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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.

Medical errors harm patients and increase costs. Engaging early clinicians in patient safety (PS) is critical but challenging. We evaluated the impact of a Patient Safety Escape Room (PSER) simulation on intern engagement in PS. During the PSER, learner teams identified PS hazards in a simulated hospital room, revealing clues that allow "escape" via event report entry. One-hundred twenty interns from 14 training programs completed 2 PSERs each. Before the PSER, 5% reported experience entering an event report. Following the PSER, all interns had participated in entering an event report. Mean learner-reported comfort in identifying PS hazards improved significantly (6.3 ± 1.57 to 8.0 ± 1.2; P0.001). Individual safety hazards were identified by between 6% and 100% of teams. Mean observer-rated teamwork was lower than learner-rated teamwork (41.5 ± 5.18 versus 45.92 ± 3.87; P = 0.01). Subsequent resident reporting rates did not increase compared with historic controls. The PSER engaged early learners, however, translating improvements into the clinical environment remains challenging.

The Cambodian community is the largest Southeast Asian cultural identity in Rhode Island (RI) with high poverty rates and limited healthcare access. Investigators conducted a cross-sectional observational survey study from 2016 to 2017 on eligible Cambodians to better understand their healthcare experiences. Questions were reviewed by the RI Cambodian Society for cultural sensitivity. 123 surveys were collected; 98 respondents had medical providers. Respondents with providers reported difficulty understanding of their providers (59%) and limited access to medical interpreters (50%). The non-provider group were less likely to have medical insurance (54.2% vs. 88.8%, p = .0001) and more likely to visit the emergency department (47.1% vs. 15.3%; p

Affective styles appear to be relevant to the development of psychopathology, especially anxiety disorders. The aim of the current study was to investigate changes in affective styles in patients with panic disorder and specific phobia, as a result of undergoing cognitive-behavioral therapy, and to identify a possible link between certain affective styles and remission. The sample consisted of outpatients (N = 101) suffering from panic disorder, specific phobia, or agoraphobia who completed the Affective Style Questionnaire (ASQ) before and after therapy, as well as at a 6-month follow-up assessment. Multivariate analyses of variance were conducted to test for changes due to therapy. Logistic regression analyses were calculated to test for the impact of affective styles on remission from anxiety disorders, and hierarchical regression analyses were calculated to examine the association between changes in affective styles and symptom reduction. Results indicated significant increases on the ASQ subscales adjusting and tolerating after therapy. Concealing did not decrease significantly after therapy. In addition, higher scores on adjusting significantly predicted remission from anxiety disorders. Finally, we found a significant association between increases on the adjusting scale and the reduction of anxiety symptoms.

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.

In Western cultural context, grandiose (overt) narcissism has been shown to be either unrelated or negatively related to negative mental health (depression, suicide ideation). Grandiose narcissism may be differently related to depression and suicide ideation variables in Eastern cultural contexts. The current study therefore aims to investigate associations between grandiose narcissism, depression, and suicide ideation in a sample of metropolitan Chinese students as well as in a sample of German students. A total of N = 935 Chinese students (73.3% female; Mage = 22.62, SDage = .89) and of N = 389 German students (75.6% female; Mage = 23.13, SDage = 2.94) completed paper-and-pencil and/or online measures of grandiose narcissism, depression, and suicide ideation. Grandiose narcissism was positively associated with depression and suicide ideation in Chinese students. Depression fully mediated the association between grandiose narcissism and suicide ideation – controlling for gender, age, and survey method. In contrast, in the German sample, no significant associations could be found. Grandiose narcissism obviously has different consequences in China than in Germany.

Introduction: Distal radius (Colles’) fractures account for one-sixth of all adult fractures and one-third of pediatric fractures in Emergency Departments (ED). One-third of ED-reduced Colles fractures are inadequately reduced and require further treatment. In light of orthopedic simulation literature supporting realistic Colles' fracture management with reliable performance metrics, the investigators implemented an interdisciplinary simulation-based training intervention to improve Emergency Provider (EP) Colles' fracture reduction skills. Methods: Twenty eligible EPs with limited Colles’ fracture reduction experience were enrolled from 2016 to 2017 at a single tertiary academic center. Learner performances were assessed using a commercial Colles’ fracture simulator model and a mini-C arm to measure post-reduction fracture angulation and displacement. Learners completed a baseline-simulated reduction and a repeat-simulated reduction, then received a video didactic on expert distal radius reduction techniques, followed by a third reduction. The differences in post-reduction measurements were compared across the subjects' three reductions with a one-way ANOVA. Acceptable angulation ranges were 10° dorsal angulation and 5° radial angulation. Results: Learners exhibited significant improvements in completing adequate simulated reductions with respect to adequate AP (anterior-posterior) displacement and lateral displacement (p

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.

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.

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.

Background and Objectives While stress is generally well established to be predictive for different indicators of mental health, little is known about the longitudinal effects of daily life stressors and the role of self-evaluation factors. We tested whether perceived general self-efficacy is a mediator for the association between daily life stressors and psychopathological symptoms as well as subjective well-being. Methods Data derived from 2160 Chinese university students was assessed at three time points with one-year intervals. We used the Brief Daily Stressor Screening, the General Self-Efficacy Scale, the Positive Mental Health Scale, and the Depression Anxiety and Stress Scales. Total, direct, and indirect effects were estimated using 95% bootstrapped confidence intervals and structural equation modeling. Results Latent variable mediation analyses showed that daily stressors were associated with increased symptoms of depression, anxiety, and stress and with decreased subjective well-being. All cross-lagged mediational paths via self-efficacy were significant in predicting positive and negative mental health. Conclusions Considering stress of daily life as well as including the two dimensions of mental health may be important for future research and practice. This study provides novel evidence for mediating stress effects by perceived self-efficacy, which should be focused in intervention- and prevention-based approaches.

Introduction Although residents are on the front lines of patient care, they enter few formal patient safety reports on the adverse events and near misses they witness. Demonstrating the rationale and mechanics of reporting may improve this. Methods We designed and implemented an escape room patient safety simulation to incorporate active learning, gamification, and adult learning theory into intern patient safety onboarding. Interns from all sponsoring institution programs participated, identifying, mitigating, and reporting a range of patient safety hazards. Props and faculty time were the major resources required. Results One hundred twenty interns participated in this simulation in June 2018. Forty-one percent reported previous training on reporting errors, and only 5% had previously entered an event report. Average confidence in ability to identify patient safety hazards improved after the simulation from 6.35 to 8.00 on a 10-point rating scale. The simulation was rated as relevant or highly relevant to practice by 96% of interns. Discussion Several factors contribute to a low error-reporting rate among house staff. We developed a simulation modeled on popular escape room activities to increase awareness of safety hazards and ensure familiarity with the actual online reporting system our interns will use in the clinical environment.

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.

Background Nonspecific orbital inflammation (NSOI) is a rare idiopathic ocular pathology characterized by unilateral, painful orbital swelling without identifiable infectious or systemic disorders, which can be complicated by optic nerve compromise. Case Report A 50-year-old man presented to the Emergency Department with recurring, progressive painless left eye swelling, decreased visual acuity, and binocular diplopia in the absence of trauma, infection, or known malignancy. His physical examination was notable for left-sided decreased visual acuity, an afferent pupillary defect, severe left eye proptosis and chemosis, and restricted extraocular movements; his dilatated funduscopic examination was notable for ipsilateral retinal folds within the macula, concerning for a disruption between the sclera and the retina. Ocular examination of the right eye was unremarkable. Laboratory data were unrevealing. Gadolinium-enhanced magnetic resonance imaging showed marked thickening of the left extraocular muscles associated with proptosis, dense inflammatory infiltration of the orbital fat, and characteristics consistent with perineuritis. The patient was diagnosed with NSOI with optic neuritis and admitted for systemic steroid therapy; he was discharged on hospital day 2 after receiving high-dose intravenous (i.v.) methylprednisolone with significant improvement. Why Should an Emergency Physician Be Aware of This? NSOI is a rare and idiopathic ocular emergency, with clinical mimicry resembling a broad spectrum of systemic diseases such as malignancy, autoimmune diseases, endocrine disorders, and infection. Initial work-up for new-onset ocular proptosis should include comprehensive laboratory testing and gadolinium-enhanced magnetic resonance imaging. Timely evaluation by an ophthalmologist is crucial to assess for optic nerve involvement. Signs of optic nerve compromise include decreased visual acuity, afferent pupillary defect, or decreased color saturation. Patients with optic nerve compromise require admission for aggressive anti-inflammatory therapy with i.v. steroids in an attempt to reduce risk of long-term visual sequelae. Our case demonstrates a severe presentation of this disorder and exhibits remarkable visual recovery after 48 h of systemic i.v. steroid 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.

The rising burden of mental and behavioral disorders has become a global challenge (Murray et al., 2012). Measurement invariant clinical instruments are necessary for the assessment of relevant symptoms across countries. The present study tested the measurement invariance of the 21-item version of the Depression, Anxiety, and Stress Scales (DASS; Lovibond & Lovibond, 1995b) in Poland, Russia, the United Kingdom (U.K.), and the United States of America (U.S.). Telephone interviews were conducted with population-based samples (nPL = 1003, nRU = 3020, nU.K. = 1002, nU.S. = 1002). The DASS-21 shows threshold measurement invariance. Comparisons of latent means did not indicate differences between U.K. and U.S. SAMPLES However, Polish and Russian samples reported more depressive symptoms compared with U.K. and U.S. samples; the Russian sample had the highest levels of anxiety symptoms and the Polish sample demonstrated the highest stress levels. The DASS-21 can be recommended to meaningfully compare the relationships between variables across groups and to compare latent means in Polish-, Russian-, and English-speaking populations. (PsycINFO Database Record

This study cross-culturally investigated resilience and social support as possible protective factors for mental health. The values of depression, anxiety, and stress symptoms, resilience and social support were collected from German (N = 4433), Russian (N = 3774), and Chinese students (N = 4982). The samples were split (two-thirds vs. one-third) to cross-validate the results. In all samples, resilience and social support were significantly negatively associated with depression, anxiety, and stress symptoms. While in Germany those associations were stronger for social support, in Russia and in China stronger associations were found for resilience. Furthermore, in all samples, resilience was found to mediate the association between social support and the negative mental health variables significantly. In conclusion, resilience and social support are universal interrelated protective factors for mental health independently of historical, cultural, social, and geographical conditions of a country.

Study objective A stable and readily accessible work surface for bedside medical procedures represents a valuable tool for acute care providers. In emergency department (ED) settings, the design and implementation of traditional Mayo stands and related surface devices often limit their availability, portability, and usability, which can lead to suboptimal clinical practice conditions that may affect the safe and effective performance of medical procedures and delivery of patient care. We designed and built a novel, open-source, portable, bedside procedural surface through an iterative development process with use testing in simulated and live clinical environments. Methods The procedural surface development project was conducted between October 2014 and June 2016 at an academic referral hospital and its affiliated simulation facility. An interdisciplinary team of emergency physicians, mechanical engineers, medical students, and design students sought to construct a prototype bedside procedural surface out of off-the-shelf hardware during a collaborative university course on health care design. After determination of end-user needs and core design requirements, multiple prototypes were fabricated and iteratively modified, with early variants featuring undermattress stabilizing supports or ratcheting clamp mechanisms. Versions 1 through 4 underwent 2 hands-on usability-testing simulation sessions; version 5 was presented at a design critique held jointly by a panel of clinical and industrial design faculty for expert feedback. Responding to select feedback elements over several surface versions, investigators arrived at a near-final prototype design for fabrication and use testing in a live clinical setting. This experimental procedural surface (version 8) was constructed and then deployed for controlled usability testing against the standard Mayo stands in use at the study site ED. Clinical providers working in the ED who opted to participate in the study were provided with the prototype surface and just-in-time training on its use when performing bedside procedures. Subjects completed the validated 10-point System Usability Scale postshift for the surface that they had used. The study protocol was approved by the institutional review board. Results Multiple prototypes and recursive design revisions resulted in a fully functional, portable, and durable bedside procedural surface that featured a stainless steel tray and intuitive hook-and-lock mechanisms for attachment to ED stretcher bed rails. Forty-two control and 40 experimental group subjects participated and completed questionnaires. The median System Usability Scale score (out of 100; higher scores associated with better usability) was 72.5 (interquartile range [IQR] 51.3 to 86.3) for the Mayo stand; the experimental surface was scored at 93.8 (IQR 84.4 to 97.5 for a difference in medians of 17.5 (95% confidence interval 10 to 27.5). Subjects reported several usability challenges with the Mayo stand; the experimental surface was reviewed as easy to use, simple, and functional. In accordance with experimental live environment deployment, questionnaire responses, and end-user suggestions, the project team finalized the design specification for the experimental procedural surface for open dissemination. Conclusion An iterative, interdisciplinary approach was used to generate, evaluate, revise, and finalize the design specification for a new procedural surface that met all core end-user requirements. The final surface design was evaluated favorably on a validated usability tool against Mayo stands when use tested in simulated and live clinical settings.

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.

Timely feedback is critical in promoting learner self-reflection. When provided effectively, feedback can assist learners with the acquisition of new skills and knowledge in the ever-changing and complex landscape of healthcare. While the literature is replete on methods to provide feedback, faculty and supervisors receive little, if any, training on writing constructive feedback. Abbreviated comments (i.e., 'good job' or 'read more') provide little information on specific behaviors learners can change. As an avid food enthusiast and restaurant reviewer, I, too, am met with the challenge of writing a meaningful, constructive review (or evaluation) of a dining experience. To better assist clinical preceptors and supervisors with writing formative, constructive student evaluations, we have aggregated, reviewed, and adapted five lessons from writing food and restaurant reviews in writing a five-star student review.

Cryptococcal meningitis is a systemic infection that can be seen in immunosuppressed patients. Altered mental status, somnolence, and obtundation are warning signs of poor prognosis or advanced disease processes. We present a 23-year-old female with a past medical history significant for human immunodeficiency virus (HIV) obtained via vertical transmission who presented to the emergency department (ED) with a gradual onset of worsening headache over 10 days, with blurry vision, photophobia, nausea and vomiting, and progressive memory lapses. Her blood tests, chest plain radiograph, and non-contrast brain computed tomography (CT) were normal. In the ED, she developed a fever of 102°F and became more confused and agitated, with interspersed screaming and yelling. A lumbar puncture (LP) showed elevated white blood cell count and was positive for Cryptococcus neoformans; an opening pressure was unable to be obtained due to patient agitation. Despite prompt intravenous antibiotics and antifungal medications, her short, but tenuous hospital course involved declining mental status, requiring intubation and multiple therapeutic lumbar punctures, with an elevated opening pressure of up to 55 cm H2O. The patient suffered global ischemic encephalopathy and died on hospital day two. This case highlights the rapid decompensation of a young immunocompromised patient with cryptococcal meningitis, as well as the importance of early disease management and consultation to neurology and neurosurgery services. An important paradigm difference for emergency medicine (EM) physicians in the management of increased intracranial pressure (ICP) in patients with cryptococcal meningitis is avoiding acetazolamide, mannitol, and steroids and considering the indication for neurosurgical interventions for severe cryptococcal meningitis.

Introduction Previous studies have shown that risk attitudes and tolerance for uncertainty are significant factors in clinical decision-making, particularly in the practice of defensive medicine. These attributes have also been linked with rates of physician burnout. To date, the risk profile of emergency medicine (EM) physicians has not yet been described. Our goal was to examine the risk profile of EM residents using a widely available risk tolerance and attitude assessment tool. Methods First-, second-, and third-year residents of Thomas Jefferson University Hospital’s EM residency program completed the commercially available, unmodified Risk Type Compass, a validated instrument offered by Multi-Health Systems (MHS Inc, New York, USA). Scored reports included information on residents’ risk type (one of eight personality types that reflect their temperament and disposition); risk attitudes (domains where residents are more likely to engage in risky behaviors); and an overall risk tolerance indicator (RTi) (a numerical estimate of risk tolerance). RTi scores are reported as means with 95% confidence intervals (CIs). Results There was no significant change in RTi scores in residents across different years of their post-graduate year (PGY) training. PGY-one residents trended towards risk aversion; PGY-two residents were more risk-taking; and PGY-three residents scored in the middle. Conclusion Our pilot assessment of risk types in EM residents highlighted shifts across the years of training. Variations between members of each PGY cohort outweighed any outright differences between classes with regards to absolute risk tolerance. There was an increase in the frequency of health and safety risk-taking attitude with higher PGY class, and this was also the risk attitude that was the prominent domain for resident risk tolerance. The study was limited by sample size and single cross-sectional evaluation.

Medical simulation competitions have become an increasingly popular method to provide a hands-on “gamified” approach to education and training in the health professions. The most well-known competition, SimWars, consists of well-coordinated teams that are tasked with completing a series of mind-bending clinical scenarios in front of a live audience through ‘bracket-style’ elimination rounds. Similarly, challenging hazards amidst observational simulation (CHAOS) in the emergency department (ED) is another novel approach to gamification in both its structure and feel. Conducted at the Council of Emergency Medicine Resident Directors (CORD) 2018 National Assembly in San Antonio, Texas, instead of assigning premeditated teams, it placed random Emergency Medicine (EM) faculty, residents, and medical students together in teams to test them on a variety of fundamental EM content areas. Additionally, the event incorporated multiple levels within each round, allowing the inclusion of additional information to be shared with participants to support “switching gears,” as is typical for teams working in the ED and augmenting the perceived level of “chaos.” To assess this pilot project, formal quantitative and qualitative feedback was solicited at the end of the session. Quantitative evaluation of the intervention was obtained through an eight-item questionnaire using a five-point Likert-type scale from 19 of the 20 enrolled participants (95% response rate). Responses were generally positive with an overall course rating score of 4.45 out of 5 (SD +/- 0.62). Qualitative feedback revealed that learners enjoyed performing procedures and networking with their EM colleagues. The majority of residents (95%) recommend the activity be integrated into subsequent conferences. Areas for improvement included shorter cases and minimizing technical malfunctions. CHAOS in the ED was a successful pilot study that incorporated gamification as a means to deploy simulation-based training at a national emergency medicine conference in a community of simulation educators. Future studies should focus on incorporating learners’ feedback into subsequent CHAOS iterations and reducing overhead costs to increase its adoption by both regional and national audiences.

The Depression Anxiety Stress Scales-21 (DASS-21) has three 7-item subscales (depression, anxiety, and stress). The current study aims assess the gender-based measurement invariance of the DASS-21 questionnaire in a Chinese university student sample from five different cities. The sample was composed of 13208 participants (62.3% female, mean age of 19.7 years, and SD age = 1.8). Multi-group confirmatory factor analysis supported full measurement invariance for the three subscales. The findings support the measurement invariance of DASS-21 scores across gender. Future research on the DASS should include additional validation across ethnicities and testing of all versions of the DASS.

Resuscitative hysterotomy is a daunting and rarely performed procedure in the emergency department (ED). Given the paucity of clinical exposure to this intervention, resuscitative hysterotomy is an ideal opportunity for simulation-mediated deliberate practice. The authors propose a novel training program using a homegrown, realistic, simulation device as a means to practice resuscitative hysterotomy. Two high-fidelity, tissue-based task-trainer models were constructed and tested on a convenience sample of 14 emergency medicine (EM) residents. The simulated human placenta, bladder, amniotic sac, and uterus were constructed through the use of porcine skin, porcine stomach, transparent plastic bag, Foley tubing, and squid mantle, all secured with nylon sutures. A Gaumard S500 Articulating Newborn was inserted in the simulated uterus, and the entire model was placed into a Gaumard S500 Childbirth Simulator. Each model required less than 1 h for assembly. Emergent hysterotomy was first demonstrated by an EM faculty facilitator, followed by hands-on deliberate practice. Formal feedback on the learners’ self-reported confidence and satisfaction levels was solicited at the end of the workshop through a survey previously cited for use with a low-fidelity resuscitative hysterotomy. Quantitative evaluation of the simulated training session was extracted through a 5-item questionnaire using a 5-point Likert-type scale (i.e., from 1, strongly disagree, to 5, strongly agree). Item scores were added for a cumulative total score, with a possible maximum score of 25 and minimum score of 5. Responses were overwhelmingly positive [24.13 (± 1.36)]. Qualitative feedback was extracted from the survey through open-ended questions; these responses highlighted learners’ appreciation for hands-on practice and the development of a novel, tissue-based simulation task trainer. All participants recommended the training session be available to future learners. Resuscitative hysterotomy is a high-stakes, low-frequency procedure that demands provider practice and confidence. Our hybrid, tissue-based hysterotomy model represents a feasible opportunity for training. The model is cost conscious, easily reproducible, and portable and allows for ample deliberate practice. Electronic supplementary material The online version of this article (10.1186/s41077-018-0078-1) contains supplementary material, which is available to authorized users.

Neurosyphilis is a dangerous and increasingly more prevalent sexually transmitted infection of the central nervous system caused by the bacterium Treponema pallidum that can present during the advanced stages of the disease (tertiary syphilis). Health care providers must remain vigilant in screening for syphilis in patients with high-risk behaviors as a delay in diagnosis and treatment may lead to symptom progression and debilitating sequelae years later. To date, there have been no published simulation case studies on neurosyphilis. This simulation case, based on a real patient encounter, is written for emergency medicine residents to diagnose and manage a patient presenting with the sequelae of neurosyphilis. This case was run for four separate iterations at a simulation center with two residents and an attending physician acting as confederates. Following the case, learners were provided with bedside debriefing, and a question and answer session. Based on post-simulation qualitative assessment, junior residents alone were less likely to perform a comprehensive integumentary exam without the presence of senior residents, although both groups failed to elicit pertinent sexual history until they discovered syphilitic lesions. After case completion and debriefing, all learners were able to demonstrate the understanding of the primary learning objectives.

Background Acute infarctions of the spinal cord are rare events characterized by sudden paralysis or sensory deficits below the level of injury. Etiologies include spinal cord trauma, vascular injury, arterial dissection, thromboembolic disease, chronic inflammatory conditions, or mass effect on the spinal cord. Case Report A 63-year-old male presented to the emergency department with sudden-onset bilateral leg numbness and weakness. His physical examination was notable for decreased light touch and temperature sensation and bilateral lower-extremity paresis. Initial magnetic resonance imaging (MRI) of his spine did not show cord injuries. Computed tomography angiography of his chest, abdomen, and pelvis demonstrated a 7.5-cm non-ruptured infrarenal abdominal aortic aneurysm (AAA) extending into bilateral iliac arteries. The patient was diagnosed with clinical spinal cord infarction secondary to a thromboembolic event from his AAA. A repeat MRI 15 h later showed spinal cord infarction from T8 down to the conus. He received an endovascular aortic repair and was ultimately discharged to rehabilitation with slightly improved lower-extremity strength. Why Should an Emergency Physician Be Aware of This? Atraumatic cord syndrome is exceedingly rare and is associated with dissection or complication of aortic aneurysm repair. There are very few reported cases of thrombotic events leading to ischemic cord syndrome. When presented with a patient with symptoms consistent with cord syndrome in the absence of trauma or mass effect on the spinal cord, providers should work up for vascular etiology.

Background Vegetarianism is linked with better physical health, but also to increased anxiety and depression. The aim of the present study is to examine the relationship between vegetarianism and both positive and negative mental health, across cultures and over time. Method Self-report questionnaire data were obtained from a large-scale multi-national cross-sectional sample including 2007 representative adult members of the German population, 3020 representative adults from Russia, and 3038 representative adults from the USA. Participants for the longitudinal analyses include university students from Germany (1608) and China (12,744). Statistical models included multiple linear regression, longitudinal linear models and longitudinal logistic models. Results Vegetarianism diet is not reliably related to positive or negative mental health in US and Russian representative samples or in German representative or student samples. Vegetarianism is related to slight increases over time in anxiety and depression in Chinese students. Conclusions: Vegetarianism is not associated with mental health in the US, Russia, or Germany, but is associated with anxiety and depression in China in this study. Future studies should examine the nuances of vegetarianism in more detail and their links with mental health, including dietary composition and cultural beliefs and economic circumstances. Future researchers in this area may also want to consider the effects of experimental manipulation of diet on mental health outcomes over time.

Simulation has become a standard training method in emergency medicine (EM). Specifically, post-simulation debriefings offer participants the opportunity for reflection while exposing their knowledge and practice gaps. The educational yield of these debriefings, however, is contingent on the debriefer's skills. Without professional development, faculty and educators may not be equipped with supportive debriefing strategies. We propose the Six Thinking Hats (6TH), originally developed by Edward de Bono (1970) as a debriefing framework to support effective, high-yield debriefing conversations. The six colored hats represent six unique approaches to critical thinking. The white hat represents the facts; the green hat, creativity and next steps; the yellow hat, benefits/optimism; the red hat, emotions; the black hat, judgments; and the blue hat, facilitation. Four junior faculty members underwent a one-hour didactic and one-hour immersive workshop on the 6TH. Two simulation cases were randomly selected from archived simulation cases, which were used for the debriefing process. Each team consisted of one EM resident and one EM faculty. After each simulated case, the facilitator introduced the 6TH at the start of the debriefing, explaining the rules of engagement and the general sequence of hats to be used. Physical hats were worn by the facilitator at the beginning of the session and changed throughout stages of the debriefing, to remind participants of the type of thinking that was taking place at any given time. Participants who were provided with a colored hat prompt that physically described the type of thinking being employed throughout stages of the debriefing were better able to stay within that respective thinking frame during the discussion, compared to participants who were not provided this visual prompt. Participants of both simulation sessions agreed that the 6TH debriefing style was successful in creating a non-judgmental, comfortable environment that supported open discussion. The 6TH has the potential to be adopted as a debriefing framework, particularly for junior faculty members without extensive debriefing training. The 6TH is intuitive and has been marked by success in the organizational psychology literature. Faculty development on the 6TH will be essential if this framework is to be used as a debriefing model for educators in health care.

Publishing a manuscript in an academic journal represents more than just 'promotional currency.' It provides the opportunity to provoke debate, share your experiences, and challenge the status quo on provider practices. Writing a manuscript relies on collaboration and shared responsibility from a research team, which can often challenge mentors as they supervise and guide its development. While there are numerous online resources and peer-reviewed journal articles on 'How to write a scientific article,' we aim to tackle an even larger and overarching theme that transcends specific journal categories, writing styles, and citation formatting. In order to guide new researchers in navigating the expansive ocean of scientific publications, we collected, reviewed, and revised 11 tips based on multiple focus-group discussions with junior and senior researchers to determine common barriers for publishing manuscript. The goal is to help mentors and mentees navigate the research and publication processes. The tips include: 1) recognizing leadership styles; 2) initiating the groundwork; 3) establishing backup plans; 4) making a deadline; 5) courting the editor; 6) determining authorship; 7) finding personal incentives; 8) writing what you know; 9) sharing with caution; 10) following directions; and 11) Consider open-access journals.

Sporting event emergencies are common among both spectators and players, with unique sets of challenges associated with patient extrication in unfamiliar and chaotic environments. It is critical for sports physicians and trainers to deliberately train and prepare for emergent situations with limited resources during athletic events. One of the most difficult, yet commonly encountered challenges is determining when and how to safely remove an injured player’s helmet and sporting equipment, particularly if a spinal injury is highly suspected. We created a high-fidelity simulation case to practice the safe extrication of a hockey player who collapses on the bench in the player’s box, a space-restricted environment. The patient is a 25-year-old male hockey player who becomes unresponsive after a syncopal episode in the player’s box, and subsequently transferred to a medical center for further evaluation. Critical actions include extrication of the player at the scene, diagnosis of syncope, placement of the unconscious player on a backboard with cervical-spine precautions, removal of the player’s faceguard, removing the player off the ice, checking the electrocardiogram and glucose level, and transferring the player to a controlled environment. The learning objectives were to identify, evaluate, and manage the reversible causes of syncope, and demonstrate appropriate techniques for the optimal removal of sports equipment. Learner assessment was based on participation in the scenario and debriefing learners after the simulation. Post-simulation debriefing revealed that participants highly appreciated practicing not-so-commonly encountered hockey-related emergencies. Athletic trainers and emergency providers were able to effectively practice their management of the unresponsive hockey player. The participants were also able to deliberately practice their teamwork and communications skills with their peers. Learning points include proper c-spine immobilization techniques in a tight space and indication for gear-removal in an unconscious patient. As hockey continues to gain popularity, this simulation case will prepare athletic trainers and emergency providers to better address the reversible causes for syncope in hockey players, as well as safely and effectively extricate injured players from space-limiting sporting environments.

Teamwork, a skill critical for quality patient care, is recognized as a core competency by the Accreditation Council for Graduate Medical Education (ACGME). To date, there is no consensus on how to effectively teach these skills in a forum that engages learners, immerses members in life-like activities, and builds both trust and rapport. Recreational ‘Escape Rooms’ have gained popularity in creating a life-like environment that rewards players for working together, solving puzzles, and completing successions of mind-bending tasks in order to effectively ‘escape the room’ in the time allotted. In this regard, escape rooms share many parallels with the multitasking and teamwork that is essential for a successful emergency department (ED) shift. A pilot group of nine emergency medicine (EM) residents and one senior EM faculty member underwent a commercial escape room as part of a team-building exercise in January 2018. The escape room required participants to practice teamwork, communication, task delegation, and critical thinking to tackle waves of increasingly complex puzzles, ranging from hidden objects, physical object assembly (i.e., jigsaw puzzles), and symbol matching. Activities required members to recognize and utilize the collective experiences, skills, knowledge base, and physical abilities of the group. After the game, players underwent a structured ‘game-master’ debriefing facilitated by an employee of the commercial escape room; this was followed by a post-event survey facilitated by a faculty member, which focused on participants’ feelings, experiences, and problem-solving techniques. Escape rooms afford learners the opportunity to engage in an activity that rewards teamwork and effective leadership through experiences that directly link to specific ACGME milestones and educational learning theories. EM participants were engaged in the activity and felt that the escape room reproduced an environment analogous to the ED. The debriefing that followed the activity provided a satisfactory conclusion to the experience; but learners preferred a more organized debriefing format that provided them with constructive and specific feedback on their performance.

As students in the health professions transition from the classroom into the clinical environment, they will be expected to effectively communicate with their team members and their patients. Effective communication skills are essential to their ability to effectively contribute to their clinical team and the patient care they deliver. The authors propose an interactive workshop that can support students' deliberate practice of communication skills. The authors designed a simulation workshop that affords students the opportunity to practice their communication and peer-to-peer coaching skills. Using LEGOs, a one-hour workshop was conducted with medical students. Students were divided into groups of two. Each student took on a different role: teacher or builder. Teachers were tasked with instructing builders on how to construct a pre-made LEGO structure, not allowing builders to look at the structure. A group debriefing followed to evaluate the activity and explore the themes that emerged. Twenty first-year medical students and 25 fourth-year medical students participated in this activity. Most groups were successful in reproducing the pre-made structure. Groups that pre-briefed before building were most successful. Unsuccessful groups did not define orientation or direction in mutually understood terms, resulting in the creation of an incorrect mirror image of the structure - a common phenomenon seen during the teaching of procedures in the clinical learning environment. The workshop was well received. Students made requests to have similar sessions throughout their training to better support the development of effective communication skills. The workshop can easily be applied to other specialties to assist with procedural skills instruction or in workshops focusing on effective communication.