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Many people experience high burden by the outbreak of the coronavirus disease (COVID-19) and its consequences for health and everyday life. The present cross-national study investigated potential factors that can reduce the burden by COVID-19 in China and Germany. Cross-sectional and longitudinal (China: N = 474, baseline, BL: 2015, follow-up, FU: 2020; Germany: N = 359, BL: 2019, FU: 2020) data on physical activity (e.g., jogging) (BL/FU), positive mental health (PMH) (BL/FU), and burden by COVID-19 (FU) were collected via online surveys. In both countries, physical activity was positively associated with PMH, and both variables were negatively related to burden by COVID-19. Furthermore, PMH mediated the link between physical activity and burden. The mediation model was significant when physical activity and PMH were assessed at the BL, while burden was measured at the FU; and it was also significant when all variables were assessed at the FU. The present findings reveal that physical activity in combination with PMH can reduce the experience of burden by COVID-19. Conscious fostering of physical activity and PMH is supported as an effective strategy to reduce the negative impact of the pandemic outbreak on mental and physical health. Additional benefits such as increased adherence to governmental measures around COVID-19 are discussed.

Cross-culturally measurement invariant instruments are useful for the assessment of mental symptoms across cultures. The current study aimed to investigate the psychometric properties and measurement invariance of the Depression, Anxiety and Stress Scales (DASS-21) (DASS) across Pakistan and Germany. German participants were recruited through an online survey (N = 1323), while Pakistani participants were recruited through online survey or paper-and-pencil survey (N = 1841). The DASS-21 showed good reliability, construct and structure validity in both countries. The DASS-21 indicated partial weak (stress subscale) and partial strong measurement invariance (depression and anxiety subscales) between both countries. Latent mean comparison of depression and anxiety symptoms between Pakistani and German students indicated that Pakistani university students experience more symptoms of depression and anxiety. Results suggest that the DASS-21 could be used in Pakistan and Germany, but caution should be taken when making direct comparisons between the two countries.

Background Diagnostic uncertainty occurs frequently in emergency medical care, with more than one-third of patients leaving the emergency department (ED) without a clear diagnosis. Despite this frequency, ED providers are not adequately trained on how to discuss diagnostic uncertainty with these patients, who often leave the ED confused and concerned. To address this training need, we developed the Uncertainty Communication Education Module (UCEM) to teach physicians how to discuss diagnostic uncertainty. The purpose of the study is to evaluate the effectiveness of the UCEM in improving physician communications. Methods The trial is a multicenter, two-arm randomized controlled trial designed to teach communication skills using simulation-based mastery learning (SBML). Resident emergency physicians from two training programs will be randomly assigned to immediate or delayed receipt of the two-part UCEM intervention after completing a baseline standardized patient encounter. The two UCEM components are: 1) a web-based interactive module, and 2) a smart-phone-based game. Both formats teach and reinforce communication skills for patient cases involving diagnostic uncertainty. Following baseline testing, participants in the immediate intervention arm will complete a remote deliberate practice session via a video platform and subsequently return for a second study visit to assess if they have achieved mastery. Participants in the delayed intervention arm will receive access to UCEM and remote deliberate practice after the second study visit. The primary outcome of interest is the proportion of residents in the immediate intervention arm who achieve mastery at the second study visit. Discussion Patients’ understanding of the care they received has implications for care quality, safety, and patient satisfaction, especially when they are discharged without a definitive diagnosis. Developing a patient-centered diagnostic uncertainty communication strategy will improve safety of acute care discharges. Although use of SBML is a resource intensive educational approach, this trial has been deliberately designed to have a low-resource, scalable intervention that would allow for widespread dissemination and uptake. Trial registration The trial was registered at clinicaltrials.gov (NCT04021771). Registration date: July 16, 2019.

Grand Rounds (GR) lectures are formal educational initiatives that are at the core of most academic clinical departments.1,2 GR have evolved over its commemorative beginnings, shifting away from real-time clinical skills demonstration to the now familiar, lecture-based format.2 Today, GR represent prestigious academic speaking opportunities for thought leaders to discuss topics intended to broaden the medical knowledge at an institution. Despite being considered a cornerstone of education in most training programs, GR have recently come under scrutiny for their dwindling educational efficacy, poor attendance, logistical challenges, and overhead cost.1,3 There is even concern that GR may be at risk of complete extinction altogether.4.

Health professions education has benefitted from standardized patient (SP) programs to develop and refine communication and interpersonal skills in trainees. Effective case design is essential to ensure an SP encounter successfully meets learning objectives that are focused on communication skills. Creative, well-designed case scenarios offer learners the opportunity to engage in complex patient encounters, while challenging them to address the personal and emotional contexts in which their patients are situated. Therefore, prior to considering the practical execution of the patient encounter, educators will first need a clear and structured strategy for writing, organizing, and developing cases. The authors reflect on lessons learned in developing standardized patient-based cases to train learners to communicate to patients during times of diagnostic uncertainty, and provide suggestions to develop a set of simulation cases that are both standardized and diverse. Key steps and workflow processes that can assist educators with case design are introduced. The authors review the need to increase awareness of and mitigate existing norms and implicit biases, while maximizing variation in patient diversity. Opportunities to leverage the breadth of emotional dispositions of the SP and the affective domain of a clinical encounter are also discussed as a means to guide future case development and maximize the value of a case for its respective learning outcomes. Supplementary Information The online version contains supplementary material available at 10.1186/s41077-021-00176-y.

Objectives The recent outbreak of the COVID‐19 altered the traditional paradigm of clinical medical education. While individual clerkships have shared their curricular adaptations via social and academic networking media, there is currently no organizational standard in establishing a non‐clinical, Emergency Medicine (EM) virtual rotation (VR). The primary objective of this study was to describe EM clerkship directors’ (CDs) perspectives on their experience adapting an EM VR curriculum during the onset of the COVID‐19 pandemic. Methods A 21‐item survey with quantitative and qualitative questions was disseminated between June and August 2020 to EM CDs via the Clerkship Director of Emergency Medicine (CDEM) Listserv to describe their experience and perspectives in adapting a VR during the spring of 2020. Results We analyzed 59 out of 77 EM clerkship survey responses. Among respondents, 52% adapted a VR while 47.5% did not. Of those who adapted a VR, 71% of CDs had 2 weeks or less to develop the new curriculum, with 84% reporting usual or increased clinical load during that time. Clerkships significantly diversified their asynchronous educational content and utilized several instructional models to substitute the loss of clinical experience. Reflecting on the experience, 71% of CDs did not feel comfortable writing a standardized letter of evaluation for students based on the VR, with the majority citing inability to evaluate students’ competencies in a clinical context. Conclusion A crisis, such as COVID‐19 necessitates change in all facets of medical education. While EM educators demonstrated the ability to create emergency remote learning with limited time, this was not equivalent to the formal development of pre‐planned VR experiences. Future faculty development and curriculum innovation are required to fully transition an in‐person immersive experience to a non‐inferior virtual experience.

AVATAR therapy offers a unique therapeutic context that uses virtual reality technology to create a virtual embodiment of the voice-hearing experience, enabling the person to visualize their persecutory voice and engage in real-time “face-to-face” dialogue. The present study explores, for the first time, the contribution of sense of voice presence, together with session-by-session reduction of anxiety and paranoid attributions about the avatar, to changes in primary outcomes following AVATAR therapy. Data from 39 participants, who completed AVATAR therapy and attended a 12-week follow-up assessment, were analysed. Mid- to high-levels of sense of voice presence were reported across the therapy sessions, along with significant reductions of anxiety levels and paranoid attributions about the avatar. The interaction of sense of voice presence and reduction of anxiety was associated with two of the significant therapy outcomes: PSYRATS total and frequency of voices. The findings suggest that improvements in voice severity and frequency at post AVATAR therapy may be influenced by the combination of feeling less anxious in the context of a realistic simulation of the voice, while voice-related distress may involve additional cognitive and relational processes.

International Medical Graduate (IMG) physicians applying to residency training programs in a country different from where they completed medical school, bring beneficial diversity to a training program, but also face significant challenges matching into an Accreditation Council for Graduate Medical Education (ACGME)-accredited residency program. Despite the growing number of IMG applications in Emergency Medicine (EM), there is a paucity of targeted recommendations for IMG applicants. As a result, the Council of Residency Directors (CORD) Advising Students Committee in EM (ASC-EM) created a dedicated IMG Advising Team to create a set of evidence-based advising recommendations based on longitudinal data from the National Residency Match Program (NRMP) and information collected from EM program directors and clerkship directors. IMG applicants should obtain at least two EM standardized letters of evaluation (SLOEs), review IMG matched percentages for programs-of-interest, analyze their objective scores with the previous matched cohorts, and rank at least 12 programs to maximize their chances of matching into EM.

Emergent thoracotomy is a rare but high-stakes procedure for trauma patients. Emergency medicine residents are expected to perform this procedure after graduation, but few get the opportunity to perform it, leading to suboptimal performance and patient morbidity and mortality. Previous low-cost thoracotomy trainers revolve around modifying an existing costly thoracotomy task trainer or bear limited resemblance to actual landmarks and anatomy. This study attempts to bridge this gap by creating a low-cost model with supplies found at most home improvement/craft stores that is more anatomically accurate. We constructed a low fidelity model, which residents ultimately found to be helpful in mastering this rare procedure, and after the training session, they reported a greater level of comfort and familiarization with the procedure.

Author(s): MacDonald, Nicholas; Garcia, Jacob; Kane, Gregory; Chi Zhang, Xiao; Papanagnou, Dimitrios

The Council of Residency Directors in Emergency Medicine (CORD) Advising Students Committee in Emergency Medicine (ASC-EM) anticipates institutional and regional variability in both the spread and response to COVID-19. Travel restrictions and host institution rotation closures will impact the number of emergency medicine (EM) rotations EM-bound medical students can complete in an unprecedented manner. They may prevent students from completing any away rotations this academic cycle, challenging the students’ ability to obtain EM Standardized Letters of Evaluation (SLOEs). EM’s emphasis on residency group SLOEs over other letter types creates an undue burden on these vulnerable students and makes the application process intrinsically inequitable. This inequity warrants a reevaluation of the current application practice. This article outlines ASC-EM's proposed recommendations for all stakeholders, including EM program leadership, medical schools, and EM-bound medical students, to consider for the upcoming EM application cycle.

Effective team building and leadership are crucial in running an effective and safe healthcare system with improved patient care and clinical outcomes. Currently, there is a great demand for formal leadership training throughout the extensive medical education curriculum. We constructed an interactive team-building activity utilizing gamification-theory with the Zoom game. The Zoom activity requires a team of learners to organize a set of sequential images, each of which contains a "zoomed out" section from the previous image, into the correct order within a set time frame. Given the unique and approachable nature of this team-based activity, we propose the following: 1) to introduce the Zoom game as a team-building and communication fostering exercise in undergraduate medical education and 2) to assess baseline teamwork skills of first-year medical students through an immersive gaming experience. With this in mind, 260 first-year medical students (class of 2020) at an urban-city medical school were enrolled in the Zoom Team Building Activity as part of their orientation. The students were randomly assigned to 11 teams, comprising 23-24 students and two faculty facilitators per team and completed the activity in the allotted time frame. The average time to complete the Zoom game was 24 minutes, and all the teams successfully placed the pictures in the correct order. Facilitators noted that the Zoom game strongly encouraged friendly interactions, intercollegiate high values, mutual respect, confidence, and trust among each other. Students observed take-home points such as selecting a leader, designating specific roles, and encouraging closed-loop communication. Overall, the Zoom activity game is an interactive, fun, and easily accessible team-building and communication fostering exercise in undergraduate medical education. Further studies on the Zoom game exercise would be essential to determine whether it has a continuous and enduring effect on developing team building among medical students.

Background The objective of this study was to determine the advising and emergency medicine (EM) residency selection practices for special population applicant groups for whom traditional advice may not apply. Methods A survey was distributed on the Council of Residency Directors in EM and Clerkship Directors in EM Academy listservs. Multiple choice, Likert-type scale, and fill-in-the-blank questions addressed the average EM applicant and special population groups (osteopathic; international medical graduate (IMG); couples; at-risk; re-applicant; dual-accreditation applicant; and military). Percentages and 95% confidence intervals [CI] were calculated. Results One hundred four surveys were completed. Of respondents involved in the interview process, 2 or more standardized letters of evaluation (SLOEs) were recommended for osteopathic (90.1% [95% CI 84–96]), IMG (82.5% [73–92]), dual-accreditation (46% [19–73]), and average applicants (48.5% [39–58]). Recommendations for numbers of residency applications to submit were 21–30 (50.5% [40.7–60.3]) for the average applicant, 31–40 (41.6% [31.3–51.8]) for osteopathic, and > 50 (50.9% [37.5–64.4]) for IMG. For below-average Step 1 performance, 56.0% [46.3–65.7] were more likely to interview with an average Step 2 score. 88.1% [81.8–94.4] will consider matching an EM-EM couple. The majority were more likely to interview a military applicant with similar competitiveness to a traditional applicant. Respondents felt the best option for re-applicants was to pursue the Supplemental Offer and Acceptance Program (SOAP) for a preliminary residency position. Conclusion Advising and residency selection practices for special population applicants differ from those of traditional EM applicants. These data serve as an important foundation for advising these distinct applicant groups in ways that were previously only speculative. While respondents agree on many advising recommendations, outliers exist.

Ocular trauma is one of the most common and vision-threatening ophthalmic presentations with a wide spectrum of complications, such as bleeding, infection, vision loss, and enucleation. A 64-year-old-male presented to the emergency department (ED) with a self-inflicted orbital penetrating injury with a hair comb. Computed tomography showed the comb traversed the medial orbit inferior to the medial rectus but did not damage the optic nerve; there were no globe or orbital wall fractures. His ocular exam was significant for a right eye afferent pupillary defect and decreased visual acuity 20/800, consistent with optic neuropathy. Primary concerns were stabilizing and removing the foreign body without causing further damage in the setting of an uncooperative patient. The comb was removed with the aid of local and systemic analgesia using gentle traction and normal saline irrigation. The patient was admitted for systemic and topical antibiotics and showed improvement in visual acuity and resolution of his optic neuropathy. This case illustrates the importance of rapid ED assessment and management of complex penetrating ocular trauma. Examination should specifically look for signs of globe rupture and optic nerve injury. Expedited foreign body removal should be managed together with an ophthalmologist with procedural sedation and broad-spectrum antibiotics to avoid further visual and infectious complications.

The relationship between resilience and mental health was examined in three phases over 4 years in a sample of 314 college students in China. The present study aimed to gain insight into the reciprocal relationship of higher levels of resilience predicting lower levels of mental ill-being, and higher levels of positive mental health, and vice versa, and track changes in both resilience, mental ill-being and positive mental health over 4 years. We used the Depression Anxiety Stress, the Positive Mental Health, and the Resilience Scales. Results revealed that first-year students and senior year students experienced higher negative mental health levels and lower positive mental health levels than junior year students. Cross-lagged structural equation modeling analyses showed that resilience could significantly predict mental health status in the short term, namely within 1 year from junior to senior year. However, the predicting function of resilience for mental health is not significant in the long term, namely within 2 years from freshman to junior year. Additionally, the significant predicting function of individuals’ mental health for resilience is fully verified for both the short and long term. These results indicate that college mental health education and interventions could be tailored based on students’ year in college.

Simultaneous bilateral central retinal vein occlusion (CRVO) is a rare presentation that warrants consideration of an underlying hyperviscosity state. Increased serum viscosity can lead to the hematologic emergency of leukostasis with resultant vascular obstruction and hypoxic tissue damage. The following case demonstrates the first case of bilateral CRVO in a young adult secondary to acute lymphoblastic leukemia (ALL). A 23-year-old female presented to the emergency department (ED) with two days of worsening bilateral blurry vision and bitemporal headache. Her ocular exam was significant for bilateral intraretinal hemorrhages consistent with CRVO with chest radiograph demonstrating widened mediastinum with perihilar lymphadenopathy and serologic testing revealing ALL with blast crisis. The patient was subsequently admitted to the oncology service for induction chemotherapy. Patients with new headache and bilateral vision changes should prompt a thorough neurological and ophthalmologic exam to assess for underlying systemic pathologies. Concurrent bilateral CRVO is a rare but specific finding for systemic hyperviscosity syndrome, blood dyscrasia, polycythemia, or other serious illness. Early recognition and treatment of the underlying condition can prevent further vision loss and overall morbidity and mortality.

Objective Despite procedural skills being recognized as an important component of medical school education, medical students are not confident in their ability to carry out a range of medical procedures. We conducted an institutional needs assessment and used the results to inform the creation of a procedure‐based preclinical elective for first‐ and second‐year students. Methods We surveyed second‐, third‐, and fourth‐year medical students at Alpert Medical School as well as select program directors to guide selection of a list of procedures to be taught in the elective. We then created an extracurricular 10‐week procedural skills course for preclerkship medical students utilizing a hands‐on, flipped classroom practice model. Volunteer preceptors were recruited from the Department of Emergency Medicine to participate with a student‐to‐faculty ratio not exceeding 5:1. Knowledge and skill acquisition were assessed using a multiple‐choice knowledge exam and 4‐station practical exam, respectively. Pre‐ and post‐course online surveys were used to assess self‐perceived confidence for all procedures. Results We implemented our procedural skills training course for first‐ and second‐year medical students in the fall of 2015. Forty‐four students applied for the first iteration of the course and 15 students were selected to participate. Fourteen students ultimately completed the elective as well as the subsequent course surveys, multiple‐choice exam, and practical exam. Students who participated in the elective had increased levels of self‐reported confidence at the conclusion of the elective and performed better on a practical exam and multiple‐choice exam compared to students who participated in only the standard curriculum. Conclusion A longitudinal preclerkship procedural course early during medical school is a feasible method of teaching procedural skills to a cohort of learners. A number of adjustments could be made to the course in order to scale up and include a larger cohort of students at our own or another institution.

Calcium pyrophosphate dihydrate (CPPD) crystal deposition disease or pseudogout is an idiopathic articular disease that predominantly affects elderly patients. It is caused by a systemic deposition of calcium pyrophosphate (CPP) crystals in the articular and hyaline joint cartilage. The majority of cases present as chronic arthritis, but a subset of CPPD can present as rapid onset of sharp pain and joint swelling, posing a diagnostic challenge. We present a case of a 64-year-old man with a history of hypertension, urologic cancer, and gout presenting to the emergency department (ED) with a sudden-onset, severe stabbing right shoulder pain radiating to the neck and upper back. On ED arrival, he was mildly hypotensive, afebrile, diaphoretic, and uncomfortable, causing concern for aortic dissection. His exam was significant for limited shoulder range of motion; his sensation, strength, and distal pulses were intact and equal in bilateral upper extremities. His plain films showed multilevel cervical degenerative disc disease and facet arthrosis and right glenohumeral osteoarthritis without fracture or malalignment. A computed tomography (CT) angiogram was negative for vascular anomalies. Throughout his ED stay, his pain was refractory to medication, and he developed a new fever, prompting a targeted shoulder ultrasound; this revealed large glenohumeral effusion, and synovial analysis revealed CPP crystals without organism growth. This case illustrates an unusual acute CPPD attack that mimicked an aortic dissection. Emergency physicians should recognize both common and uncommon presentations for chronic disease processes in maintaining a broad differential diagnosis and delivering quick, targeted treatment.

Highlights • Study of smoking and panic, depression, and anxiety over time and across two cultures. • Smoking at baseline did not predict higher panic or depression at follow-up in either German or Chinese students. • Smoking did predict lower anxiety in German students. • Baseline anxiety predicted increased likelihood of smoking at follow-up in German, but not Chinese students. • Baseline depression did not predict smoking at follow-up in German or Chinese students., The present study examines the relationship between smoking and panic, depression, and anxiety over time and across two cultures, using data from the BOOM studies. The relationship between smoking and anxiety disorders, including panic requires further exploration, in order to reconcile inconsistent, contradictory findings and cross-cultural differences. Participants in the present study included 5,416 Chinese university students and 282 German university students. Participants completed surveys assessing smoking, panic, depression, and anxiety. Multiple logistic regressions were used to examine predict later mental health from smoking, as well as later smoking from mental health. In sum, across the regressions, smoking at baseline did not predict higher panic or depression at follow-up in either German or Chinese students. It did predict lower anxiety in German students. Anxiety at baseline, but not depression, predicted increased likelihood of smoking at follow-up in German students. The relationship between smoking and anxiety disorders is one that will require further exploration, in order to reconcile inconsistent, contradictory findings and cross-cultural differences. The present data point to a relationship between anxiety and later smoking, and also to a negative, though small, relationship between smoking and later anxiety in German students, and no prospective relationship in either direction in Chinese students.

Bartonella henselae is a relatively uncommon pathogen that can present as a serious disease in immunocompromised patients. We present a case of a 76-year-old man with stable chronic lymphocytic leukemia (CLL) who presented to the emergency department (ED) with an onset of right axillary lymphadenitis after recovering from a recent cat bite on the ipsilateral finger. Doppler ultrasound demonstrated an irregular, circumscribed 5cm x 4cm, hypoechoic mass with mild vascular flow consistent with an enlarged abnormal lymph node. The patient was diagnosed with cat scratch disease and discharged on oral antibiotics with spontaneous drainage of the purulent materials in subsequent outpatient oncology visits. This case highlights the classic presentation of this rare disease in an immunocompromised patient with feline contact. Early antibiotics should be considered for at-risk and immunocompromised patients due to low sensitivity and specificity for Bartonella serologic tests. CLL can also present with similar progressive lymphadenopathy with severe systemic symptoms and extranodal involvement that requires emergent oncologic interventions and diagnostic vigilance.

OBJECTIVES: Despite increasing prevalence in emergency medicine (EM), the vice chair of education (VCE) role remains ambiguous with regard to associated responsibilities and expectations. This study aimed to identify training experiences of current VCEs, clarify responsibilities, review career paths, and gather data to inform a unified job description. METHODS: A 40‐item, anonymous survey was electronically sent to EM VCEs. VCEs were identified through EM chairs, residency program directors, and residency coordinators through solicitation e‐mails distributed through respective listservs. Quantitative data are reported as percentages with 95% confidence intervals and continuous variables as medians with interquartiles (IQRs). Open‐ and axial‐coding methods were used to organize qualitative data into thematic categories. RESULTS: Forty‐seven of 59 VCEs completed the survey (79.6% response rate); 74.4% were male and 89.3% were white. Average time in the role was 3.56 years (median = 3.0 years, IQR = 4.0 years), with 74.5% serving as inaugural VCE. Many respondents held at least one additional administrative title. Most had no defined job description (68.9%) and reported no defined metrics of success (88.6%). Almost 78% received a reduction in clinical duties, with an average reduction of 27.7% protected time effort (median = 27.2%, IQR = 22.5%). Responsibilities thematically link to faculty affairs and promotion of the departmental educational mission and scholarship. CONCLUSION: Given the variability in expectations observed, the authors suggest the adoption of a unified VCE job description with detailed responsibilities and performance metrics to ensure success in the role. Efforts to improve the diversity of VCEs are encouraged to better match the diversity of learners.

Background The use of design principles in tackling complex health issues is gaining significant traction. Medical education must evolve to prepare future clinicians on design thinking methods. Method Twenty second-year medical students and seven EM faculty mentors from the Sidney Kimmel Medical College were enrolled in eight, 3-hour experiential design didactic sessions in 2017-18. Student teams were matched with EM physician-mentors to apply design thinking methods to specific ED problems. Didactic content included: 1) empathy building; 2) idea generation; 3) prototyping; 4) testing; 5) the user experience; 6) service design; 7) business canvas planning; 8) idea presentation. The curriculum was developed based the Kolb’s cycle, constructivist framework and Stanford d.school design thinking and students were evaluated using the Kirkpatrick Model through self-evaluation, group presentations, and project deliverables. Results Quantitative evaluation of the simulated training session was extracted through an 11-item questionnaire using a 5-point Likert scale. Overall responses were positive. Both students and faculty reported that participation in the curriculum was a valuable experience and provided deeper insight into applying design in healthcare. Areas of improvement included requests for longitudinal feedback, diverse collaborative efforts, and practical design workshops. The majority of learners recommended this curriculum to future learners. Conclusion Innovation per DiEM is a unique design curriculum that focuses on EM challenges with active EM clinician mentorship. Future goals include developing longitudinal evaluation and broadening healthcare challenges beyond the context of the ED.