPA-10 is the entrustment of a graduate to care for the emergent patient. The purpose of this project was to design a realistic performance assessment method for evaluating fourth-year medical students on EPA-10. Methods. First, we wrote five emergent patient case-scenarios that a medical trainee would likely confront in an acute care setting. Furthermore, we developed high-fidelity simulations to realistically portray these patient case-scenarios. Finally, we designed a performance assessment instrument to evaluate the medical student’s performance on executing critical actions related to EPA-10 competencies. Critical actions included: triage skills, mustering the medical team, identifying causes of patient decompensation, and initiating care. Up to four students were involved with each case-scenario, however only the team leader was evaluated using the assessment instruments developed for each case. Results. One hundred fourteen students participated in the EPA-10 assessment during their final year of medical school. Most students demonstrated competence in recognizing unstable vital signs (97%), engaging the team (93%), and making appropriate dispositions (92%). Almost 87% of the students were rated as having reached entrustment to manage the care of an emergent patient (99 of 114). Inter-rater reliability varied by case-scenario, ranging from moderate to near perfect agreement. Three of five case-scenario assessment instruments contained items that were internally consistent at measuring student performance. Additionally, the individual item scores for these case scenarios were highly correlated with the global entrustment decision. Conclusions. High fidelity simulation showed good potential for effective assessment of medical student entrustment of caring for the emergent patient. Preliminary evidence from this pilot project suggests content validity of most cases and associated checklist items. The assessments also demonstrated moderately strong faculty inter-rater reliability.

“Let Me Tell You About My…” Provider Self-Disclosure in the Emergency Department Builds Patient Rapport

ABSTRACT

Background

As patients become increasingly involved in their medical care, physician-patient communication gains importance. A previous study showed that physician self-disclosure (SD) of personal information by primary care providers decreased patient rating of the provider communication skills.

Objective

The objective of this study is to explore the incidence and impact of Emergency Department (ED) provider self-disclosure on patients’ rating of provider communication skills.

Methods

A survey was administered to 520 adult patients or parents of pediatric patients in a large tertiary care ED during the summer of 2014. The instrument asked patients whether the provider self-disclosed and subsequently asked patients to rate providers’ communication skills. We compared patients’ ratings of communication measurements between encounters where self-disclosure occurred to those where it did not.

Results

Patients reported provider SD in 18.9% of interactions. Provider SD was associated with more positive patient perception of provider communication skills (p<0.005), more positive ratings of provider rapport (p<0.05) and higher satisfaction with provider communication (p<0.05). Patients who noted SD scored their providers’ communication skills as “excellent” (63.4%) compared to patients without self-disclosure (47.1%). Patients reported that they would like to hear about their providers’ experiences with a similar chief complaint (64.4% of patients), their providers’ education (49%), family (33%), personal life (21%) or an injury/ailment unlike their own (18%). Patients responded that providers self-disclose to make patients comfortable/at ease and to build rapport.

Conclusion

Provider self-disclosure in the ED is common and is associated with higher ratings of provider communication, rapport, and patient satisfaction.

Keywords

Patient, resident, provider communication, education

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Who to Interview? Low Adherence by US Medical Schools to Medical Student Performance Evaluation Format Makes Resident Selection Difficult

INTRODUCTION: The Medical Student Performance Evaluation (MSPE) appendices provide a program director with comparative performance for a student’s academic and professional attributes, but they are frequently absent or incomplete. METHODS: We reviewed MSPEs from applicants to our emergency medicine residency program from 134 of 136 (99%) US allopathic medical schools, over two application cycles (2012-13, 2014-15). We determined the degree of compliance with each of the five recommended MSPE appendices. RESULTS: Only three (2%) medical schools were compliant with all five appendices. The medical school information page (MSIP, appendix E) was present most commonly (85%), followed by comparative clerkship performance (appendix B, 82%), overall performance (appendix D, 59%), preclinical performance (appendix A, 57%), and professional attributes (appendix C, 18%). Few schools (7%) provided student-specific, comparative professionalism assessments. CONCLUSION: Medical schools inconsistently provide graphic, comparative data for their students in the MSPE. Although PDs value evidence of an applicant’s professionalism when selecting residents, medical schools rarely provide such useful, comparative professionalism data in their MSPEs. As PDs seek to evaluate applicants based on academic performance and professionalism, rather than standardized testing alone, medical schools must make MSPEs more consistent, objective, and comparative.

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Teaching the Emergency Department Patient Experience: Needs Assessment from the CORD-EM Task Force

ABSTRACT

INTRODUCTION

Since the creation of HCAHPS Patient Satisfaction (PS) scores, Patient Experience (PE) has become a metric that can profoundly affect the fiscal balance of hospital systems, reputation of entire departments and welfare of individual physicians. While government and hospital mandates demonstrate the prominence of PE as a quality measure, no such mandate exists for its education. The objective of this study was to determine the education and evaluation landscape for PE in categorical Emergency Medicine (EM) residencies.

METHODS

This was a prospective survey analysis of the Council of Emergency Medicine Residency Directors (CORD) membership. Program directors (PDs), assistant PDs and core faculty who are part of the CORD listserv were sent an email link to a brief, anonymous electronic survey. Respondents were asked their position in the residency, the name of their department, and questions regarding the presence and types of PS evaluative data and PE education they provide.

RESULTS

146 responses were obtained from 139 individual residencies, representing 72% of all categorical EM residencies. This survey found that only 27% of responding residencies provide PS data to their residents. Of those programs, 61% offer simulation scores, 39% provide third party attending data on cases with resident participation, 37% provide third party acquired data specifically about residents and 37% provide internally acquired quantitative data.

Only 35% of residencies reported having any organized PE curricula.  Of the programs that provide an organized PE curriculum, most offer multiple modalities.  96% provide didactic lectures, 49% small group sessions, 47% simulation sessions and 27% specifically use standardized patient encounters in their simulation sessions.

CONCLUSION

The majority of categorical EM residencies do not provide either PS data or any organized PE curriculum. Those that do utilize a heterogeneous set of data collection modalities and educational techniques. AOA and ACGME residencies show no significant differences in their resident PS data provision or formal curricula. Further work is needed improve education given the high stakes of PS scores in the EM physician’s career.

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An Analysis of the Top-cited Articles in Emergency Medicine Education Literature

Introduction

Dissemination of educational research is critical to improving medical education, promotion of faculty and, ultimately, patient care. The objective of this study was to identify the top 25 cited education articles in the emergency medicine (EM) literature and the top 25 cited EM education articles in all journals, as well as report on the characteristics of the articles.

Methods

Two searches were conducted in the Web of Science in June 2016 using a list of education related search terms. Nineteen EM journals were searched for education articles as well as all other literature for emergency medicine education-related articles. Articles identified were reviewed for citation count, article type, journal, authors, and publication year.

Results

With regards to EM journals, the greatest number of articles were classified as articles/reviews followed by research articles on topics such as deliberate practice (cited 266 times) and cognitive errors (cited 201 times). In contrast, in the non-EM journals, research articles were predominant. Both searches found several simulation and ultrasound articles to be included. The most common EM journal was Academic Emergency Medicine (n = 18) and Academic Medicine was the most common non-EM journal (n=5). A reasonable number of articles included external funding sources (6 EM articles and 13 non-EM articles).

Conclusion

This study identified the most frequently cited medical education journals in the field of EM education, published in EM journals as well as all other journals indexed in Web of Science. The results identify impactful articles to medical education, providing a resource to educators while identifying trends that may be used to guide emergency medicine educational research and publishing efforts.

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Supplemental Milestones for Emergency Medicine Residency Programs: A Validation Study

Introduction: Emergency Medicine (EM) residency programs may be 36 or 48 months in length. The Residency Review Committee for EM requires that 48-month programs provide educational justification for the incremental 12 months. We developed additional milestones that EM training programs might use to outcomes in domains that meet this accreditation requirement. This study aims to validate these supplemental milestones using a similar methodology to that of the original EM Milestones validation study.

Methods: A panel of EM program directors and content experts at two institutions identified domains of additional training not covered by the existing EM Milestones. This led to the development of 6 novel subcompetencies: Operations and Administration, Critical Care, Leadership and Management, Research, Teaching and Learning, and Career Development. Subject-matter experts at other 48-month EM residency programs refined the milestones for these subcompetencies. Program directors of all 48-month EM programs were then asked to order the proposed milestones using the Dreyfus model of skill acquisition for each subcompetency. Data analysis mirrored that used in the original EM Milestones validation study, leading to the final version of our supplemental milestones.

Results: Twenty of 33 subjects (58.8%) completed the study. No subcompetency or individual milestone met deletion criteria. Of the 97 proposed milestones, 67 (69.1%) required no further editing and remained at the same level as proposed by the study authors. Thirty milestones underwent level changes: 15 (15.5%) were moved one level up and 13 (13.4%) were moved one level down. One milestone (1.0%) in ‘Leadership and Management’ was moved two levels up, and one milestone in ‘Operations and Administration’ was moved two levels down. One milestone in ‘Research’ was ranked by the survey respondents at one level higher than that proposed by the authors, however this milestone was kept at its original level assignment.

Conclusion: Six additional subcompetencies were generated and validated using the same methodology as was used to validate the current EM Milestones. These optional milestones may serve as an additional set of assessment tools that will allow EM residency programs to report these additional educational outcomes using a familiar milestone rubric.

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Are All Competencies Equal In The Eyes Of Residents? A Multicenter Study Of Emergency Medicine Residents' Interest in Feedback

Introduction: Feedback, particularly real-time feedback, is critical to resident education.  The emergency medicine (EM) milestones were developed in 2012 to enhance resident assessment and many programs utilize them to provide focused resident feedback. The purpose of this study was to evaluate EM residents’ level of interest in receiving real-time feedback on each of the 23 milestone sub-competencies.

Methods: This was a multicenter cross sectional study of EM residents. Participants were surveyed on their level of interest in receiving real-time on-shift feedback on each of the 23 milestone sub-competencies. Anonymous paper or computerized surveys were distributed to residents at three 4-year training programs and three 3-year training programs with a total of 223 resident respondents. Residents rated their level of interest in each milestone on a 6-point semantic differential response scale. Average level of interest was calculated for each of the 23 sub-competencies, both as an average of all 223 respondents as well as by individual postgraduate year (PGY) level of training. One-way ANOVA analysis was performed to determine statistical significance.

Results: The overall survey response rate across all institutions was 82%. Emergency stabilization had the highest mean rating (5.47/6) while technology had the lowest rating (3.24/6). However, none of the 23 milestone sub-competencies were statistically significant based on ANOVA analysis.

Conclusion: It is unclear whether residents ascribe much more value to certain sub-competency domains than others.  Further studies are necessary to determine whether residents’ sub-competency valuations need to be considered when developing an assessment or feedback program focusing on the 23 EM milestones.

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Efficient and Effective Use of Peer Teaching for Medical Student Simulation

Introduction: Simulation is increasingly utilized in medical education promoting active learning and retention, however increasing use also requires considerable instructor resources.

Simulation may provide a safe environment for students to teach each other, which many will need to do when they enter residency. Along with reinforcing learning and increasing retention, peer teaching could decrease instructor demands. The objective was to determine the effectiveness of peer taught simulation compared to physician-led simulation. We hypothesized that peer-taught simulation would lead to equivalent knowledge acquisition when compared to physician-taught sessions and would be viewed positively by participants.

Method: This was a quasi-experimental study in an emergency medicine clerkship. The control group was faculty taught. In the peer-taught intervention group, students were assigned to teach one of the three simulation-based medical emergency cases. Each student was instructed to master their topic and teach it to their peers using the provided objectives and resource materials. The students were assigned to groups of three, with all three cases represented; students took turns leading their case. Three groups ran simultaneously. During the intervention sessions, one physician was present to monitor the accuracy of learning and to answer questions, while three physicians were required for the control groups. Outcomes compared pre-test and post-test knowledge and student reaction between control and intervention groups.

Results: Both methods led to equally improved knowledge; mean score for the post-test was 75% for both groups (p=0.6) and were viewed positively. Students in the intervention group agreed that peer-directed learning was an effective way to learn. However, students in the control group scored their simulation experience more favorably.

Conclusion: In general, students’ response to peer teaching was positive, students learned equally well, and found peer-taught sessions to be interactive and beneficial.

Interview day environment may influence applicant selection of emergency medicine residency programs

Introduction The structure of the interview day affects applicant interactions with faculty and residents, which can influence the applicant's rank list decision. We aim to determine if there was a difference in matched residents between those interviewing on a day on which didactics were held and had increased resident and faculty presence (Didactic Day) versus an interview day with less availability for applicant interactions with residents and faculty (Non-Didactic Day).

Methods Retrospective study reviewing interview dates of matched residents from 2009-2015.

Results 42 (61.8%) matched residents interviewed on a Didactic Day with increased faculty and resident presence versus 26 (38.2%) on a Non-Didactic interview day with less availability for applicant interactions (p=0.04).

Conclusion There is an association between interviewing on a Didactic Day with increased faculty and resident presence and matching in our program.

 

Characteristics of Real-Time, Non-Critical Incident Debriefing Practices in the Emergency Department

Introduction

Benefits of post-simulation debriefings as an educational and feedback tool have been widely accepted for nearly a decade. Real-time, non-critical incident debriefing is similar to post-simulation debriefing, however, data on its practice is limited. Although tools such as TeamSTEPPS® (Team Strategies and Tools to Enhance Performance and Patient Safety) suggest debriefing after complicated medical situations, they do not teach debriefing skills suited to this purpose. Anecdotal evidence suggests that real-time debriefings (or non-critical incident debriefings) do in fact occur in emergency departments, however, limited research has been performed on this subject.  The objective of this study is to characterize real-time, non-critical incident debriefing practices in Emergency Medicine (EM).

Methods

This was a multicenter cross sectional study of EM attendings and residents conducted at 4 large, high volume, academic EM residency programs in New York City. Questionnaire design was based on a Delphi panel and pilot testing with expert panel. A convenience sample was obtained from a potential pool of approximately 300 physicians across the 4 sites with the goal of obtaining >100 responses. The survey was sent electronically to the 4 residency list-serves with a total of 6 monthly completion reminder emails. All data was collected electronically and anonymously using surveymonkey.com and was entered and analyzed Microsoft Excel.

Results

The data elucidates various characteristics of current real-time debriefing trends in EM, including its definition, perceived benefits and barriers, as well as the variety of formats of debriefings currently being conducted.

Conclusion

This survey regarding the practice of real-time, non-critical incident debriefings in four major academic emergency programs within New York City sheds light on three major, pertinent points: 1) Real-time, non-critical incident debriefing definitely occurs in clinical emergency practice; 2) In general, real-time debriefing is perceived to be of some value with respect to education, systems and performance improvement; 3) Although being practiced by clinicians, most report no formal training in actual debriefing techniques. Further study is needed to clarify actual benefits of real-time/non-critical incident debriefing as well as details on potential pitfalls of this practice and recommendations for best practices for use.

 

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Continuing medical education speakers with high evaluation scores use more image-based slides

Introduction: Although continuing medical education (CME) presentations are common across health professions, it is unknown whether audience evaluations of the speaker is independently associated with slide design. Based on the conceptual framework of Mayer’s theory of multimedia learning, this study aimed to determine whether image use and text density in presentation slides are associated with overall speaker evaluations.

Methods: This retrospective analysis of six sequential CME conferences (two annual emergency medicine conferences over a three-year period) used a mixed linear regression model to assess whether post-conference speaker evaluations were associated with image fraction (percent of slides with at least one image) and text density (number of words per slide).

Results: A total of 105 lectures were given by 49 faculty members, and 1,179 evaluations (67.8% response rate) were available for analysis. On average, 47.4% (SD=25.36) of slides had at least one image (image fraction). Image fraction significantly predicted overall higher evaluation scores [F(1, 100.676)=6.158, p=0.015] in the mixed linear regression model. The mean (SD) text density was 25.61 (8.14) words/slide but was not a significant predictor [F(1, 86.293)=0.55, p=0.815]. Of note, the speaker [χ2(1)=2.952, p=0.003] and speaker seniority [F(3, 59.713)=4.083, p=0.011] significantly predicted higher scores.

Conclusion: This is the first published study to date assessing the linkage between slide design and CME speaker evaluations by an audience of practicing clinicians. The incorporation of images was associated with higher evaluation scores, in alignment with Mayer’s theory of multimedia learning. Contrary to this theory, however, text density showed no significant association, suggesting that these scores are multifactorial. Professional development efforts should focus on teaching best practices in both slide design and presentation skills.

Can Emergency Medicine Residents Predict Cost of Diagnostic Testing?

INTRODUCTION:  Diagnostic testing represents a significant portion of healthcare spending, and cost should be considered when ordering such tests.  Needless and excessive spending may occur without an appreciation of the impact on the larger health care system. Knowledge regarding the cost of diagnostic testing among Emergency Medicine residents has not previously been studied.

METHODS: A survey was administered to 20 Emergency Medicine residents from a single ACGME-accredited three-year EM residency program, asking an estimation of the patient charges for 20 commonly ordered laboratory tests and 7 radiological exams. Responses were compared between residency classes to evaluate whether there was a difference based on level of training.

RESULTS: The survey completion rate was 100% (20/20 residents).  Significant discrepancies were noted between the median resident estimates and actual charge to patient for both laboratory and radiological exams.  Nearly all responses were an underestimate of the actual cost. The group median underestimation for laboratory testing was $114, for radiographs $57, and for computed tomography (CT) exams was $1058.   There was statistically significant improvement in accuracy with increasing level of training.

CONCLUSION: This pilot study demonstrates that EM residents have a poor understanding of the charges burdened by patients and health insurance providers.  In order to make balanced decisions with regard to diagnostic testing, providers must appreciate these factors.  Education regarding the cost of providing emergency care is a potential area for improvement of Emergency Medicine residency curricula, and warrants further attention and investigation.

Exploring Scholarship and the Emergency Medicine Educator: A Workforce Study

Introduction: Recent literature calls for initiatives to improve the quality of education studies and support faculty in approaching educational problems in a scholarly manner. Understanding the emergency medicine (EM) educator workforce is a crucial precursor to developing policies to support educators and promote education scholarship in EM.  This study aims to illuminate the current workforce model for the academic emergency medicine educator.

Methods: Program leadership at EM training programs completed an online survey consisting of multiple choice, completion, and free response type items. Descriptive statistics were calculated and reported.

Results: 112 programs participated.  Mean number of core faculty/program: 16.02 ± 7.83 [14.53-17.5]. Mean number of faculty full time equivalents (FTEs)/program dedicated to education is 6.92 ± 4.92 [5.87-7.98], including (mean FTE): Vice Chair for education (0.25); Director of Medical Education (0.13); Education Fellowship Director (0.2); Residency Program Director (0.83); Associate Residency Director (0.94); Assistant Residency Director (1.1); Medical Student Clerkship Director (0.8); Assistant/Associate Clerkship Director (0.28); Simulation Fellowship Director (0.11); Simulation Director (0.42); Director of Faculty Development (0.13). Mean number of FTEs/program for education administrative support is 2.34 ± 1.1 [2.13-2.61]. Determination of clinical hours varied. 38.75% of programs had personnel with education research expertise.

Conclusion: Education faculty represent about 43% of the core faculty workforce. Many programs do not have the full spectrum of education leadership roles and educational faculty divide their time among multiple important academic roles. Clinical requirements vary. Many departments lack personnel with expertise in education research. This information may inform interventions to promote education scholarship.

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The Cost and Burden of the Residency Match in Emergency Medicine

Abstract

Background

In order to obtain a residency match, medical students entering Emergency Medicine (EM) must complete away rotations, submit a number of lengthy applications, and travel to multiple programs to interview. The expenses incurred acquiring this residency position are burdensome, but there is little specialty specific data estimating it.

Objective

We sought to quantify the actual cost spent by medical students applying to EM residency programs by surveying students as they attended a residency interview.

Methods

Researchers created a 16-item survey, which asked about the time and monetary costs associated with the entire EM residency application process. Applicants chosen to interview for an EM residency position at our institution were invited to complete the survey during their interview day.

Results

In total, 66 out of a possible 81 residency applicants (an 81% response rate) completed our survey. The “average applicant” who interviewed at our residency program for the 2015-16 cycle completed 1.6 away or audition rotations, each costing an average of $1,065 to complete. This “applicant” applied to 42.8 programs, and then attended 13.7 interviews. The cost of interviewing at our program averaged $342 and in total, an average of $8,312 would be spent in the pursuit of an EM residency.

Conclusions

Due to multiple factors, the costs of securing an EM residency spot are escalating at an alarming rate. By understanding the components that are driving this trend, we hope that the academic EM community can explore avenues to help curtail these costs.

Differences in Self-expression Reflect Formal Evaluation in a Fourth-year Emergency Medicine Clerkship

Introduction: Medical schools have begun to incorporate self-reflection exercises into their curricula, with the belief that these exercises help students master the material more deeply and perform better. Reflection may be a potential learning tool for Emergency Medicine, but there are few data supporting this hypothesis. The authors evaluated the relationship between a linguistic marker of the degree of reflection after a student’s shift in an emergency department and that student’s clerkship performance.

Methods: The authors conducted a retrospective case series by analyzing the performance and reflective statements of 116 students from a single medical school who participated in a required emergency medicine clerkship at one or two of four clinical sites from 2013-14. After each shift, an attending emergency medicine physician evaluated the student according to the RIME (Reporter-Interpreter-Manager-Educator) scheme. The authors developed software to extract the text from those comments, remove uninformative words and standardize the remaining words. The authors determined the most common words and two-word phrases that students used to describe their shift.  The correlation between students’ final clerkship grades and the fraction of student comments with at least one content word was analyzed.

Results: Of the 145 possible records, 116 were included for analysis. The other 29 were excluded as they were visiting students who did not receive a final numeric grade. The correlation between final grade and the number of completed self-reflections was 0.32. The correlation between final grade and the average number of words in each self-reflection was 0.21. The first correlation is significantly greater than 0 (p=0.03, t-test), but the second correlation is not (p=0.16, t-test). The median final grade of those who wrote reflections on more than half of their shifts was significantly greater than those who wrote reflections half of the time, 83.675 versus 79.23 (p=0.05, 2-sample Kolmogorov-Smirnov test).

Conclusions: Students who reflected more frequently received a higher grade in an emergency medicine clerkship for fourth year medical students. The number of words in each reflection was not significantly correlated with grade performance. The most common words and phrases students wrote were associated with learning and managing patients.