Maintaining procedural skills for academic emergency medicine faculty: A needs assessment

A needs assessment for formal emergency medicine curriculum and training in Zambia

Emergency medicine (EM) is a nascent field in Zambia. While not yet recognized as a medical specialty, there is national interest for developing more robust emergency care systems in this setting. One key element of strengthening EM in Zambia is identifying current gaps in emergency healthcare provision and opportunities for advancement in the field. This research used a modified version of the Emergency Care Assessment Tool to characterize the landscape of EM in Zambia. We collected data on the extent of EM training and teaching engagement among physicians practicing EM in Zambia. The survey assessed three aspects of core EM "signal functions" among the respondents which included; how often they performed the function, how confident they felt with the function, and how important they deemed the function to be in their practice. Finally, we asked respondents to identify barriers to performing the functions in their departments. The majority of respondents were early in their career, all below the age of 50, and participated in some form of teaching and supervision of learners, with minimal access to teaching resources to enhance their work. There was unanimous agreement with the need for formal postgraduate EM training in Zambia. The EM functions performed least often by EM physicians, and in which they felt the least confident, were high-acuity low-occurrence (HALO) procedures such as surgical airway and pericardiocentesis. The most common barrier to performing an EM function was access to supplies, equipment and medication. The second most commonly cited barrier was healthcare worker training. This research identified several critical needs for EM curricula in Zambia, specifically teaching resources for clinicians who supervise learners, directed learning on HALO procedures, and formal postgraduate training in EM based in Zambia.

Walk the line: a systemic perspective on stress experienced by emergency medical personnel by comparing military and civilian prehospital settings

Introduction

Emergency Medicine (EM) personnel in both military and civilian prehospital settings are often exposed to stressful and extreme events. Therefore, a cross-pollination between both contexts in terms of coping strategies may generate new information for purposes of training, prevention, and support programs. In the current study, we aimed at comparing both contexts to understand the type of stress events personnel experience; whether experience differs between civilian and military personnel; and how they cope with it.

Methods

We used a mixed method approach, combining the results of a quantitative questionnaire and a thematic analysis of 23 in-depth semi-structured interviews to gain additional qualitative information.

Results

Whereas the questionnaire pointed to a significant preference for task-oriented coping over avoidant and emotion-oriented coping, the interviews offered a more nuanced insight, showing a constant aim to position themselves on a continuum between emotional disconnection from the patient to preserve operationality on the one hand; and remaining enough empathic to preserve humanity on the other hand. We further identified an ambivalent awareness regarding emotions and stress, a vulnerable disbalance between an excessive passion for the job with the sacrifice of own's personal life (for a growing volatile and dangerous working environment) and a lack of recognition from both the patient and organizational environment. The combination of these factors may carry the risk for moral injury and compassion fatigue. Therefore, mutual trust between the organizational level and EM personnel as well as among team members is crucial.

Discussion

The results are discussed from a systemic SHELL perspective, indicating how the specific profile of EM personnel relates to the software, hardware, environmental and liveware components of their professional and private life. Trainings on stress- and risk awareness should be approached both on an individual and systemic level, knowing that there is clearly no "one-size-fits-all" manner.

How Good is Good Enough?: Current-Day Pediatric Residency Program Directors' Challenges in Assessing and Achieving Resident Procedural Competency

OBJECTIVE

Significant gaps exist in the pediatric resident (PR) procedural experience. Graduating PRs are not achieving competency in the 13 ACGME recommended procedures. It is unclear why PR are not able to achieve competency, or how existing gaps may be addressed.

METHODS

We performed in-depth one-on-one semistructured interviews with 12 pediatric residency program directors (PPDs). The interviews were audio-recorded, and transcribed verbatim. Coding of the data using conventional content analysis led to generation of categories, which were validated through consensus development.

RESULTS

We identified 4 main categories, including (1) programs struggle to ensure adequate training in procedural skills for PRs, with various barriers reported; (2) programs develop individualized strategies to address challenges in procedural skills training, and multiple options are necessary; (3) PPDs face challenges defining procedural competency and standardizing expectations; and (4) expectations for PR procedural training may require modification based upon current practice environments. Solutions include simulation, procedural boot camps, and procedural/subspecialty electives.

CONCLUSIONS

Numerous methods to combat challenges in PR procedural training have been identified by participating PPDs, including simulation, tailoring electives, and developing institutional guidelines. However, accreditation bodies may need to update procedural expectations based on individual resident career goals and realities of current day practice.

Procedural task trainer gaps in emergency medicine: A rift in the simulation universe

Objectives

We identified and quantified the gap between emergency medicine (EM) procedures currently taught using simulation versus those that educators would teach if they had better procedural task trainers. Additionally, we endeavored to describe which procedures were taught using homemade models and the barriers to creation and use of additional homemade models.

Methods

Using a modified Delphi process, we developed a survey and distributed it to a convenience sample of EM simulationists via the Society for Academic Emergency Medicine Simulation Academy listserv. Survey items asked participants to identify procedures they thought should be taught using simulation ("most important"), do teach using simulation ("most frequent"), would teach if a simulator or model were available ("most needed"), and do teach using simulation with "homemade" models ("most frequent homemade").

Results

Thirty-seven surveys were completed. The majority of respondents worked at academic medical centers and were involved in simulation-based education for at least 6 years. Three procedures ranked highly in overall teaching importance and currently taught categories. We identified four procedures that ranked highly as both important techniques to teach and would teach via simulation. Two procedures were selected as the most important procedures that the participants do teach via simulation but would like to teach in an improved way. We found 14 procedures that simulationists would teach if an adequate model was available, four of which are of high importance.

Conclusions

This study captured data to illuminate the procedural model gap and inform future interventions that may address it and meet the overarching objective to create better and more readily available procedure models for EM simulation educators in the future. It offers an informed way of prioritizing procedures for which additional homemade models should be created and disseminated as well as barriers to be aware of and to work to overcome. Our work has implications for learners, educators, administrators, and industry.

The Ethics of Procedural Education Under Pandemic Conditions

Background: The COVID-19 pandemic significantly disrupted emergency medicine residents’ education. Early in the pandemic, many facilities lacked adequate personal protective equipment (PPE), and intubation was considered particularly high risk for transmission to physicians, leading hospitals to limit the number of individuals present during the procedure. This posed difficulties for residents and academic faculty, as opportunities to perform endotracheal intubation during residency are limited, but patients with COVID-19 requiring intubation are unstable and have difficult airways.

Case Scenario: When PPE is being rationed, who should be the one to perform an intubation on a patient with respiratory failure from severe COVID-19?

Discussion: We examined this case scenario using the ethical frameworks of bioethical principles and virtue ethics. Bioethical principles include justice, beneficence, nonmalfeasance, and autonomy, and virtue ethics emphasizes the provision of moral exemplars and opportunities to exercise practical wisdom. Arguments for an attending-only strategy include the role of the attending as a truly autonomous decision maker and the importance of providing residents with a moral exemplar. A resident-only strategy benefits a resident's future patients and provides opportunities for residents to exercise character. Strategies preserving the dyad of attending and resident maintain these advantages and mitigate some drawbacks, while intubation teams may provide the most parsimonious use of PPE, but may elide resident involvement.

Conclusions: There exist compelling motivations for involving senior residents and attendings in high-risk intubations during the COVID-19 pandemic. A just strategy will preserve residents’ role whenever possible, while maximizing supervision and providing alternative routes for intubation practice.

Procedural skill maintenance: Perspectives and motivations of pediatric emergency medicine faculty

BACKGROUND

Pediatric emergency medicine (PEM) physicians receive training in critical procedures, but these procedures are rare in practice. The literature on maintenance of procedural skills focuses on ways to practice (e.g., via simulation) and pays little attention to motivation's role. Understanding what motivates PEM physicians to maintain procedural skills can inform the design of supportive policies and interventions. Our study explores how PEM physicians conceptualize maintenance of procedural skills, what motivates them to maintain procedural skills, and barriers to procedural skill maintenance.

METHODS

This was a qualitative study of 12 PEM faculty guided by the self-determination theory (SDT) of motivation. SDT describes a typology that distinguishes extrinsic and intrinsic motivation, with intrinsic motivation based on autonomy, competence, and relatedness. Interviews were transcribed and coded using constant-comparative technique, and interviews continued until thematic sufficiency was achieved.

RESULTS

Participants had difficulty defining procedural skill maintenance by specific criteria and expressed ambivalence about external standards for competence, noting the need to account for individual and local practice factors. Three themes characterizing participants' motivation for procedural skills maintenance included: (1) desire to provide optimal patient care and fear of unsuccessful performance (competence), (2) procedural competence as part of the identity of a PEM physician who teaches and performs procedures (competence and relatedness), and (3) desire for accessibility and choice of options in maintaining procedural skills (autonomy). Participants identified lack of opportunities, time, and support as barriers to motivation and skills maintenance.

CONCLUSION

SDT concepts were integral to understanding faculty motivation, and this highlights the need for prioritizing faculty autonomy, competence, and relatedness in designing supports for procedural skill maintenance. Our findings regarding the difficulty in defining maintenance of skills emphasize the need for further discussion and study of this topic.