The 2011 model of the clinical practice of emergency medicine

Implementation of the resident exposure to nursing and administration curriculum

OBJECTIVES

Clinical competence is an essential component of the practice of emergency medicine (EM), but a well-rounded physician must gain appreciation and understanding of the many nonclinical aspects of EM, including emergency department (ED) throughput, operational metrics, financial principles, policies and procedures, interaction with nursing, and patient experience. While most residency programs include an administrative component, the majority are during the final year of training. We designed and piloted the Resident Exposure To Nursing and Administration (RETNA) curriculum for postgraduate year one (PGY-1) residents during orientation. The curriculum included a lecture, departmental tour with operational focus, and nurse shadowing experience, which were completed prior to their first clinical shift. We hypothesized that residents would view this favorably and advocate for formal adoption of the RETNA curriculum. Furthermore, we anticipated that the curriculum would improve relationships between residents and nursing.

METHODS

The three-component RETNA curriculum was piloted at an urban, academic center, with 14 PGY-1 residents per class, to two PGY-1 classes over a two-year period. Surveys were used to assess the resident perception of each component of the curriculum. Quantitative survey results were compared year over year using an unpaired t-test. Qualitative comments were also recorded and analyzed for content. Nursing evaluation scores of PGY-1 residents were used to independently analyze the impact of the curriculum on nurse-resident interactions.

RESULTS

The overall survey response rate was 82%. There was no statistically significant difference between the responses recorded in 2019 versus 2020 (p < 0.05). All PGY-1s, with one exception, agreed or strongly agreed that a similar session should be included in future orientations. Of the respondents, 88% thought that the lecture on ED flow was educational and 91% agreed that the nurse shadowing shift was a valuable learning experience. All subjective survey responses were positive, and all three components of the curriculum, ED flow, nursing workflow, and patient experience, were mentioned in the comments. Nurse-resident relationships improved after implementation of the curriculum.

CONCLUSION

The overwhelmingly positive feedback we received on this curriculum has led to the adoption of the RETNA curriculum as a core component for future EM orientations at the study institution. Introducing trainees to ED administration and nursing early in residency has few drawbacks and many potential benefits. As such, we advocate for further study and adoption of similar curricula to enhance and supplement existing postgraduate EM resident education.

Update on Medical Education, Insurance Coverage, and Health Care Policy for Lesbian, Gay, Bisexual, Transgender, Questioning, Intersexual, and Asexual Patients

There are important gaps in LGBTQIA knowledge, clinical competency, and cultural sensitivity, as well as attitudes among health care professionals, medical educators, and those in the public and insurance policy sectors. These are not only professional deficiencies but also perpetuate discrimination, limit access to health care, and lead to poor health outcomes. Research supports the notion that acquiring skills and knowledge through dedicated training programs leads to more compassionate and competent care for LGBTQIA patients.

Including Insonation in Undergraduate Medical School Curriculum

Insonation, or the use of ultrasound, has been proposed to be included in the medical school curriculum, both for education and bedside physical examination. It is important to consider what impact insonation should have on medical student education. Increasingly students are exposed to ultrasound use on clinical rotations, but to what extent should ultrasound be an integrated part of the preclinical curriculum in the United States? Ultrasound can serve to augment an existing curriculum in anatomy, physiology, physical examination, and disease assessment and treatment. In addition, the actual performance and interpretation of the insonation component of physical examination in real time may be an emerging skill set to be expected of medical students. Here we describe the utility and challenges of incorporating an ultrasound curriculum into undergraduate medical education, including examples from institutions that have pioneered this innovative curricular change.

Task errors by emergency physicians are associated with interruptions, multitasking, fatigue and working memory capacity: a prospective, direct observation study

BACKGROUND

Interruptions and multitasking have been demonstrated in experimental studies to reduce individuals' task performance. These behaviours are frequently used by clinicians in high-workload, dynamic clinical environments, yet their effects have rarely been studied.

OBJECTIVE

To assess the relative contributions of interruptions and multitasking by emergency physicians to prescribing errors.

METHODS

36 emergency physicians were shadowed over 120 hours. All tasks, interruptions and instances of multitasking were recorded. Physicians' working memory capacity (WMC) and preference for multitasking were assessed using the Operation Span Task (OSPAN) and Inventory of Polychronic Values. Following observation, physicians were asked about their sleep in the previous 24 hours. Prescribing errors were used as a measure of task performance. We performed multivariate analysis of prescribing error rates to determine associations with interruptions and multitasking, also considering physician seniority, age, psychometric measures, workload and sleep.

RESULTS

Physicians experienced 7.9 interruptions/hour. 28 clinicians were observed prescribing 239 medication orders which contained 208 prescribing errors. While prescribing, clinicians were interrupted 9.4 times/hour. Error rates increased significantly if physicians were interrupted (rate ratio (RR) 2.82; 95% CI 1.23 to 6.49) or multitasked (RR 1.86; 95% CI 1.35 to 2.56) while prescribing. Having below-average sleep showed a >15-fold increase in clinical error rate (RR 16.44; 95% CI 4.84 to 55.81). WMC was protective against errors; for every 10-point increase on the 75-point OSPAN, a 19% decrease in prescribing errors was observed. There was no effect of polychronicity, workload, physician gender or above-average sleep on error rates.

CONCLUSION

Interruptions, multitasking and poor sleep were associated with significantly increased rates of prescribing errors among emergency physicians. WMC mitigated the negative influence of these factors to an extent. These results confirm experimental findings in other fields and raise questions about the acceptability of the high rates of multitasking and interruption in clinical environments.

Evaluating and assessing the prevalence of bedside ultrasound in emergency departments in China

Background

To survey the prevalence of bedside ultrasound assessment in emergency departments (EDs) in China.

Methods

We designed an online survey for emergency physicians based in the China. The questionnaire included sixteen items querying common ED bedside ultrasound practices. Respondents were recruited via weblinks sent through social media and a popular Chinese emergency medicine website. Survey data was collected from April through June, 2016.

Results

Four hundred and twenty-eight physicians responded to this survey; more than 80% of respondents reported working clinically in the ED. Ninety-eight percent of respondents agreed on the clinical importance and value of bedside ultrasound. However, less than half of participants' EDs had ultrasound devices, and less than half of the respondents said they knew how to perform bedside ultrasound. Less than 20% of respondents reported having had formal training in bedside ultrasound.

Conclusions

There is a strong interest in bedside ultrasound in Chinese EDs. Emergency physicians participating in this study considered bedside ultrasound a necessary skill, but, because there is a lack of training, most emergency physicians reported they did not know how to perform bedside ultrasonography. There is likely an acute desire and need for bedside ultrasound training for Chinese emergency physicians.

Evolution of the Model of the Clinical Practice of Emergency Medicine: 1979 to Present

The Model of the Clinical Practice of Emergency Medicine (the EM Model) is a three-dimensional representation of the clinical practice of emergency medicine. It is a product of successful collaboration involving the American Board of Emergency Medicine (ABEM), the American College of Emergency Physicians (ACEP), the Society for Academic Emergency Medicine (SAEM), the Emergency Medicine Residents' Association (EMRA), the Council of Emergency Medicine Residency Directors (CORD), the Residency Review Committee for Emergency Medicine (RRC-EM), and the American Academy of Emergency Medicine (AAEM). In 2017, the most recent update and revision of the EM Model will be published. This document will represent the culmination of nearly 40 years of evolution, from a simple listing of presenting patient complaints, clinical symptoms, and disease states into a three-dimensional representation of the clinical practice of emergency medicine. These dimensions include conditions and components, physician tasks, and patient acuity. In addition, over the years, two other documents have been developed, the Knowledge, Skills, and Abilities (KSAs) and the Emergency Medicine Milestones. Both serve as related and complementary educational and assessment tools. This article will review the development of the EM Model from its inception in 1979 to today.

Can You Multitask? Evidence and Limitations of Task Switching and Multitasking in Emergency Medicine

Emergency physicians work in a fast-paced environment that is characterized by frequent interruptions and the expectation that they will perform multiple tasks efficiently and without error while maintaining oversight of the entire emergency department. However, there is a lack of definition and understanding of the behaviors that constitute effective task switching and multitasking, as well as how to improve these skills. This article reviews the literature on task switching and multitasking in a variety of disciplines-including cognitive science, human factors engineering, business, and medicine-to define and describe the successful performance of task switching and multitasking in emergency medicine. Multitasking, defined as the performance of two tasks simultaneously, is not possible except when behaviors become completely automatic; instead, physicians rapidly switch between small tasks. This task switching causes disruption in the primary task and may contribute to error. A framework is described to enhance the understanding and practice of these behaviors.

Assessing knowledge base on geriatric competencies for emergency medicine residents

Introduction

Emergency care of older adults requires specialized knowledge of their unique physiology, atypical presentations, and care transitions. Older adults often require distinctive assessment, treatment and disposition. Emergency medicine (EM) residents should develop expertise and efficiency in geriatric care. Older adults represent over 25% of most emergency department (ED) volumes. Yet many EM residencies lack curricula or assessment tools for competent geriatric care. Fully educating residents in emergency geriatric care can demand large amounts of limited conference time. The Geriatric Emergency Medicine Competencies (GEMC) are high-impact geriatric topics developed to help residencies efficiently and effectively meet this training demand. This study examines if a 2-hour didactic intervention can significantly improve resident knowledge in 7 key domains as identified by the GEMC across multiple programs.

Methods

A validated 29-question didactic test was administered at six EM residencies before and after a GEMC-focused lecture delivered in summer and fall of 2009. We analyzed scores as individual questions and in defined topic domains using a paired student t test.

Results

A total of 301 exams were administered; 86 to PGY1, 88 to PGY2, 86 to PGY3, and 41 to PGY4 residents. The testing of didactic knowledge before and after the GEMC educational intervention had high internal reliability (87.9%). The intervention significantly improved scores in all 7 GEMC domains (improvement 13.5% to 34.6%; p<0.001). For all questions, the improvement was 23% (37.8% pre, 60.8% post; P<0.001) Graded increase in geriatric knowledge occurred by PGY year with the greatest improvement post intervention seen at the PGY 3 level (PGY1 19.1% versus PGY3 27.1%).

Conclusion

A brief GEMC intervention had a significant impact on EM resident knowledge of critical geriatric topics. Lectures based on the GEMC can be a high-yield tool to enhance resident knowledge of geriatric emergency care. Formal GEMC curriculum should be considered in training EM residents for the demands of an aging population.

Sensitivity of emergency bedside ultrasound to detect hydronephrosis in patients with computed tomography-proven stones

Introduction

Non-contrast computed tomography (CT) is widely regarded as the gold standard for diagnosis of urolithiasis in emergency department (ED) patients. However, it is costly, time-consuming and exposes patients to significant doses of ionizing radiation. Hydronephrosis on bedside ultrasound is a sign of a ureteral stone, and has a reported sensitivity of 72–83% for identification of unilateral hydronephrosis when compared to CT. The purpose of this study was to evaluate trends in sensitivity related to stone size and number.

Methods

This was a structured, explicit, retrospective chart review. Two blinded investigators used reviewed charts of all adult patients over a 6-month period with a final diagnosis of renal colic. Of these charts, those with CT evidence of renal calculus by attending radiologist read were examined for results of bedside ultrasound performed by an emergency physician. We included only those patient encounters with both CT-proven renal calculi and documented bedside ultrasound results.

Results

125 patients met inclusion criteria. The overall sensitivity of ultrasound for detection of hydronephrosis was 78.4% [95% confidence interval (CI)=70.2–85.3%]. The overall sensitivity of a positive ultrasound finding of either hydronephrosis or visualized stones was 82.4% [95%CI: 75.6%, 89.2%]. Based on a prior assumption that ultrasound would detect hydronephrosis more often in patients with larger stones, we found a statistically significant (p=0.016) difference in detecting hydronephrosis in patients with a stone ≥6 mm (sensitivity=90% [95% CI=82–98%]) compared to a stone <6 mm (sensitivity=75% [95% CI=65–86%]). For those with 3 or more stones, sensitivity was 100% [95% CI=63–100%]. There were no patients with stones ≥6 mm that had both a negative ultrasound and lack of hematuria.

Conclusion

In a population with CT-proven urolithiasis, ED bedside ultrasonography had similar overall sensitivity to previous reports but showed better sensitivity with increasing stone size and number. We identified 100% of patients with stones ≥6 mm that would benefit from medical expulsive therapy by either the presence of hematuria or abnormal ultrasound findings.

Scribe Impacts on Provider Experience, Operations, and Teaching in an Academic Emergency Medicine Practice

INTRODUCTION

Physicians dedicate substantial time to documentation. Scribes are sometimes used to improve efficiency by performing documentation tasks, although their impacts have not been prospectively evaluated. Our objective was to assess a scribe program's impact on emergency department (ED) throughput, physician time utilization, and job satisfaction in a large academic emergency medicine practice.

METHODS

We evaluated the intervention using pre- and post-intervention surveys and administrative data. All site physicians were included. Pre- and post-intervention data were collected in four-month periods one year apart. Primary outcomes included changes in monthly average ED length of stay (LOS), provider-specific average relative value units (RVUs) per hour (raw and normalized to volume), self-reported estimates of time spent teaching, self-reported estimates of time spent documenting, and job satisfaction. We analyzed data using descriptive statistics and appropriate tests for paired pre-post differences in continuous, categorical, and ranked variables.

RESULTS

Pre- and post-survey response rates were 76.1% and 69.0%, respectively. Most responded positively to the intervention, although 9.5% reported negative impressions. There was a 36% reduction (25%-50%; p<0.01) in time spent documenting and a 30% increase (11%-46%, p<0.01) in time spent in direct patient contact. No statistically significant changes were seen in job satisfaction or perception of time spent teaching. ED volume increased by 88 patients per day (32-146, p=0.04) pre- to post- and LOS was unchanged; rates of patients leaving against medical advice dropped, and rates of patients leaving without being seen increased. RVUs per hour increased 5.5% and per patient 5.3%; both were statistically significant. No statistically significant changes were seen in patients seen per hour. There was moderate correlation between changes in ED volume and changes in productivity metrics.

CONCLUSION

Scribes were well received in our practice. Documentation time was substantially reduced and redirected primarily to patient care. Despite an ED volume increase, LOS was maintained, with fewer patients leaving against medical advice but more leaving without being seen. RVUs per hour and per patient both increased.

An educational measure to significantly increase critical knowledge regarding interfacility patient transfers

BACKGROUND

Patient transfers among medical facilities are high-risk situations. Despite this, there is very little training of physicians regarding the medical and legal aspects of transport medicine.

OBJECTIVES

To examine the effects of a one hour, educational intervention on Emergency Medicine (EM) residents' and Critical Care (CC) fellows' knowledge regarding the medical and legal aspects of interfacility patient transfers.

METHODS

Prior to the intervention, physician knowledge regarding 12 key concepts in patient transfer was assessed using a pre-test instrument. A one hour, interactive, educational session followed immediately thereafter. Following the intervention, a post-intervention test was given between two and four weeks after delivery. Participants were also asked to describe any prior transportation-medicine-related education, their opinions as they relate to the relevance of the topic, and their comfort levels with patient transfers before and after the intervention.

RESULTS

Only a minority of participants had received any formal training in patient transfers prior to the intervention, despite dealing with patient transfers on a frequent, often daily, basis. Both groups improved in several categories on the post-intervention test. They reported improved comfort levels with the medicolegal aspects of interfacility patient transfers after the intervention and felt well-prepared to manage transfers in their daily practice.

CONCLUSION

A one hour, educational intervention objectively increased EM and CC physician trainees' understanding of some of the medicolegal aspects of interfacility patient transfers. The study demonstrated a lack of previous training on this important topic and improved levels of comfort with transfers after study participation.

Educating Emergency Medicine Residents in Emergency Department Administration and Operations: Needs and Current Practice

BACKGROUND

Emergency medicine (EM) residents are expected to develop competence in emergency department (ED) administration and operations.

OBJECTIVES

We assessed current needs and educational practices related to preparing EM residents for their role in ED operations, and explored whether there was an association between program characteristics and the presence of ED operations education in US EM residency programs.

METHODS

We conducted a cross-sectional needs assessment, using a web-based survey sent to all US EM residency programs to assess program characteristics, provision of ED operations-related lectures, availability of an ED administrative fellowship, and presence of a formal ED operations curriculum. Logistic regression was used to determine if any program characteristics were associated with the presence of lectures and a formal operations curriculum.

RESULTS

Of the 158 Accreditation Council for Graduate Medical Education-accredited EM programs, 117 (74%) responded. Of these, 109 (93%) respondents had at least 1 lecture on ED operational topics. Sixty programs (54%) measured resident productivity. Knowledge of Centers for Medicaid & Medicare Services reimbursement guidelines was significantly positively associated with presence of an ED operations curriculum (OR, 3.52, P  =  .009) and with lectures on patient satisfaction (OR, 3.99, P  =  .006). Measuring resident productivity was positively associated with having lectures on productivity (OR, 2.50, P  =  .02) and with ED throughput (OR, 2.32, P  =  .03). No 2 variables were simultaneously significant in the model.

CONCLUSIONS

Most EM programs had at least 1 lecture on ED operations topics. Roughly half of the programs measured resident productivity and half had a formal ED operations curriculum.

Teaching and evaluating multitasking ability in emergency medicine residents - what is the best practice?

Multitasking is an essential skill to develop during Emergency Medicine (EM) residency. Residents who struggle to cope in a multitasking environment risk fatigue, stress, and burnout. Improper management of interruption has been causally linked with medical errors. Formal teaching and evaluation of multitasking is often lacking in EM residency programs. This article reviewed the literature on multitasking in EM to identify best practices for teaching and evaluating multitasking amongst EM residents. With the advancement in understanding of what multitasking is, deliberate attempts should be made to teach residents pitfalls and coping strategies. This can be taught through a formal curriculum, role modeling by faculty, and simulation training. The best way to evaluate multitasking ability in residents is by direct observation. The EM Milestone Project provides a framework by which multitasking can be evaluated. EM residents should be deployed in work environments commiserate with their multitasking ability and their progress should be graduated after identified deficiencies are remediated.

Should pediatric emergency physicians be decentralized in the medical community?

INTRODUCTION

Pediatric emergency physicians (PEPs) are well established as primary emergency department (ED) providers in dedicated pediatric centers and university settings. However, the optimum role of these subspecialists is less well defined in the community hospital environment. This study examined the impact on the ED care of children after the introduction of 10 PEPs into a simulated medical community.

METHODS

A computer-generated community was created, containing 10 community hospitals treating 250,000 pediatric ED patients. Children requiring ED treatment received their care at the closest ED to their location. Ten PEPs were introduced into the community, and their impact on patient care was examined under 2 different models. In a restrictive model, the PEPs established 2 full-time pediatric EDs within the 2 busiest hospitals, whereas, in a distributive model, the PEPs were distributed throughout the 8 busiest hospitals. In the 8-hospital model, the PEPs provided direct patient care along with the general emergency physicians in that facility and also provided educational, administrative, and performance improvement support for the department. In the restrictive model, the PEPs impacted the care of 100% of the children presenting for treatment at their 2 practice sites. In the distributive model, impact included the direct patient care by the PEP but also included changes produced in the care provided by the general emergency physicians at the site. Three different levels of impact were considered for the presence of the PEPs: a low-impact version in which the PEPs' presence only impacted 25% of the children at that site, a moderate-impact version in which the impact affected 50% of the children, and a high-impact version in which the impact affected 75% of the children. A secondary analysis was performed to account for the possibility of patients self-diverting from the closest ED to 1 of the pediatric EDs in the restrictive model.

RESULTS

In the restrictive model, the addition of 10 PEPs to the community would impact 27% of the pediatric ED care in the community. In the 3 distributive models, the PEPs would impact 23% of pediatric care in the low-impact version, 46% of pediatric care in the moderate-impact version, and 69% of pediatric care in the high-impact version. If self-diversion were to occur in the restrictive model, then 19% of the patients would need to bypass the closest ED and travel to the pediatric ED to match the same effect on patient care produced in the moderate-impact version of the distributive model and 46% would need to divert to match the effect of the high-impact version.

CONCLUSIONS

The greatest impact of PEPs on an ED population of children is produced when the PEPs distribute themselves throughout a medical community rather than create individual pediatric EDs in a small number of hospitals.

Practicing emergency physicians report performing well on most emergency medicine milestones

BACKGROUND

The Accreditation Council for Graduate Medical Education's Next Accreditation System endorsed specialty-specific milestones as the foundation of an outcomes-based resident evaluation process. These milestones represent five competency levels (entry level to expert), and graduating residents will be expected to meet Level 4 on all 23 milestones. Limited validation data on these milestones exist. It is unclear if higher levels represent true competencies of practicing emergency medicine (EM) attendings.

OBJECTIVE

Our aim was to examine how practicing EM attendings in academic and community settings self-evaluate on the new EM milestones.

METHODS

An electronic self-evaluation survey outlining 9 of the 23 EM milestones was sent to a sample of practicing EM attendings in academic and community settings. Attendings were asked to identify which level was appropriate for them.

RESULTS

Seventy-nine attendings were surveyed, with an 89% response rate. Sixty-one percent were academic. Twenty-three percent (95% confidence interval [CI] 20%-27%) of all responses were Levels 1, 2, or 3; 38% (95% CI 34%-42%) were Level 4; and 39% (95% CI 35%-43%) were Level 5. Seventy-seven percent of attendings found themselves to be Level 4 or 5 in eight of nine milestones. Only 47% found themselves to be Level 4 or 5 in ultrasound skills (p = 0.0001).

CONCLUSIONS

Although a majority of EM attendings reported meeting Level 4 milestones, many felt they did not meet Level 4 criteria. Attendings report less perceived competence in ultrasound skills than other milestones. It is unclear if self-assessments reflect the true competency of practicing attendings. The study design can be useful to define the accuracy, precision, and validity of milestones for any medical field.

The 2013 Model of the Clinical Practice of Emergency Medicine

In 2001, "The Model of the Clinical Practice of Emergency Medicine" was first published. This document, the first of its kind, was the result of an extensive practice analysis of emergency department (ED) visits and several expert panels, overseen by representatives from six collaborating professional organizations (the American Board of Emergency Medicine, the American College of Emergency Physicians, the Society for Academic Emergency Medicine, the Residency Review Committee for Emergency Medicine, the Council of Emergency Medicine Residency Directors, and the Emergency Medicine Residents' Association). Every 2 years, the document is reviewed by these organizations to identify practice changes, incorporate new evidence, and identify perceived deficiencies. For this revision, a seventh organization was included, the American Academy of Emergency Medicine.

The prevalence of lesbian, gay, bisexual, and transgender health education and training in emergency medicine residency programs: what do we know?

BACKGROUND

The Institute of Medicine, The Joint Commission, and the U.S. Department of Health and Human Services all have recently highlighted the need for cultural competency and provider education on lesbian, gay, bisexual, and transgender (LGBT) health. Forty percent of LGBT patients cite lack of provider education as a barrier to care. Only a few hours of medical school curriculum are devoted to LGBT education, and little is known about LGBT graduate medical education.

OBJECTIVES

The objective of this study was to perform a needs assessment to determine to what degree LGBT health is taught in emergency medicine (EM) residency programs and to determine whether program demographics affect inclusion of LGBT health topics.

METHODS

An anonymous survey link was sent to EM residency program directors (PDs) via the Council of Emergency Medicine Residency Directors listserv. The 12-item descriptive survey asked the number of actual and desired hours of instruction on LGBT health in the past year. Perceived barriers to LGBT health education and program demographics were also sought.

RESULTS

There were 124 responses to the survey out of a potential response from 160 programs (response rate of 78%). Twenty-six percent of the respondents reported that they have ever presented a specific LGBT lecture, and 33% have incorporated topics affecting LGBT health in the didactic curriculum. EM programs presented anywhere from 0 to 8 hours on LGBT health, averaging 45 minutes of instruction in the past year (median = 0 minutes, interquartile range [IQR] = 0 to 60 minutes), and PDs support inclusion of anywhere from 0 to 10 hours of dedicated time to LGBT health, with an average of 2.2 hours (median = 2 hours, IQR = 1 to 3.5 hours) recommended. The majority of respondents have LGBT faculty (64.2%) and residents (56.2%) in their programs. The presence of LGBT faculty and previous LGBT education were associated with a greater number of desired hours on LGBT health.

CONCLUSIONS

The majority of EM residency programs have not presented curricula specific to LGBT health, although PDs desire inclusion of these topics. Further curriculum development is needed to better serve LGBT patients.

Reporting for duty during mass casualty events: a survey of factors influencing emergency medicine physicians

BACKGROUND

Academic medical centers play a major role in disaster response, and residents frequently serve as key resources in these situations. Studies examining health care professionals' willingness to report for duty in mass casualty situations have varying response rates, and studies of emergency medicine (EM) residents' willingness to report for duty in disaster events and factors that affect these responses are lacking.

OBJECTIVE

We sought to determine EM resident and faculty willingness to report for duty during 4 disaster scenarios (natural, explosive, nuclear, and communicable), to identify factors that affect willingness to work, and to assess opinions regarding disciplinary action for physicians unwilling to work in a disaster situation.

METHODS

We surveyed residents and faculty at 7 US teaching institutions with accredited EM residency programs between April and November 2010.

RESULTS

A total of 229 faculty and 259 residents responded (overall response rate, 75.4%). Willingness to report for duty ranged from 54.1% for faculty in a natural disaster to 94.2% for residents in a nonnuclear explosive disaster. The 3 most important factors influencing disaster response were concern for the safety of the family, belief in the physician's duty to provide care, and availability of protective equipment. Faculty and residents recommended minimal or no disciplinary action for individuals unwilling to work, except in the infectious disease scenario.

CONCLUSIONS

Most EM residents and faculty indicated they would report for duty. Residents and faculty responses were similar in all but 1 scenario. Disciplinary action for individuals unwilling to work generally was not recommended.

Ethical considerations in education research in emergency medicine

The 2012 Academic Emergency Medicine consensus conference on education research in emergency medicine (EM) addressed various issues, including that of ethics in medical education research for EM. Education research in EM is essential to patient care and safety, and with recent advances in simulation and the advent of the Milestones project, it will become even more vital. Education research in EM is guided by the same principles that guide the ethical conduct of all human subjects' research: respect for persons, beneficence, and justice. Regulatory provisions and widely accepted ethical standards provide a framework for research in EM education; however, special considerations exist for education research. To ensure patient and trainee safety and to maintain the integrity of new knowledge, ethical considerations should remain at the forefront of EM education research. For EM education researchers, recognition of the vulnerability of residents, medical students, and others as research subjects is paramount. This article fills an important gap by outlining the principles guiding education research in EM, exploring the ethical challenges and approaches to education research, and offering a framework and future directions for the ethical conduct of education research in EM.

Assessing medical knowledge of emergency medicine residents

The Accreditation Council for Graduate Medical Education (ACGME) requires that emergency medicine (EM) residency graduates are competent in the medical knowledge (MK) core competency. EM educators use a number of tools to measure a resident's progress toward this goal; it is not always clear whether these tools provide a valid assessment. A workshop was convened during the 2012 Academic Emergency Medicine consensus conference "Education Research in Emergency Medicine: Opportunities, Challenges, and Strategies for Success" where assessment for each core competency was discussed in detail. This article provides a description of the validity evidence behind current MK assessment tools used in EM and other specialties. Tools in widespread use are discussed, as well as emerging methods that may form valid assessments in the future. Finally, an agenda for future research is proposed to help address gaps in the current understanding of MK assessment.

The current state of core competency assessment in emergency medicine and a future research agenda: recommendations of the working group on assessment of observable learner performance

In 2012, the Accreditation Council for Graduate Medical Education (ACGME) introduced the Next Accreditation System (NAS) for residency program accreditation. With implementation of the NAS, residents are assessed according to a series of new emergency medicine (EM)-specific performance milestones, and the frequency of assessment reporting is increased. These changes are driving the development of new assessment tools for the NAS that can be feasibly implemented by EM residency programs and that produce valid and reliable assessment data. This article summarizes the recommendations of the writing group on assessment of observable learner performance at the 2012 Academic Emergency Medicine consensus conference on education research in EM that took place on May 9, 2012, in Chicago, Illinois. The authors define an agenda for future assessment tool research and development that was arrived at by consensus during the conference.