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Open Access Publications from the University of California

Volume 21, Issue 1, 2019

CDEM/CORD Special Education Issue

WestJEM Full-Text Issue

CDEM/CORD Special Education Issue 21.1

Clerkship Directors in Emergency Medicine (CDEM)/Council of Residency Directors in Emergency Medicine (CORD) Special Issue in Educational Research and Practice

Brief Educational Advances - Print

Targeting Implicit Bias in Medicine: Lessons from Art and Archaeology

Implicit bias training is not currently a required component of residency education, yet implicit bias in medicine exists and may influence care provided to patients. We propose an innovative exercise that allows trainees to explore implicit bias outside of the clinical environment, in an interdisciplinary manner with museum anthropologists and archaeologists. The curriculum was designed with leaders at the Penn Museum and focuses on differentiating between objective and subjective assessments of historical objects. The first part of the exercise consists of a pre-brief, to introduce trainees to bias through the lens of an anthropologist/archaeologist. The second part guides trainees through“deep description,” where they explore objective and subjective findings of three different objects. The exercise concludes with a debrief and application of concepts learned to everyday clinical practice. This innovation was successful at introducing trainees to implicit bias in a nontraditional environment, and participants reported an improved understanding of implicit bias. Residency programs could consider partnering with local museums to implement a similar exercise as acomponent of conference curriculum.

Brief Research Report - Print

Misunderstanding the Match: Do Students Create Rank Lists Based on True Preferences?

Introduction: The “stable marriage” algorithm underlying the National Residency Match Program (NRMP) has been shown to create optimal outcomes when students submit true preference lists. Previous research has shown students may allow external information to affect their rank lists. The objective of this study was to determine whether medical students consistently make rank lists that reflect their true preferences.

Methods: A voluntary online survey was sent to third-year students at a single midwestern medical school. Students were given hypothetical scenarios that either should or should not affect their true residency preferences and rated the importance of six factors to their final rank list. The survey was edited by a group of education scholars and revised based on feedback from a pilot with current postgraduate year 1 residents.

Results: Of 175 students surveyed, 140 (80%) responded; 63% (88/140) reported that their “perceived competitiveness” would influence their rank list at least a “moderate amount. Of 135 students, 31 (23%) moved a program lower on their list if they learned they were ranked “low” by that program, while 6% (8/135) of respondents moved a program higher if they learned they were ranked “at the top of the list.” Participants responded similarly (κ = 0.71) when presented with scenarios asking what they would do vs what a classmate should do.

Conclusion: Students’ hypothetical rank lists did not consistently match their true residency preferences. These results may stem from a misunderstanding of the Match algorithm. Medical schools should consider augmenting explicit education related to the NRMP Match algorithm to ensure optimal outcomes for students.

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Establishing an Elective Rotation Director and Its Effect on Elective Opportunities and Satisfaction

Elective rotations are valuable, allowing trainees to personalize their educational experience, focuson areas of weakness, and offer personal and professional development. Emergency medicine(EM) residency program elective rotations may be limited due to the absence of awareness ofopportunities and administrative support. We sought to increase the breadth of elective rotationopportunities, improve residents’ satisfaction with their elective rotations, and enhance theopportunities for clinical training. To increase the breadth of our elective rotation opportunities, weestablished an elective rotation director—a dedicated faculty member to aid in elective planningand provide administrative support. This faculty member met with all residents during their secondyear, coordinated new electives with the graduate medical education office, and assisted withadministrative tasks. Ten new rotations (two local, five domestic away, three international away)were established during the position’s first two years, increasing available rotations from nine to 19.A survey was sent to graduates of the program two years before and two years after the positionwas established to inquire about their elective experience. Of 64 graduates, 49 (76.6%) participatedin the survey. Graduates exposed to the dedicated faculty member reported increased exposure tonovel learning environments (p<0.001), improved wellness (p<0.001), and were more likely than predirectorgraduates to choose the same elective rotation (p=0.006). Programs with multiple electiverotations may benefit more from this position, but additional resources may be needed given theassociated increase in administrative time.

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Original Research - Print

A Roadmap for the Student Pursuing a Career in Pediatric Emergency Medicine

Introduction: Three pathways are available to students considering a pediatric emergency medicine(PEM) career: pediatric residency followed by PEM fellowship (Peds-PEM); emergency medicineresidency followed by PEM fellowship (EM-PEM); and combined EM and pediatrics residency(EM&Peds). Questions regarding differences between the training pathways are common amongmedical students. We present a comparative analysis of training pathways highlighting majorcurricular differences to aid in students’ understanding of these training options.

Methods: All currently credentialed training programs for each pathway with curricula publishedon their websites were included. We analyzed dedicated educational units (EU) core to all threepathways: emergency department (ED), pediatric-only ED, critical care, and research. Minimumrequirements for primary residencies were assumed for fellowship trainees.

Results: Of the 75 Peds-PEM, 34 EM-PEM, and 4 EM&Peds programs screened, 85% of Peds-PEM and EM-PEM and all EM&Peds program curricula were available for analysis. AveragePeds-PEM EUs were 20.4 EM, 20.1 pediatric-only EM, 5.8 critical care, and 9.0 research. AverageEM-PEM EUs were 33.2 EM, 18.3 pediatric-only EM, 6.5 critical care, and 3.3 research. AverageEM&Peds EUs were 26.1 EM, 8.0 pediatric-only EM, 10.0 critical care, and 0.3 research.

Conclusion: All three pathways exceed pediatric-focused training required for EM or pediatricresidency. Peds-PEM has the most research EUs, EM-PEM the most EM EUs, and EM&Pedsthe most critical care EUs. All prepare graduates for a pediatric emergency medicine career. Understanding the difference in emphasis between pathways can inform students to select the bestpathway for their own careers.


Does the Medium Matter? Evaluating the Depth of Reflective Writing by Medical Students on Social Media Compared to the Traditional Private Essay Using the REFLECT Rubric

Introduction: Social media is a novel medium to host reflective writing (RW) essays, yet its impact on depth of students’ reflection is unknown. Shifting reflection on to social platforms offers opportunities for students to engage with their community, yet may leave them feeling vulnerable and less willing to reflect deeply. Using sociomateriality as a conceptual framework, we aimed to compare the depth of reflection in RW samples submitted by medical students in a traditional private essay format to those posted on a secure social media platform.

Methods: Fourth-year medical students submitted a RW essay as part of their emergency medicine clerkship, either in a private essay format (academic year [AY] 2015) or onto a closed, password-protected social media website (AY 2016). Five raters used the Reflection Evaluation for Learners’ Enhanced Competencies Tool (REFLECT) to score 122 de-identified RW samples (55 private, 67 social media). Average scores on two platforms were compared. Students were also surveyed regarding their comfort with the social media experience.

Results: There were no differences in average composite REFLECT scores between the private essay (14.1, 95% confidence interval [CI], 12.0-16.2) and social media (13.7 95% CI, 11.4-16.0) submission formats (t [1,120] = 0.94, p = 0.35). Of the 73% of students who responded to the survey, 72% reported feeling comfortable sharing their personal reflections with peers, and 84% felt comfortable commenting on peers’ writing.

Conclusion: Students generally felt comfortable using social media for shared reflection. The depth of reflection in RW essays was similar between the private and social media submission formats.

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What’s All the Chatter? A Mixed-Methods Analysis of Emergency Physicians’ Tweets

Introduction: Twitter is growing in popularity and influence among emergency physicians (EP), with over 2200 self-identified EP users. As Twitter’s popularity has increased among EPs so too has its influence. While there has been debate about the value of Twitter as an effective educational delivery tool, little attention has been paid to the nature of the conversation occurring on Twitter. We aim to describe how influential EPs use Twitter by characterizing the language, purpose, frequencies, content, and degree of engagement of their tweets.

Methods: We performed a mixed-methods analysis following a combined content analysis approach. We conducted qualitative and quantitative analyses of a sample of tweets from the 61 most influential EPs on Twitter. We present descriptive tweet characteristics and noteworthy themes.

Results: We analyzed 1375 unique tweets from 57 unique users, representing 93% of the influential Twitter EPs. A majority of tweets (1104/1375, 80%) elicited some response in the form of retweets, likes, or replies, demonstrating community engagement. The qualitative analysis identified 15 distinct categories of tweets.

Conclusion: Influential EPs on Twitter were engaged in largely medical conversations in which most messages generated some form of interaction. They shared resources and opinions while also building social rapport in a community of practice. This data can help EPs make informed decisions about social media engagement.


Educational Advances - Print

Synchronous Online Journal Club Connects Subspecialty Trainees Across Geographic Barriers

Introduction: Journal club holds a well-respected place in medical education by promoting critical review of the literature and fostering scholarly discussions. Journal clubs are often not available to trainees with niche interests due to the geographic limitations of subspecialty programs such assimulation, medical education, disaster medicine, ultrasound, global health, and women’s health.

Methods: A recurring online journal club was held on a quarterly basis to connect simulation fellows. An online conferencing program with screen-sharing capabilities served as the platform for this scholarly exchange. Articles were presented by fellows supported by more seasoned mentors. We surveyed participants to evaluate the program and provide feedback to the presenter.

Results: The first eight sessions drew participants from across the United States and Canada. The program was highly rated by participants who commented specifically on its value. Presenters were also highly rated, suggesting that fellows, with online support and mentoring, were effective in providing a quality program.

Conclusion: Online synchronous journal clubs can fill an educational niche for subspecialists andtheir trainees, as demonstrated with this curriculum piloted with simulation fellows. Challenges of scheduling across time zones, distribution of materials, and recruitment of participants can be overcome by a dedicated team of facilitators aided by readily accessible technology.

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Women’s Night in Emergency Medicine Mentorship Program: A SWOT Analysis

Introduction: Women in emergency medicine (EM) at all career stages report gender-specific obstacles to satisfaction and advancement. Programs that facilitate longitudinal mentoring, professional development, and networking may ameliorate these barriers.

Methods: We designed and implemented a program for female residents, faculty, and alumnae from our EM training program to enhance social support, leadership training and professional mentorship opportunities. An anonymous, online survey was sent to participants at the end of the academic year, using a SWOT (strengths, weaknesses, opportunities, and threats) format. The survey collected free-text responses designed to evaluate the program.

Results: Of 43 invited participants, 32 responded (74.4%). Eight themes emerged from the free-text responses and were grouped by SWOT domain. We identified four themes relating to the “strength” domain: 1) creating a dedicated space; 2) networking community; 3) building solidarity; and 4) providing forward guidance. Responses to the “weaknesses” and “threats” questions were combined due to overlapping codes and resulted in three themes: 5) barriers to participation; 6) the threat of poorly structured events lapsing into negativity; and 7) concerns about external optics. A final theme: 8) expansion of program scope was noted in the “opportunity” domain.

Conclusion: This program evaluation of the Women’s Night curriculum demonstrates it was a positive addition to the formal curriculum, providing longitudinal professional development opportunities. Sharing the strengths of the program, along with identified weaknesses, threats, and opportunities for advancement allows other departments to learn from this experience and implement similar models that use existing intellectual and social capital.

Exploring Action Items to Address Resident Mistreatment through an Educational Workshop

Mistreatment of trainees is common in the clinical learning environment. Resident mistreatment is less frequently tracked than medical student mistreatment, but data suggest mistreatment remains prevalent at the resident level. To address resident mistreatment, the authors developedan Educational Advance to engage emergency medicine residents and faculty in understanding and improving their learning environment. The authors designed a small-group session with the following goals: 1) Develop a shared understanding of mistreatment and its magnitude; 2) Recognize the prevalence of resident mistreatment data and identify the most common types ofmistreatment; 3) Relate study findings to personal or institutional experiences; and 4) Generate strategies for combating mistreatment and strengthening the clinical learning environment attheir home institutions. Design was a combination of presentation, small group discussion, and facilitated discussion. Results were presented to participants from a previously administered surveyof resident mistreatment. Public humiliation and sexist remarks were the most commonly reported forms. Faculty were the most frequent perpetrators, followed by residents and nurses. A majority of respondents who experienced mistreatment did not report the incident. Session participants were then asked to brainstorm strategies to combat mistreatment. Participants rated the session as effective in raising awareness about resident mistreatment and helping departments develop methods to improve the learning environment. Action items proposed by the group included coaching residents about how to respond to mistreatment, displaying signage in support of a positive learning environment, zero tolerance for mistreatment, clear instructions for reporting, and intentionality training to improve behavior.

An Innovative Feedback Tool Leading to Improved Faculty Feedback and Positive Reception by Residents

Introduction: In 2012 the Accreditation Council for Graduate Medical Education implemented trainee milestones as tools for clinical competency committees to use for evaluation, feedback, remediation, and promotion purposes. Prior to this innovation, there has not been an adequate method to capture, organize, and graphically illustrate the evaluations by attendings in a simple, fast and organized fashion.

Methods: We created a novel, web-based, mobile-friendly evaluation tool to help fill this identified gap. The survey-based program creates a milestone-based evaluation, takes only a few minutes to complete, and easily collates the results in a graphic format creating an individualized “dashboard.” The dashboard is then used by both trainees and their evaluators as a feedback platform.

Results: With the implementation of the dashboard, educational leadership has noted an increase in the number of submitted evaluations of residents and the amount of face-to-face feedback given by attendings to residents. A post-implementation survey of the residents revealed that they found the dashboard-provided feedback more helpful than prior modes of feedback, although the number of evaluations was still too few.

Conclusion: The use of our feedback dashboard is useful to multiple targeted end-users, including general faculty evaluators, program leadership, and the residents themselves for gathering formative feedback that is specific and timely. This tool is adaptable and likely generalizable to other residency programs and specialties.

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Critical Electrocardiogram Curriculum: Setting the Standard for Flipped-Classroom EKG Instruction

Introduction: Electrocardiogram (EKG) interpretation is integral to emergency medicine (EM).1 In 2003 Ginde et al. found 48% of emergency medicine (EM) residency directors supported creating a national EKG curriculum.2 No formal national curriculum exists, and it is unknown whether residents gain sufficient skill from clinical exposure alone.

Methods: The authors sought to assess the value of this EKG curriculum, which provides exposure to critical EKG patterns, a framework for EKG interpretation when the diagnosis is not obvious, and implementation guidelines and open access to any interested residency. The Foundations of Emergency Medicine (FoEM) EKG I course launched in January 2016, followed by EKG II in July 2017; they are benchmarked to post-graduate year 1 (PGY) and PGY2 level learners, respectively. Selected topics included 15 published critical EKG diagnoses and 33 selected by the authors.5 Cases included presenting symptoms, EKGs, and Free Open Access Medical Education (FOAM) links. Full EKG interpretations and question answers were provided.

Results: Enrollment during 2017-2018 included 37 EM residencies with 663 learners in EKG I and 22 EM residencies with 438 learners in EKG II. Program leaders and learners were surveyed annually. Leaders indicated that content was appropriate for intended PGY levels. Leaders and learners indicated the curriculum improved the ability of learners to interpret EKGs while working in the emergency department (ED).

Conclusion: There is an unmet need for standardization and improvement of EM resident EKG training. Leaders and learners exposed to FoEM EKG courses report improved ability of learners to interpret EKGs in the ED. [West J Emerg Med. 2020;21(1)52-57.]


Impact of a Dedicated Teaching Attending Experience on a Required Emergency Medicine Clerkship

Introduction: One published strategy for improving educational experiences for medical students in the emergency department (ED) while maintaining patient care has been the implementation of dedicated teaching attending shifts. To leverage the advantages of the ED as an exceptional clinical educational environment and to address the challenges posed by the rapid pace and high volume of the ED, our institution developed a clerkship curriculum that incorporates a dedicated clinical educator role – the teaching attending – to deliver quality bedside teaching experiences for students in a required third-year clerkship. The purpose of this educational innovation was to determine whether a dedicated teaching attending experience on a third-year required emergency medicine (EM) clerkship would improve student-reported clinical teaching evaluations and student-reported satisfaction with the overall quality of the EM clerkship.

Methods: Using a five-point Likert-type scale (1 - poor to 5 - excellent), student-reported evaluation ratings and the numbers of graduating students matching into EM were trended for 10 years retrospectively from the inception of the clerkship for the graduating class of 2009 through and including the graduating class of 2019. We used multinomial logistic regression to evaluate whether the presence of a teaching attending during the EM clerkship improved student-reported evaluation ratings for the EM clerkship. We used sample proportion tests to assess the differences between top-box (4 or 5 rating) proportions between years when the teaching attending experience was present and when it was not. Results: For clinical teaching quality, when the teaching attending is present the estimated odds of receiving a rating of 5 is 77.2 times greater (p <0.001) than when the teaching attending is not present and a rating of 4 is 27.5 times greater (p =0.0017). For overall clerkship quality, when the teaching attending is present, the estimated odds of receiving a rating of 5 is 13 times greater (p <0.001) and a rating of 4 is 5.2 times greater (p=0.0086) than when the teaching attending is not present.

Conclusion: The use of a dedicated teaching attending shift is a successful educational innovation for improving student self-reported evaluation items in a third-year required EM clerkship.

#DidacticsRevolution: Applying Kotter’s 8-Step Change Management Model to Residency Didactics

Introduction: Leading change effectively is critical to advancing medical education. Residency didactics often require change in order to meet stakeholder’s needs. Kotter’s change management model (KCMM) is an 8-step method for implementing change that can be applied to educational initiatives. This innovation improved an emergency medicine residency didactics curriculum through application of KCMM.

Methods: An initiative to improve residency didactics curriculum was titled the “Didactics Revolution” and implemented according to KCMM: establish a sense of urgency, form a powerful guiding coalition, create a vision, communicate the vision, empower others to act on the vision, plan for and create short-term wins, consolidate improvements and produce still more change, and institutionalize new approaches. Data from the Annual Program Review was utilized to assess the impact of the KCMM strategy.

Results: The percentage of residents who agreed or strongly agreed that lectures provide a valuable learning experience increased from 39.1% in the year prior to 88.0% in the year during the implementation (p < .001), and remained relatively high at 73.5% in the year following. The percentage of residents who agreed or strongly agreed that they felt well-prepared for the written boards increased from 60.9% in the year prior to 92.0% in the year during the implementation (p = .01) and remained high at 73.5% in the year following.

Conclusion: Residency didactics can be improved through the use of KCMM, a change management model originally developed in the corporate context.

Brief Educational Advances

Back in My Day: A Journal Club Using Landmark Articles for Emergency Medicine-Bound Medical Students

This journal club style curriculum was developed to advance 4th year medical students in Emergency Medicine (EM) Milestone 19. The curriculum was introduced as part of a longitudinal boot camp course for EM- bound students. Students met monthly with faculty members to critically evaluate landmark articles within the field of EM. The curriculum culminated with student group presentations of two contemporary research articles with opposing conclusions. Discussed articles covered the following topics: stroke care, head trauma, cervical spine trauma, pulmonary embolism, cardiology treatments, syncope, post- cardiac arrest care, pediatrics, sepsis, and fluid resuscitation. The curriculum was evaluated using the institution’s standard student educational session evaluation form. Students rated the quality of the sessions highly, and based on thematic review of comments, the journal club was a beneficial addition to the boot camp curriculum.

Brief Research Report

Maggots, Mucous and Monkey Meat: Does Disgust Sensitivity Affect Case Mix Seen During Residency?

Introduction: Emergency physicians encounter scenarios daily that many would consider “disgusting,” including exposure to blood, pus, and stool. Physicians in procedural specialties such as surgery and emergency medicine (EM) have lower disgust sensitivity overall, but the role this plays in clinical practice is unclear. The objective of this study was to determine whether emergency physicians with higher disgust sensitivity see fewer “disgusting” cases during training.

Methods: All EM residents at a midsize urban EM program were eligible to complete the Disgust Scale Revised (DS-R). We preidentified cases as “disgust elicitors” based on diagnoses likely to induce disgust due to physician exposure to bodily fluids, anogenital anatomy, or gross deformity. The “disgust elicitor” case percent was determined by “disgust elicitor” cases seen as the primary resident divided by the number of cases seen thus far in residency. We calculated Pearson’s r, t-tests and descriptive statistics on resident and population DS-R scores and “disgust elicitor” casesper month.

Results: Mean DS-R for EM residents (n = 40) was 1.20 (standard deviation [SD] 1.24), significantly less than the population mean of 1.67 (SD 0.61, p<0.05). There was no correlation (r = -0.04) between “disgust elicitor” case (n = 2191) percent and DS-R scores. There was no significant difference between DS-R scores for junior residents (31.1, 95% confidence interval [CI], 26.8-35.4) and for senior residents (29.0, 95% CI, 23.4-34.6).

Conclusion: Higher disgust sensitivity does not appear to be correlated with a lower percentage of “disgust elicitor” cases seen during EM residency.

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Increasing Education Research Productivity: A Network Analysis

Introduction: Forming effective networks is important for personal productivity and career development. Although critical for success, these networks are not well understood. The objective of this study was to usze a social network analysis tool to demonstrate the growth of institutional publication networks for education researchers and show how a single institution has expanded its publication network over time.

Methods: Publications from a single institution’s medical education research group (MERG) were pulled since its inception in 2010 to 2019 using Web of Science to collect publication information. Using VOSViewer software, we formed and plotted a network sociogram comparing the first five years to the most recent 4.25 years to compare the institutions of authors from peer reviewed manuscripts published by this group.

Results: We found 104 peer-reviewed research articles, editorials, abstracts, and reviews for the MERG authors between 2010 and 2019 involving 134 unique institutions. During 2010-2014, there were 26 publications involving 56 institutions. From 2015- 2019, there were 78 publications involving 116 unique institutions.

Conclusion: This brief report correlates successful research productivity in medical education with the presence of increased inter-institutional collaborations as demonstrated by network sociograms.  Programs to intentionally expand collaborative networks may prove to be an important element of facilitating successful careers in medical education scholarship.

Educational Advances

An Inexpensive Conceptual Training Model for Transvenous Pacemaker Placement

Introduction: Emergent transvenous (TV) pacemaker placement can be life-saving, but it has associated complications. Emergency medicine (EM) educators must be able to teach this infrequent procedure to trainees.

Methods: We constructed a conceptually-focused, inexpensive training model made from polyvinyl chloride pipes and connectors, vinyl tubing, and a submersible pump. Cost of the model was $51. We tested the model with a group of 15 EM residents. We then asked participants to complete a survey reporting confidence with the procedure before and after the session. Confidence was compared using a Wilcoxon matched-pairs test.

Results: Confidence improved after the session, with a median confidence before the session of 2 (minimally confident; interquartile range [IQR] 1-3) and a median confidence after the session of 4 (very confident; IQR 3-4, p=0.001). All residents agreed that the model helped them to understand the process of placing a TV pacemaker.

Conclusion: Our TV pacemaker placement model was inexpensive and allowed for practice of a complex emergency procedure with direct visualization. It improved trainee confidence.

Difficult Delivery and Neonatal Resuscitation: A Novel Simulation for Emergency Medicine Residents

Introduction: Newborn delivery and resuscitation are rare, but essential, emergency medicine (EM) skills. We evaluated the effect of simulation on EM residents’ knowledge, confidence, and clinical skills in managing shoulder dystocia and neonatal resuscitation.

Methods: We developed a novel simulation that integrates a shoulder dystocia with neonatal resuscitation and studied a convenience sample of EM residents. Each 15-minute simulation was run with one learner, a simulated nurse, and a standardized patient in situ in the emergency department. The learner was required to reduce a shoulder dystocia and then perform neonatal resuscitation. We debriefed with plus/delta format, standardized teaching points, and individualized feedback. We assessed knowledge with a nine-question multiple choice test, confidence with five-point Likert scales, and clinical performance using a checklist of critical actions. Residents repeated all measures one year after the simulation.

Results: A total of 23 residents completed all measures. At one-year post-intervention, residents scored 15% higher on the knowledge test. All residents increased confidence in managing shoulder dystocia on a five-point Likert scale (1.4 vs 2.8) and 80% increased confidence in performing neonatal resuscitation (1.8 vs 3.0). Mean scores on the checklist of critical actions improved by 19% for shoulder dystocia and by 27% for neonatal resuscitation.

Conclusion: Implementing simulation may improve EM residents’ knowledge, confidence, and clinical skills in managing shoulder dystocia and neonatal resuscitation.

Early Impact of the Western Journal of Emergency Medicine CDEM/CORD Special Issue in Educational Research & Practice

Introduction: In 2015, with a stated goal of disseminating best teaching practices and developing a community of educational scholars, the Council of Emergency Medicine Directors (CORD) and th eClerkship Directors of Emergency Medicine (CDEM) created an annual Special Issue in Educational Research and Practice (Special Issue) in cooperation with the Western Journal of Emergency Medicine. The intention of this study was to analyze the impact of this effort to date.

Methods: Bibliometric data was gathered on all four special issues, 2015-2019, from the Web of Scienceand then verified with the eScholarship website. Authorship, academic affiliation, date published, articletype, and format were tabulated for descriptive analysis. Using metrics from Google Scholar, alternative scholarly impact metrics (altmetrics), and the eScholarship website, the authors identified top articles and grouped them into themes.

Results: Of the 136 articles included in the first four years of the Special Issue, 126 represented peer reviewed publications with an overall acceptance rate of 25.0% (126/505). Authors from this cohort represented 103 of the 182 (56.6%) Accreditation Council for Graduate Medical Education (ACGME) programs in existence at the time of the inaugural issue. Multi-institutional studies represented 34.9% (44/126) of the peer-reviewed publications. Traditional and alternative publication metrics are reported to assess the impact of articles from the Special Issues.

Conclusion: The Special Issue is a proven outlet to share best practices, innovations, and research related to education. Additionally, the infrastructure of this process promotes the development of individual faculty and a community of teaching scholars.

A Structured Curriculum for Interprofessional Training of Emergency Medicine Interns

Interprofessional education (IPE) has been shown to improve health outcomes and patient satisfaction. IPE is now represented in the Accreditation Council for Graduate Medical Education’s emergency medicine (EM) milestones given the team-based nature of EM. The Highland Allied Health Rotation Program (H-AHRP) was developed by residents to enhance and standardize IPE for EM residents in a single hospital setting. H-AHRP was incorporated into the orientation month for interns starting in the summer of 2016. EM interns were paired with emergency department preceptors in registered nursing (RN), respiratory therapy (RT), pharmacy (PH), laboratory (LAB), and social work (SW) in either a four-hour shadowing experience (RN, RT, PH) or lecture-based overview (LAB, SW). We conducted a survey before and after the program. Overall, the EM interns reported an improved understanding of the scope of practice and day-to-day logistics after working with the preceptors. They found the program helpful to their future as physicians and would recommend it to other residencies. The H-AHRP program allows for the early incorporation of IPE into EM training, enhances interns’ understanding of both the scope and logistics of their colleagues, and is a well-received effort at improving team-based care.

Original Research

Usability of Learning Moment: Features of an E-learning Tool That Maximize Adoption by Students

Introduction: E-learning is widely used in medical education. To maximize the potential of E-learning tools, every effort should be made to encourage adoption by optimizing usability. We created Learning Moment (LM), a web-based application that integrates principles of asynchronous learning and learning portfolios into a platform on which students can document and share learning experiences that occur during clinical work. We sought to evaluate the usability of LM and identify features that optimize adoption by users.

Methods: We implemented LM in August 2016 at a busy, urban, tertiary care emergency department that hosts an emergency medicine residency, robust third and fourth year medical student clerkships as well as a physician assistant student rotation. We conducted a single-center, mix-methods study using the System Usability Scale (SUS) questionnaire and qualitative interviews. We sent e-mail invitations with subsequent reminders to all students who rotated in our emergency medicine clerkship from August 2016 to April 2017 to complete the SUS questionnaire anonymously and to participate in qualitative interviews. We employed purposive sampling to recruit students who used LM during their rotation to participate in our qualitative interviews. We conducted semi-structured interviews with 13 participants (10 individual interviews and one 3-person group interview) between January and March 2017 using an ethnographic approach and utilized a general inductive method to analyze and code for potential themes.

Results: Thirty of the seventy students invited to participate completed the SUS questionnaire (Response rate of 42.8%). The mean SUS score is 80.9 (SD 18.2, 80% CI 76.5 – 85.3). The internal consistency of the responses achieved the Cronbach’s Alpha of 0.95. The participants stressed the importance of the following in the adoption of LM: maximal simplicity and usability, compatibility with learning preferences, and department-wide acceptance and integration.

Conclusion: The overall perceived usability of LM was high. Our qualitative data revealed important implications for future designers to maximize adoption: include target users in every step of the design and development process to maximize simplicity and usability; build features that cater to a diversity of learning preferences; involve the entire department and find ways to incorporate the tool into the educational infrastructure and daily workflow.

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Which Emergency Medicine Milestone Sub-competencies are Identified Through Narrative Assessments?

Introduction: Evaluators use assessment data to make judgments on resident performance within the Accreditation Council for Graduate Medical Education (ACGME) milestones framework. While workplace-based narrative assessments (WBNA) offer advantages to rating scales, validity evidence for their use in assessing the milestone sub-competencies is lacking. This study aimed to determine the frequency of sub-competencies assessed through WBNAs in an emergency medicine (EM) residency program.

Methods: We performed a retrospective analysis of WBNAs of postgraduate year (PGY) 2-4 residents. A shared mental model was established by reading and discussing the milestones framework, and we created a guide for coding WBNAs to the milestone sub-competencies in an iterative process. Once inter-rater reliability was satisfactory, raters coded each WBNA to the 23 EM milestone sub-competencies.

Results: We analyzed 2517 WBNAs. An average of 2.04 sub-competencies were assessed per WBNA. The sub-competencies most frequently identified were multitasking, medical knowledge, practice-based performance improvement, patient-centered communication, and team management. The sub-competencies least frequently identified were pharmacotherapy, airway management, anesthesia and acute pain management, goal-directed focused ultrasound, wound management, and vascular access. Overall, the frequency with which WBNAs assessed individual sub-competencies was low, with 14 of the 23 sub-competencies being assessed in less than 5% of WBNAs.

Conclusion: WBNAs identify few milestone sub-competencies. Faculty assessed similar sub-competencies related to interpersonal and communication skills, practice-based learning and improvement, and medical knowledge, while neglecting sub-competencies related to patient care and procedural skills. These findings can help shape faculty development programs designed to improve assessments of specific workplace behaviors and provide more robust data for the summative assessment of residents.

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The Impact of Anonymity in Emergency Medicine Morbidity and Mortality Conferences: Findings from a National Survey of Resident Physicians

Introduction: Although the Accreditation Council for Graduate Medical Education mandates structured case review and discussion as a part of residency training, there remains little guidance on how best to structure these conferences to cultivate a culture of safety, promote learning, and ensure that system-based improvements can be made. We hypothesized that anonymous case discussion was associated with a more effective, and less punitive, morbidity and mortality (M&M) conference. Secondarily, we were interested in determining whether this core structural element was correlated with the culture of safety at an institution.

Methods: We conducted a national survey at 33 emergency medicine residency programs evaluating residents’ perceptions of M&M and the culture of safety at their institutions. Data was analyzed using descriptive statistics and bivariate analyses. We summarized Likert scores using mean and 95% confidence intervals. We also performed content analysis of the free-text comments and report on the themes identified.

Results: There were 1248 residents at the 33 programs surveyed. Of the 1002 who replied (80.3% response rate), 231 respondents reported anonymous case presentations and 744 reported non-anonymous case presentations. Residents at programs with anonymous case presentations were more likely to report that M&M was non-punitive. There were no other significant differences between anonymous and non-anonymous case presentations on any of the culture of safety domains measured. When these comments were systematically analyzed and coded, we found that the comments related to anonymity were both positive and negative. Among the themes identified were anonymity’s impact on punitive response to error, the ability to learn from cases, and professional responsibility.

Conclusion: Anonymous M&Ms are associated with a perception of a less-punitive M&M and with better ratings in several conference-specific outcomes; however, there appears to be no association between the other Agency for Healthcare Research and Quality culture of safety scores and anonymity in M&M.

Efficacy of and Satisfaction with an In-house Developed Natural Rubber Cardiopulmonary Resuscitation Manikin

Introduction: A barrier to cardiopulmonary resuscitation (CPR) training in low-income countries is limitedresources. Our goal was to build a CPR training model of simple design that would provide a goodfeedback system.

Methods: We developed a low-cost, Basic Life Support training manikin made entirely of natural rubber.Our in-house manikin provides feedback when performing correct chest compression and rescuebreathing. The properties of the manikin were tested using simulated chest compression in a laboratoryand compared with a commercial manikin. Forty healthy nurse volunteers with CPR experienceperformed CPR in both types of manikins and responded to questionnaires.

Results: A tensile test in a laboratory demonstrated that both types of manikins had acceptable rangesof properties for real-situation CPR in cardiac arrest patients. There were no differences in aestheticproperties, and the manikins felt to the volunteers like a real patient when they were performing chestcompression. The feedback response was clear when chest compressions and rescue breathing wereperformed correctly, and the overall satisfaction with the manikin was good. In addition, the mean scoresin terms of the manikin feeling like a real patient when performing rescue breathing and the positivefeedback from the rubber manikin were statistically higher than those for the commercial manikin(p=0.001 vs. p=0.023).

Conclusion: The in-house developed CPR manikin employing real-time feedback by simple mechanicsis effective compared with a commercial manikin. The advantage of our manikin is that it is easy to buildand costs substantially less than a commercial manikin. The use of an in-house developed manikin couldmake effective CPR training more available in limited-resource areas.

Effectiveness of a Pediatric Emergency Medicine Curriculum in a Public Tanzanian Referral Hospital

Introduction: The World Health Organization recently recognized the importance of emergency and trauma care in reducing morbidity and mortality. Training programs are essential to improving emergency care in low-resource settings; however, a paucity of comprehensive curricula focusing specifically on pediatric emergency medicine (PEM) currently exists. The African Federation for Emergency Medicine (AFEM) developed a PEM curriculum that was pilot-tested in a non-randomized, controlled study to evaluate its effectiveness in nurses working in a public Tanzanian referral hospital.

Methods: Fifteen nurses were recruited to participate in a two-and-a-half-day curriculum of lectures, skill sessions, and simulation scenarios covering nine topics; they were matched with controls. Both groups completed pre- and post-training assessments of their knowledge (multiple-choice test), self-efficacy (Likert surveys), and behavior. Changes in behavior were assessed using a binary checklist of critical actions during observations of live pediatric resuscitations.

Results: Participant-rated pre-training self-efficacy and knowledge test scores were similar in both control and intervention groups. However, post-training, self-efficacy ratings in the intervention group increased by a median of 11.5 points (interquartile range [IQR]: 6-16) while unchanged in the control group. Knowledge test scores also increased by a median of three points (IQR: 0-4) in the nurses who received the training while the control group’s results did not differ in the two periods. A total of 1192 pediatric resuscitation cases were observed post-training, with the intervention group demonstrating higher rates of performance of three of 27 critical actions.

Conclusion: This pilot study of the AFEM PEM curriculum for nurses has shown it to be an effective tool in knowledge acquisition and improved self-efficacy of pediatric emergencies. Further evaluation will be needed to assess whether it is currently effective in changing nurse behavior and patient outcomes or whether curricular modifications are needed.

  • 4 supplemental files

Post-interview Thank-you Communications Influence Both Applicant and Residency Program Rank Lists in Emergency Medicine

Introduction: The National Residency Matching Program (NRMP) allows post-interview contactbetween residency applicants and residency programs. Thank-you communications representone of the most common forms, but data on their value to applicants and program directors (PD)are limited. The objective of this study was to assess the effect of thank-you communications onapplicant- and residency-program rank lists.

Methods: Two anonymous, voluntary surveys were sent after the 2018 NRMP Match, one toapplicants who were offered an interview at a single academic site in the 2017-2018 Match cycle,and one to EM PDs nationwide. The surveys were designed in conjunction with a nationallyrecognizedsurvey center and piloted and revised based on feedback from residents and faculty.

Results: Of 196 residency applicants, 97 (49.5%) responded to the survey. Of these, 73/95 (76.8%)reported sending thank-you communications. Twenty-two of 73 (30%) stated that they sent thank-youcommunications to improve their spot on a program’s rank list; and 16 of 73 (21.9%) reported that theychanged their rank list based upon the responses they received to their thank-you communications. Of 163 PDs, 99 (60.7%) responded to the survey. Of those PDs surveyed, 22.6% reported that anapplicant could be moved up their program’s rank list and 10.8% reported that an applicant could movedown a program’s rank list based on their thank-you communications (or lack thereof).

Conclusion: The majority of applicants to EM are sending thank-you communications. Asignificant minority of applicants and PDs changed their rank list due to post-interview thank-youcommunications.

  • 2 supplemental PDFs

When the Learner Is the Expert: A Simulation-Based Curriculum for Emergency Medicine Faculty

Emergency physicians supervise residents performing rare clinical procedures, but they infrequently perform those procedures independently. Simulation offers a forum to practice procedural skills, but simulation labs often target resident learners, and barriers exist to faculty as learners in simulation-based training. Simulation-based curricula focused on improving emergency medicine (EM) faculty’s rare procedure skills were not discovered on review of published literature. Our objective was to create a sustainable, simulation-based faculty education curriculum for rare procedural skills in EM. Between 2012 and 2019, most EM teaching faculty at a single, urban, Level 1 trauma center completed an annual two-hour simulation-based rare procedure lab with small-group learning and guided hands-on instruction, covering 30 different procedural education sessions for faculty learners. A questionnaire administered before and after each session assessed EM faculty physicians’ self-perceived ability to perform these rare procedures. Participants’ self-reported confidence in their performance improved for all procedures, regardless of prior procedural experience. Faculty participation was initially mandatory, but is now voluntary. Diverse strategies were used to address barriers in this learner group including eliciting learner feedback, offering continuing medical education credits, gradual roll-out of checklist assessments, and welcoming expertise of faculty leaders from EM and other specialties and professions. Participants perceived training to be most helpful for the most rarely-encountered clinical procedures. Similar curricula could be implemented with minimal risk at other institutions.

  • 2 supplemental files

Teaching Endotracheal Intubation Using a Cadaver Versus a Manikin-based Model: a Randomized Controlled Trial

Introduction: The optimal method to train novice learners to perform endotracheal intubation (ETI)is unknown. The study objective was to compare two models: unembalmed cadaver vs simulationmanikin.

Methods: Fourth-year medical students, stratified by baseline ETI experience, were randomized 1:1to train on a cadaver or simulation manikin. Students were tested and video recorded on a separatecadaver; two reviewers, blinded to the intervention, assessed the videos. Primary outcome wastime to successful ETI, analyzed with a Cox proportional hazards model. Authors also comparedpercentage of glottic opening (POGO), number of ETI attempts, learner confidence, and satisfaction.

Results: Of 97 students randomized, 78 were included in the final analysis. Median time to ETI didnot differ significantly (hazard ratio [HR] 1.1; 95% CI [confidence interval], 0.7-1.8): cadaver group =34.5 seconds (interquartile ratio [IQR]: 23.3-55.8) vs manikin group = 35.5 seconds (IQR: 23.8-80.5),with no difference in first-pass success (odds ratio [OR] = 1; 95% CI, 0.1-7.5) or median POGO: 80%cadaver vs 90% manikin (95% CI, -14-34%). Satisfaction was higher for cadavers (median difference= 0.5; p = 0.002; 95% CI, 0-1) as was change in student confidence (median difference = 0.5; p= 0.03; 95% CI, 0-1). Students rating their confidence a 5 (“extremely confident”) demonstrateddecreased time to ETI (HR = 4.2; 95% CI, 1.0-17.2).

Conclusion: Manikin and cadaver training models for ETI produced similar time to ETI, POGO,and first-pass success. Cadaver training was associated with increased student satisfaction andconfidence; subjects with the highest confidence level demonstrated decreased time to ETI.

Standardized Video Interview Scores Correlate Poorly with Faculty and Patient Ratings

The Standardized Video Interview (SVI) was developed by the Association of American Medical Colleges to assess professionalism, communication, and interpersonal skills of residency applicants. How SVI scores compare with other measures of these competencies is unknown. The goal of this study was to determine whether there is a correlation between the SVI score and both faculty and patient ratings of these competencies in emergency medicine (EM) applicants. This was a retrospective analysis of a prospectively collected dataset of medical students. Students enrolled in the fourth-year EM clerkship at our institution and who applied to the EM residency Match were included. We collected faculty ratings of the students’ professionalism and patient care/ communication abilities as well as patient ratings using the Communication Assessment Tool (CAT) from the clerkship evaluation forms. Following completion of the clerkship, students applying to EM were asked to voluntarily provide their SVI score to the study authors for research purposes. We compared SVI scores with the students’ faculty and patient scores using Spearman’s rank correlation. Of the 43 students from the EM clerkship who applied in EM during the 2017-2018 and 2018-2019 application cycles, 36 provided their SVI scores. All 36 had faculty evaluations and 32 had CAT scores available. We found that SVI scores did not correlate with faculty ratings of professionalism (rho = 0.09, p = 0.13), faculty assessment of patient care/communication (rho = 0.12, p = 0.04), or CAT scores (rho = 0.11, p = 0.06). Further studies are needed to validate the SVI and determine whether it is indeed a predictor of these competencies in residency.

  • 3 supplemental files

A Multimodal Curriculum With Patient Feedback to Improve Medical Student Communication: Pilot Study

Introduction: Despite the extraordinary amount of time physicians spend communicating withpatients, dedicated education strategies on this topic are lacking. The objective of this study was todevelop a multimodal curriculum including direct patient feedback and assess whether it improvescommunication skills as measured by the Communication Assessment Tool (CAT) in fourth-yearmedical students during an emergency medicine (EM) clerkship.

Methods: This was a prospective, randomized trial of fourth-year students in an EM clerkship atan academic medical center from 2016-2017. We developed a multimodal curriculum to teachcommunication skills consisting of 1) an asynchronous video on communication skills, and 2)direct patient feedback from the CAT, a 15-question tool with validity evidence in the emergencydepartment setting. The intervention group received the curriculum at the clerkship midpoint. Thecontrol group received the curriculum at the clerkship’s end. We calculated proportions and oddsratios (OR) of students achieving maximum CAT score in the first and second half of the clerkship.

Results: A total of 64 students were enrolled: 37 in the control group and 27 in the interventiongroup. The percentage of students achieving the maximum CAT score was similar between groupsduring the first half (OR 0.70, p = 0.15). Following the intervention, students in the intervention groupachieved a maximum score more often than the control group (OR 1.65, p = 0.008).

Conclusion: Students exposed to the curriculum early had higher patient ratings on communicationcompared to the control group. A multimodal curriculum involving direct patient feedback may be aneffective means of teaching communication skills.

  • 2 supplemental files

Professionalism Milestones Assessments Used by Emergency Medicine Residency Programs: A Cross-sectional Survey

Introduction: Professionalism is a vital component of quality patient care. While competency in professionalism is Accreditation Council for Graduate Medical Education (ACGME)-mandated, the methods used to evaluate professionalism are not standardized, calling into question the validity of reported measurements. We aimed to determine the type and frequency of methods used by United States (US) -based emergency medicine (EM) residencies to assess accountability (Acc) and professional values (PV), as well as how often graduating residents achieve competency in these areas.

Methods: We created a cross-sectional survey exploring assessment and perceived competency in Acc and PV, and then modified the survey for content and clarity through feedback from emergency physicians not involved in the study. The final survey was sent to the clinical competency committee (CCC) chair or program director (PD) of the 185 US-based ACGME-accredited EM residencies. We summarized results using descriptive statistics and Fisher’s exact testing.

Results: A total of 121 programs (65.4%) completed the survey. The most frequently used methods of assessment were faculty shift evaluation (89.7%), CCC opinion (86.8%), and faculty summative evaluation (76.4%). Overall, 37% and 42% of residency programs stated that nearly all (greater than 95%) of their graduating residents achieve mastery of Acc and PV non-technical skills, respectively. Only 11.2% of respondents felt their programs were very effective at determining mastery of non-technical skills.

Conclusion: EM residency programs relied heavily on faculty shift evaluations and summative opinions to determine resident competency in professionalism, with feedback from peers, administrators, and other staff less frequently incorporated. Few residency programs felt their current methods of evaluating professionalism were very effective.

  • 1 supplemental file

How Well Do Core Faculty Understand The Emergency Medicine Milestones?

Introduction: It is unclear how emergency medicine (EM) programs educate core faculty about the use of milestones in competency-based evaluations. We conducted a national survey to profile how programs educate core faculty regarding their use and to assess core faculty’s understanding of the milestones.

Methods: Our survey tool was distributed over six months in 2017 via the Council of Emergency Medicine Residency Directors (CORD) listserv. Responses, which were de-identified, were solicited from program directors (PDs), assistant/associate program directors (APDs), and core faculty. A single response from a program was considered sufficient.

Results: Our survey had a 69.7% response rate (n=140/201). 62.9% of programs reported educating core faculty about the EM Milestones via the distribution of physical or electronic media. Although 82.6% of respondents indicated that it was important for core faculty to understand how the EM Milestones are used in competency-based evaluations, respondents estimated that 48.6% of core faculty possess “fair or poor” understanding of the milestones. Furthermore, only 50.7% of respondents felt that the EM Milestones were a valuable tool.

Conclusion: These data suggest there is sub-optimal understanding of the EM Milestones among core faculty and disagreement as to whether the milestones are a valuable tool.

  • 1 supplemental file