Search

The structure of the interview day affects applicant interactions with faculty and residents, which can influence the applicant’s rank list decision. We aimed 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). This was a retrospective study reviewing interview dates of matched residents from 2009-2015. Forty-two (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). There is an association between interviewing on a didactic day with increased faculty and resident presence and matching in our program.

ObjectivesThe objectives were to critically appraise the emergency medicine (EM) medical education literature published in 2016 and review the highest-quality quantitative and qualitative studies.MethodsA search of the English language literature in 2016 querying MEDLINE, Scopus, Education Resources Information Center (ERIC), and PsychInfo identified 510 papers related to medical education in EM. Two reviewers independently screened all of the publications using previously established exclusion criteria. The 25 top-scoring quantitative studies based on methodology and all six qualitative studies were scored by all reviewers using selected scoring criteria that have been adapted from previous installments. The top-scoring articles were highlighted and trends in medical education research were described.ResultsSeventy-five manuscripts met inclusion criteria and were scored. Eleven quantitative and one qualitative papers were the highest scoring and are summarized in this article.ConclusionThis annual critical appraisal series highlights the best EM education research articles published in 2016.

Introduction: Emergency physicians (EP) experience high rates of workplace violence, the risks of which increase with the presence of weapons. Up to 25% of trauma patients brought to the emergency department (ED) have been found to carry weapons. Given these risks, we conducted an educational needs assessment to characterize EPs’ knowledge of firearms, frequency of encountering firearms in the ED, and level of confidence with safely removing firearms from patient care settings.Methods: This was a survey study of attending and resident EPs at two academic and four community hospitals in the Midwest and Northeast. A 26-item questionnaire was emailed to all EPs at the six institutions. Questions pertained to EPs’ knowledge of firearms, experience with handling firearms, and exposure to firearms while at work. We calculated response proportions and p-values. Results: Of 243 recipients who received the survey, 149 (61.3%) completed it. Thirty-three respondents (22.0%) reported encountering firearms in the workplace, 91 (60.7%) reported never handling firearms, and 25 (16.7%) reported handling firearms at least once per year. Thirty-six respondents (24.0%) reported formal firearms training, and 63 (42.3%) reported no firearms training. There were no significant regional differences regarding firearms training or exposure. Residents from the Northeast were more likely to be moderately confident that they could safely handle a firearm prior to law enforcement involvement (p=0.043), while residents from the Midwest were more likely to be not at all confident (p=0.018). Conclusion: The majority of surveyed attending and resident EPs reported little experience with handling firearms. Among resident EPs, there was a regional difference in confidence in handling firearms prior to law enforcement involvement. Given the realities of workplace violence and the frequency with which firearms are encountered in the ED, further investigation is needed to evaluate provider competence in safely handling them. EPs may benefit from training on this topic.

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.

Introduction: Chest pain is a common emergency department (ED) presentation accounting for 8-10million visits per year in the United States. Physician-level factors such as risk tolerance are predictive ofadmission rates. The recent advent of accelerated diagnostic pathways and ED observation units mayhave an impact in reducing variation in admission rates on the individual physician level.Methods: We conducted a single-institution retrospective observational study of ED patients with adiagnosis of chest pain as determined by diagnostic code from our hospital administrative database.We included ED visits from 2012 and 2013. Patients with an elevated troponin or an electrocardiogram(ECG) demonstrating an ST elevation myocardial infarction were excluded. Patients were divided into twogroups: “admission” (this included observation and inpatients) and “discharged.” We stratified physiciansby age, gender, residency location, and years since medical school. We controlled for patient- andhospital-related factors including age, gender, race, insurance status, daily ED volume, and lab values.Results: Of 4,577 patients with documented dispositions, 3,252 (70.9%) were either admitted to thehospital or into observation (in an ED observation unit or in the hospital), while 1,333 (29.1%) weredischarged. Median number of patients per physician was 132 (interquartile range 89-172). Averageadmission rate was 73.7±9.5% ranging from 54% to 96%. Of the 3,252 admissions, 2,638 (81.1%) wereto observation. There was significant variation in the admission rate at the individual physician level withadjusted odds ratio ranging from 0.42 to 5.8 as compared to the average admission. Among physicians’characteristics, years elapsed since finishing medical school demonstrated a trend towards associationwith a higher admission probability.Conclusion: There is substantial variation among physicians in the management of patients presentingwith chest pain, with physician experience playing a role.

Objectives: Despite decades of literature recognizing racial disparities (RDs) in emergency medicine (EM), published curricula dedicated to addressing them are sparse. We present details of our novel RD curriculum for EM clerkships and its educational outcomes. Methods: We created a 30‐min interactive didactic module on the topic designed for third‐ and fourth‐year medical students enrolled in our EM clerkships. Through a modified Delphi process, education faculty and content experts in RD developed a 10‐question multiple‐choice test of knowledge on RD that the students completed immediately prior to and 2 weeks following the activity. Students also completed a Likert‐style learner satisfaction survey. Median pre‐ and posttest scores were compared using a paired Wilcoxon signed‐rank test and presented using medians and 95% confidence intervals (CIs). Satisfaction survey responses were dichotomized into favorable and neutral/not favorable. Results: For the 36 students who completed the module, the median pretest score was 40% (95% CI 36%–50%) and the posttest score was 70% (95% CI 60%–70%) with a p‐value of <0.001. Thirty‐five of the 36 students improved on the posttest with a mean increase of 24.2% (95% CI 20.2–28.2). The satisfaction survey also showed a positive response, with at least 83% of participants responding favorably to all statements (overall mean favorable response 93%, 95% CI 90%–96%). Conclusions This EM‐based module on RD led to improvement in students' knowledge on the topic and positive reception by participants. This is a feasible option for educating students in EM on the topic of RD. [ABSTRACT FROM AUTHOR]

The present study examined current and lifetime psychiatric morbidity, chest pain, and health care utilization in 229 patients with noncardiac chest pain (NCCP), angina-like pain in the absence of cardiac etiology. Diagnostic interview findings based on the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) revealed a psychiatrically heterogeneous sample of whom 44% had a current Axis I psychiatric disorder. A total of 41% were diagnosed with a current anxiety disorder, and 13% were diagnosed with a mood disorder. Overall, 75% of patients had an Axis I clinical or subclinical disorder. Lifetime diagnoses of anxiety (55%) and mood disorders (44%) were also prevalent, including major depressive disorder (41%), social phobia (25%), and panic disorder (22%). Patients with an Axis I disorder reported more frequent and more painful chest pain compared with those without an Axis I disorder. Presence of an Axis I disorder was associated with increased life interference and health care utilization. Findings reveal that varied DSM-IV Axis I psychiatric disorders are prevalent among patients with NCCP, and this psychiatric morbidity is associated with a less favorable NCCP presentation. Implications for early identification of psychiatric disorders are discussed. Keywords: morbidity, chest pain, panic, anxiety disorders, cardiac

Background: Communication and interpersonal skills are one of the Accreditation Council for Graduate Medical Education's six core competencies. Validated methods for assessing these among trainees are lacking. Educators have developed various communication assessment tools from both the supervising attending and the patient perspectives. How these different assessment methods and tools compare with each other remains unknown. The goal of this study was to determine the degree of agreement between attending and patient assessment of resident communication skills. Methods: This was a retrospective study of emergency medicine (EM) residents at an academic medical center. From July 2017 to June 2018, residents were assessed on communication skills during their emergency department shifts by both their supervising attending physicians and their patients. The attendings rated residents' communication skills with patients, colleagues, and nursing/ancillary staff using a 1 to 5 Likert scale. Patients completed the modified Communication Assessment Tool (CAT), a 14‐item questionnaire based on a 1 to 5 Likert scale. Mean attending ratings and patient CAT scores were calculated for each resident. Means were divided into tertiles due to nonparametric distribution of scores. Agreement between attending and patient ratings of residents were measured using Cohen's kappa for each attending evaluation question. Scores were weighted to assign adjacent tertiles partial agreement. Results: During the study period, 1,097 attending evaluations and 952 patient evaluations were completed for 26 residents. Attending scores and CAT scores of the residents showed slight to fair agreement in the following three domains: patient communication (κ = 0.21), communication with colleagues (κ = 0.21), and communication with nursing/ancillary staff (κ = 0.26). Conclusions: Attending and patient ratings of EM residents' communication skills show slight to fair agreement. The use of different types of raters may be beneficial in fully assessing trainees' communication skills. [ABSTRACT FROM AUTHOR]

Background: We investigated whether T‐wave heterogeneity (TWH) can identify patients who are at risk for near‐term cardiac mortality. Methods: A nested case–control analysis was performed in the 888 patients admitted to the Emergency Department (ED) of our medical center in July through September 2018 who had ≥2 serial troponin measurement tests within 6 hr for acute coronary syndrome evaluation to rule‐in or rule‐out the presence of acute myocardial infarction. Patients who died from cardiac causes during 90 days after ED admission were considered cases (n = 20; 10 women) and were matched 1:4 on sex and age with patients who survived during this period (n = 80, 40 women). TWH, that is, interlead splay of T waves, was automatically assessed from precordial leads by second central moment analysis. Results: TWHV4‐6 was significantly elevated at ED admission in 12‐lead resting ECGs of female patients who died of cardiac causes during the following 90 days compared to female survivors (100 ± 14.9 vs. 40 ± 3.6 µV, p <.0001). TWHV4‐6 generated areas under the receiver‐operating characteristic (ROC) curve (AUC) of 0.933 in women (p <.0001) and 0.573 in men (p =.4). In women, the ROC‐guided 48‐µV TWHV4‐6 cut point for near‐term cardiac mortality produced an adjusted odds ratio of 121.37 (95% CI: 2.89–6,699.84; p =.02) with 100% sensitivity and 82.5% specificity. In Kaplan–Meier survival analysis, TWHV4‐6 ≥ 48 µV predicted cardiac mortality in women during 90‐day follow‐up with a hazard ratio of 27.84 (95% CI: 7.29–106.36, p <.0001). Conclusion: Elevated TWHV4‐6 is associated with near‐term cardiac mortality among women evaluated for acute coronary syndrome. [ABSTRACT FROM AUTHOR]

Objective: Linking emergency medical services (EMS) electronic patient care reports (ePCRs) to emergency department (ED) records can provide clinicians access to vital information that can alter management. It can also create rich databases for research and quality improvement. Unfortunately, previous attempts at ePCR and ED record linkage have had limited success. In this study, we use supervised machine learning to derive and validate an automated record linkage algorithm between EMS ePCRs and ED records.Materials and Methods: All consecutive ePCRs from a single EMS provider between June 2013 and June 2015 were included. A primary reviewer matched ePCRs to a list of ED patients to create a gold standard. Age, gender, last name, first name, social security number, and date of birth were extracted. Data were randomly split into 80% training and 20% test datasets. We derived missing indicators, identical indicators, edit distances, and percent differences. A multivariate logistic regression model was trained using 5-fold cross-validation, using label k-fold, L2 regularization, and class reweighting.Results: A total of 14 032 ePCRs were included in the study. Interrater reliability between the primary and secondary reviewer had a kappa of 0.9. The algorithm had a sensitivity of 99.4%, a positive predictive value of 99.9%, and an area under the receiver-operating characteristic curve of 0.99 in both the training and test datasets. Date-of-birth match had the highest odds ratio of 16.9, followed by last name match (10.6). Social security number match had an odds ratio of 3.8.Conclusions: We were able to successfully derive and validate a record linkage algorithm from a single EMS ePCR provider to our hospital EMR. [ABSTRACT FROM AUTHOR]

Background: Diagnostic errors in emergency medicine (EM) can lead to patient harm as well as potential malpractice claims and quality assurance (QA) reviews. It is therefore essential that these topics are part of the core education of trainees. The methods training programs use to educate residents on these topics are unknown. The goal of this study was to identify the current methods used to teach EM residents about diagnostic errors, QA, and malpractice/risk management and determine the amount of educational teaching time EM programs dedicate to these topics. Methods: An 11-item questionnaire pertaining to resident education on diagnostic errors, QA, and malpractice was sent through the Council of Emergency Medicine Residency Directors (CORD) listserv. Differences in the proportions of responses by duration of training program were analyzed using chi-squared or Fisher's exact tests. Results: Fifty-four percent (91/168) of the EM programs responded. There was no difference in prevalence of formal education on these topics among 3- and 4-year programs. The majority of programs (59.5%) offer fewer than 4 h per year of additional QA education beyond morbidity and mortality rounds; a minority of the programs (18.8%) offer more than 4 h per year of medical malpractice/risk management education. Conclusions: This needs assessment demonstrated that there is a lack of dedicated educational time devoted to these topics. A more formalized and standard curricular approach with increased time allotment may enhance EM resident education about diagnostic errors, QA, and malpractice/risk management. [ABSTRACT FROM AUTHOR]

Introduction: Chest pain is a common emergency department (ED) presentation accounting for 8–10 million visits per year in the United States. Physician-level factors such as risk tolerance are predictive of admission rates. The recent advent of accelerated diagnostic pathways and ED observation units may have an impact in reducing variation in admission rates on the individual physician level. Methods: We conducted a single-institution retrospective observational study of ED patients with a diagnosis of chest pain as determined by diagnostic code from our hospital administrative database. We included ED visits from 2012 and 2013. Patients with an elevated troponin or an electrocardiogram (ECG) demonstrating an ST elevation myocardial infarction were excluded. Patients were divided into two groups: “admission” (this included observation and inpatients) and “discharged.” We stratified physicians by age, gender, residency location, and years since medical school. We controlled for patient- and hospital-related factors including age, gender, race, insurance status, daily ED volume, and lab values. Results: Of 4,577 patients with documented dispositions, 3,252 (70.9%) were either admitted to the hospital or into observation (in an ED observation unit or in the hospital), while 1,333 (29.1%) were discharged. Median number of patients per physician was 132 (interquartile range 89–172). Average admission rate was 73.7±9.5% ranging from 54% to 96%. Of the 3,252 admissions, 2,638 (81.1%) were to observation. There was significant variation in the admission rate at the individual physician level with adjusted odds ratio ranging from 0.42 to 5.8 as compared to the average admission. Among physicians’ characteristics, years elapsed since finishing medical school demonstrated a trend towards association with a higher admission probability. Conclusion: There is substantial variation among physicians in the management of patients presenting with chest pain, with physician experience playing a role., Version of Record