Bedside teaching in the emergency department

IFEM model curriculum: emergency medicine learning outcomes for undergraduate medical education

BACKGROUND

The International Federation for Emergency Medicine (IFEM) published its model curriculum for medical student education in emergency medicine in 2009. Because of the evolving principles of emergency medicine and medical education, driven by societal, professional, and educational developments, there was a need for an update on IFEM recommendations. The main objective of the update process was creating Intended Learning Outcomes (ILOs) and providing tier-based recommendations.

METHOD

A consensus methodology combining nominal group and modified Delphi methods was used. The nominal group had 15 members representing eight countries in six regions. The process began with a review of the 2009 curriculum by IFEM Core Curriculum and Education Committee (CCEC) members, followed by a three-phase update process involving survey creation [The final survey document included 55 items in 4 sections, namely, participant & context information (16 items), intended learning outcomes (6 items), principles unique to emergency medicine (20 items), and content unique to emergency medicine (13 items)], participant selection from IFEM member countries and survey implementation, and data analysis to create the recommendations.

RESULTS

Out of 112 invitees (CCEC members and IFEM member country nominees), 57 (50.9%) participants from 27 countries participated. Eighteen (31.6%) participants were from LMICs, while 39 (68.4%) were from HICs. Forty-four (77.2%) participants have been involved with medical students' emergency medicine training for more than five years in their careers, and 56 (98.2%) have been involved with medical students' training in the last five years. Thirty-five (61.4%) participants have completed a form of training in medical education. The exercise resulted in the formulation of tiered ILO recommendations. Tier 1 ILOs are recommended for all medical schools, Tier 2 ILOs are recommended for medical schools based on perceived local healthcare system needs and/or adequate resources, and Tier 3 ILOs should be considered for medical schools based on perceived local healthcare system needs and/or adequate resources.

CONCLUSION

The updated IFEM ILO recommendations are designed to be applicable across diverse educational and healthcare settings. These recommendations aim to provide a clear framework for medical schools to prepare graduates with essential emergency care capabilities immediately after completing medical school. The successful distribution and implementation of these recommendations hinge on support from faculty and administrators, ensuring that future healthcare professionals are well-prepared for emergency medical care.

Making goals count: A theory-informed approach to on-shift learning goals

Supervisors often ask emergency medicine trainees for their learning goals at the start of a clinical shift, though they may do so without considering the reasons for this practice. Recognizing the underlying rationale for voicing on-shift learning goals and proactively considering solutions for some of the associated challenges can help learners and supervisors employ this practice to its full potential. Goal articulation is rooted in educational principles such as self-regulated learning, targeted performance feedback, and collaborative relationships between learner and supervisor. Despite the potential for on-shift learning goals to augment learning, there are numerous barriers that make it challenging for learners and supervisors alike to create or follow up on meaningful goals. Learner-related challenges include uncertainty about how to develop goals within an unpredictable clinical environment and creating goals too narrow or broad in scope. Supervisor-related challenges include difficulties integrating direct observation into the clinical workflow and a desire to avoid negative feedback. The learning environment also presents inherent challenges, such as lack of longitudinal supervisor-learner relationships, time constraints, space limitations, and incentives for learners to conceal their knowledge gaps. The authors discuss these challenges to effective on-shift learning goals and propose solutions that target the learner's approach, the supervisor's approach, and the learning environment itself.

Understanding the uptake and adaption of targeted implementation interventions for reducing bronchiolitis investigations and therapies

AIM

To understand and evaluate the uptake and local adaptations of proven targeted implementation interventions that have effectively reduced unnecessary investigations and therapies in infants with bronchiolitis within emergency departments.

METHODS

A multi-centred, mixed-methods quality improvement study in four Australian hospitals that provide paediatric emergency and inpatient care from May to December 2021. All hospitals were provided with the same implementation intervention package and training. Real-time tracking logs of adaptions were completed followed by semi-structured interviews. Interviews were recorded, transcribed and subsequently coded using FRAME-IS to further describe the adaptions made.

RESULTS

Tracking logs were summarised and data from 12 interviews were compared from participating sites. The intervention resulted in 116 education sessions and a total of 23 adaptations made to educational materials, both content and contextual. Shortening education presentations, addition of bronchiolitis definitions, formatting of materials and novel interventions were the most common modifications. Audit and feedback were completed across all sites with varying utilisation. Targeted teaching was noted to dictate adaptions prior to and during implementation.

CONCLUSION

Quantitative and qualitative analysis of clinical 'real-world' adaptations to proven targeted implementation interventions allows invaluable insight for future de-implementation initiatives and national roll-out of implementation packages in the ED setting.

Obstetrics and gynecology patients' perceptions about bedside teaching at a Saudi teaching hospital

BACKGROUND

Bedside teaching (BST) is a crucial component of medical education. It entails the interaction of students with patients in outpatient clinics and inpatient wards under the supervision of their tutors in order to improve the clinical skills of the students and, ultimately, patient outcomes. This teaching relies heavily on patients' willingness and cooperation. The aim of this study was to assess the perception of Obstetrics and Gynecology (OB/GYN) patients regarding the presence and participation of medical students in BST.

MATERIALS AND METHODS

A cross-sectional survey was conducted among OB/GYN patients at the outpatient clinics and inpatient wards at King Fahd Hospital of the University (KFHU) in Al-Khobar from January 1 to April 30, 2023. Data were collected online through the Google Drive survey tool using a validated and pilot tested questionnaire. Data were analyzed utilizing SPSS version 26.0. Chi-squared test was employed to test for association between two categorical variables. Multiple logistic regression model was used to determine variables associated with positive attitudes.

RESULTS

A total of 507 patients completed online questionnaire. A highly positive patients' attitude was observed toward the presence and participation of medical students during BST with a mean score of 81.8 ± 10.4. The acceptance rates were higher for female students compared to male students (91.9% vs 61.7%) and for senior doctors compared to junior doctors (89.9% vs 58.9%). Patients who came to the outpatient clinics were also more likely to accept students' presence than those who went to hospital wards. Age, marital status, and previous clinic visits were positively associated with the acceptance level of the presence and involvement of medical students in BST without a significant difference.

CONCLUSION

In general, patients had a good perception of medical students' engagement in their care and that the gender of the medical students/doctors and clinical setting could affect this perception. Raising patients' awareness of their valuable role in male medical students' and doctors' education should be raised, as this will increase their acceptance during BST.

Is boarding compromising our residents' education? A national survey of emergency medicine program directors

Background

Boarding patients in the emergency department (ED) potentially affects resident education. Program director (PD) perceptions of the impact of boarding on their trainees have not been previously described.

Methods

We surveyed a cross-sectional convenience sample of emergency medicine PDs using a mixed-methods approach to explore their perceptions of how boarding has affected their residents' training. Descriptive data were reported as percentages and differences were calculated using Pearson's chi-square test, with p < 0.05 considered significant. A framework model was used to qualitatively analyze free-text responses.

Results

A total of 170 responses were collected, for a response rate of 63%. Most respondents felt that boarding had at least some effect on resident education with 29%, 35%, 18%, and 12% noting "a little," "a moderate amount," "a lot," and "a great deal," respectively, and 5% noting "no effect at all." Respondents perceived a negative impact of boarding on resident education and training, with 80% reporting a "somewhat" or "extremely negative" effect, 18% feeling neutral, and 2% noting a "somewhat positive" effect. Most noted a "somewhat" or "extremely negative" effect on resident education in managing ED throughput (70%) and high patient volumes (66%). Fifty-four percent noted a "somewhat" or "extremely negative" impact on being involved in the initial workup of undifferentiated patients. Thirty-two percent saw a "somewhat" or "extremely positive" effect on learning the management of critically ill patients. Qualitative analysis of challenges, mitigation strategies, and resident feedback emphasized the lack of exposure to managing departmental patient flow, impact on bedside teaching, and need for flexibility in resident staffing.

Conclusions

Most PDs agree that boarding negatively affects resident education and identify several strategies to mitigate the impact. These findings can help inform future interventions to optimize resident learning in the complex educational landscape of high ED boarding.

Student mistakes and teacher reactions in bedside teaching

We analyse interactions between teachers and students during video-recorded bedside teaching sessions in internal medicine, orthopaedics and neurology. Multiple raters used a high-inference categorical scheme on 36 sessions. Our research questions concern the types of student mistakes, clinical teachers' reactions to them and if they use different strategies to address different types of mistakes. We used a Poisson model and generalized mixed models to analyse these research questions. Most frequently, students made reproduction mistakes. Relatively high rates of rejection and a similar prevalence of low and high levels of elaboration and correction time for students were observed. Reproduction mistakes were associated with the highest level of rejection and the lowest level of elaboration. High levels of elaboration were observed when students were applying skills in new situations. Students were most often allowed time to correct when mistakes in the areas of analysis or application of skills and knowledge had occurred. There is a decrease in the rate of making mistakes for neurology and orthopaedics compared to internal medicine. Reproduction mistakes influence significantly the outcome feedback compared to application mistakes. Analytic and reproduction mistakes influence elaboration significantly compared to application mistakes. We found a significant effect whether the lecturer allows time for correction of reproduction mistakes compared to application mistakes. These results contribute to the understanding of interactive, patient-centred clinical teaching as well as student mistakes and how teachers are reacting to them. Our descriptive findings provide an empirical basis for clinical teachers to react to student mistakes in didactically fruitful ways.

The Use and Teaching of Telemedicine in Allergy/Immunology Training Programs

PURPOSE OF REVIEW

The use of telemedicine has greatly increased since the onset of the coronavirus disease 2019 (COVID-19) pandemic. This review discusses the types of telemedicine, current telehealth curricula in medical education, and benefits and disadvantages of incorporation of telemedicine into Allergy/Immunology training programs.

RECENT FINDINGS

The majority of Allergists/Immunologists use telemedicine in their clinical practice with leaders in graduate medical education recommending inclusion of telemedicine in training. Fellows-in-training reported that use of telemedicine in Allergy/Immunology training during the pandemic mitigated some concerns for lack of adequate clinical experience. Still, no standardized curriculum for telemedicine training in Allergy/Immunology exists, although curricula from internal medicine and primary care residencies can provide a framework for incorporation of telemedicine training into fellowship. Benefits of telemedicine in Allergy/Immunology training include enhanced immunology training, home environment monitoring, and flexibility to reduce physician burnout while disadvantages include limited physical examination skill building and lack of a standardized curriculum. As telemedicine has been widely accepted in medicine with high patient satisfaction, it is necessary to incorporate a standardized telehealth curriculum in Allergy/Immunology fellowship training, both as a tool for patient care as well as trainee education.

National evaluation of trauma teaching for students (NETTS)

Despite the shift towards consultant-led care, many patients with trauma are still seen by junior doctors. Previous research has demonstrated that junior doctors feel unprepared to work in acute care but there is a paucity of recent research in trauma specifically. Thus, a national study is required to investigate the current state of undergraduate trauma teaching and identify specific areas for improvement. Between August and September 2020, a 35-item structured questionnaire was distributed among doctors who graduated from UK medical schools within the last 4 years. The questionnaire retrospectively assessed their experience of trauma teaching at medical school and their confidence to diagnose and manage patients with trauma. 398 responses were recorded from graduates of 39 UK medical schools. With 79.6% reporting only 0-5 hours of bedside trauma teaching and 51.8% reporting less than 20 hours in Accident and Emergency, graduates reported that trauma teaching was deficient compared with other specialties (78.1%). The majority of graduates were not confident in the initial assessment (72.9%) of a patient with trauma and almost all felt that a short course in trauma would be useful (93.7%). 77.4% of students felt that online learning would be beneficial and 92.9% felt that simulation would be useful. There is lack of standardised undergraduate trauma teaching nationally; a formal undergraduate teaching to ensure that new graduates are competent in the management of trauma would be supported by students. It is likely that a blended learning approach, incorporating e-learning with traditional teaching and clinical experience would be well received.

Examining trust between supervisors and trainees in the pediatric emergency department

Objective

Lack of trust between supervisors and trainees can have harmful consequences. Trust has been examined between physicians, patients, and staff in multiple settings but has not been examined in a bidirectional manner in the pediatric emergency department (PED). Debra Meyerson in 1996 discussed the theory of swift trust, a type of trust that develops quickly between temporary groups through reliance on categories. Meyerson describes categories as groups unified by social identities such as gender or profession. We explored the applicability of swift trust in the relationship between supervisors and trainees in the PED.

Methods

This multimethods study used qualitative interviews and the validated interpersonal mistrust trust measure (IMTM) to assess baseline trusting style. PED attendings from a single institution and residents from various training levels, specialties, and institutions rotating through the same PED were sampled until thematic saturation was reached. Interviews were analyzed using directed content analysis. IMTM scores were triangulated with interviewee's reported trusting styles.

Results

Seventeen PED attendings and 16 residents participated. Residents and attendings emphasized different factors that influence trust. Common factors across groups included affect, the need for vulnerability, and appropriate communication. Most described reliance on certain categories (level of training, specialty, etc.) when making trusting decisions. Categories such as gender and race were noted to be unimportant when making trusting decisions about others, although some participants believed these attributes played into decisions made by others. Quantitative data from the IMTM supported qualitative conclusions regarding trusting style.

Conclusions

The trusting relationship between supervisors and trainees in the PED dovetails with the swift trust theory. Common factors that influence trust reveal entry points for attendings and residents to improve trust and ultimately prevent negative patient outcomes. Future studies may examine how reliance on categories influences an individual's trust in their colleagues.

Exploring Teamwork Challenges Perceived by International Medical Graduates in Emergency Medicine Residency

INTRODUCTION

Non-US international medical graduates (IMG) represent a gradually increasing portion of emergency medicine (EM) residents in the United States. Yet there are no previous studies that explore the needs of this learner population. We conducted a qualitative study to examine non-US IMGs' perceptions of challenges they face specifically regarding team dynamics during their first year of an EM residency.

METHOD

Nine non-US IMGs in EM from all over the US participated in anonymous, semi-structured phone interviews lasting 45-60 minutes. We then coded and analyzed the interviews to identify axes and themes using an inductive approach informed by grounded theory. Focused coding and member checking were employed.

RESULTS

Non-US IMGs' perceptions of challenges regarding team dynamics during their first year of an EM residency coalesced into two themes: system-based challenges, such as a new power dynamic and understanding the local hospital system, and interpersonal challenges, such as establishing rapport and articulation of critical thinking.

CONCLUSION

Non-US IMGs perceived several unique challenges regarding team dynamics during their first year of an EM residency, whether system-based or interpersonal-based. We propose solutions such as a transitional curriculum (as suggested by the participants as well) and cultural-competence training for academic leadership.

How is modern bedside teaching structured? A video analysis of learning content, social and spatial structures

BACKGROUND

Bedside teaching (BST) is an essential and traditional clinical teaching format. It has been subject to various impediments and has transformed over time. Besides a decrease in bedside time, there has also been a didactic diversification. In order to use time at the bedside effectively and understand the current design of BST, we here offer an evidence-based insight into how BST is practiced. This may serve as a basis for a refinement of its didactic design.

METHODS

In the current study, we investigate the interrelationships between learning content and the social as well as spatial structures of BST. To this end, we have empirically analysed almost 80 hours of video material from a total of 36 BST sessions with good interrater reliability.

RESULTS

BST lasted on average 125 min, most of which was spent in plenary and less than a third of the time at the patient's bedside. History taking was primarily practiced at the bedside while case presentations, clinical reasoning and theoretical knowledge were largely taught away from the patient. Clinical examination took place to a similar extent in the patient's room and in the theory room.

CONCLUSIONS

Even though the filmed BSTs are not purely "bedside", the teaching format investigated here is a typical example of undergraduate medical education. In order to maximize the teaching time available, a suitable learning space should be provided in addition to the bedside. Moreover, the clinical examination should be revised in its general sequence prior to the BST, and conscious decisions should be made regarding the social structure so as to optimize the potential of small groups and plenary sessions.

Targeted organized teaching scripts (TOTS) in the pediatric emergency department

In the pediatric emergency department (PED), considerable challenges inhibit educational opportunities for residents outside of being precepted. The use of teaching scripts specifically addresses these challenges by allowing faculty to have prepared, hyperfocused content that can be delivered in a short time. We developed a series of teaching scripts for 10 high-yield topics in the PED and assessed their effectiveness at improving educational experiences. Teaching scripts were inconsistently used but well received. Their use also correlated with increased resident satisfaction with clinical teaching. The majority of residents and faculty showed considerable interest in expanding the TOTS program to include additional pediatric emergency medicine topics.

Consolidating human disease learning in the Dental Emergency Clinic

INTRODUCTION

Dental undergraduates typically learn and are assessed on aspects of human disease (HD) in the early part of their programme, but it is not until later in the programme that their HD knowledge is put into practice when they provide courses of treatment for numerous patients over multiple visits. The teaching of HD provides core knowledge on medical conditions and medications and is therefore essential in allowing newly graduated dentists to provide safe treatment for medically compromised patients or those taking medications. We wanted to examine the medical complexity of patients attending a university hospital dental emergency clinic to determine whether this was a suitable group that would help students to consolidate their HD learning in the context of a single visit where treatment was also provided.

MATERIALS AND METHODS

We examined the medical history of 200 patients attending the dental emergency clinic in the University Dental Hospital, Cardiff, using a previous study as a benchmark. Anonymous data were collected using the medical history proforma, and included age, gender, medications, types and number of medical conditions/disorders.

RESULTS

Patients attending the clinic were more medically complex than those in the comparator study and the demographics reflect wider population data showing increasing numbers of older patients with greater medical morbidity.

DISCUSSION/CONCLUSIONS

The emergency dental clinic is the place where most patients are new to the hospital, have a dental history, medical history, investigations, diagnosis and treatment in a single visit, and offers excellent opportunities for consolidating HD learning in a one-stop clinical treatment episode, guided by suitable instructors.

The Effect of Bedside Rounds on Learning Outcomes in Medical Education: A Systematic Review

PURPOSE

To determine if bedside rounds, compared with other forms of hospital ward rounds, improve learning outcomes in medical education.

METHOD

For this systematic review, the authors searched Ovid MEDLINE, Embase, and Scopus from inception through February 20, 2020. Experimental studies were included if they (1) compared bedside rounds to any other form of rounds in a hospital-based setting, and (2) reported a quantitative comparison of a learning outcome (e.g., learner reaction, knowledge, skills, behavior, health care delivery) among physicians-in-training (medical students, residents, fellows). Extraction elements were summarized using descriptive statistics and a narrative synthesis of design, implementation, and outcomes.

RESULTS

Twenty studies met inclusion criteria, including 7 randomized trials. All studies involved resident physicians, and 11 also involved medical students. The design and implementation of bedside rounds varied widely, with most studies (n = 13) involving cointerventions (e.g., staff education, real-time order entry).Of the 15 studies that reported learner satisfaction, 7 favored bedside rounds, 4 favored the control, and 4 were equivocal. Of the 4 studies reporting an outcome of learners' knowledge and skills, 2 favored bedside rounds and 2 were equivocal. Of the 8 studies that reported on learner behavior (e.g., bedside communication with patients), 5 favored bedside rounds, 1 favored the control, and 2 were equivocal. Finally, of the 14 studies that reported a health care delivery outcome (e.g., teamwork, rounding time), 8 favored bedside rounds and 6 were equivocal. Due to the high risk of bias and unexplained heterogeneity across studies, the overall strength of evidence was low.

CONCLUSIONS

In hospital-based settings, learners' satisfaction with bedside rounds is mixed. However, bedside rounds appear to have a positive effect on learner behavior and health care delivery. Given their potential value, additional research is needed to identify barriers to and facilitators of educationally successful bedside rounds.

Low Concordance Between Pediatric Emergency Attendings and Pediatric Residents for Predictors of Serious Intracranial Injury

OBJECTIVES

Minor head trauma is a common cause of pediatric emergency room visits. The Pediatric Emergency Care Applied Research Network head trauma clinical decision rules (PECARN-CDR) are designed to assist clinicians in determining which patients require imaging. However, only minimal data are available on the accuracy of residents' assessments using PECARN-CDR. Prior research suggests that trainees often come to erroneous conclusions about pediatric head trauma. The objective of the present study was to assess concordance between pediatric residents' and attending physicians' assessments of children with low-risk head trauma, with the ultimate goal of improving education in pediatric trauma assessment.

METHODS

This is a retrospective cohort study analyzing concordance between pediatric residents and pediatric emergency attendings who provided PECARN-CDR-based evaluations of low-risk head injuries. It is a planned subanalysis based on a prospectively collected, multicenter data set tracking pediatric head trauma encounters from July 2014 to June 2019.

RESULTS

Data were collected from 436 pediatric residents, who encountered 878 patients. In the case of patients younger than 2 years, low concordance between residents and attendings was observed for the following elements of the PECARN-CDR: severe mechanism (κ = 0.24), palpable skull fracture (κ = 0.23), Glasgow Coma Scale (GCS) score less than 15 (κ = 0.14), and altered mental status (AMS; κ = -0.03). There was moderate to high agreement between residents and attendings for loss of consciousness (κ = 0.71), nonfrontal hematoma (κ = 0.48), and not acting normally per parent (κ = 0.35). In the case of patients older than 2 years, there was low concordance for signs of basilar skull fracture (κ = 0.28) and GCS score less than 15 (κ = 0.10). Concordance was high to moderate for history of vomiting (κ = 0.88), loss of consciousness (κ = 0.67), severe headache (κ = 0.50), severe mechanism (κ = 0.44), and AMS (κ = 0.42). Residents were more conservative, that is, more likely to report a positive finding, in nearly all components of the PECARN-CDR.

CONCLUSIONS

Resident assessment of children presenting to the ED with minor head trauma is often poorly concordant with attending assessment on the major predictors of clinically important traumatic brain injury (abnormal GCS, AMS, signs of skull fracture) based on the PECARN-CDR. Future work may explore the reasons for low concordance and seek ways to improve pediatric resident education in the diagnosis and management of trauma.

Types and Timing of Teaching During Clinical Shifts in an Academic Emergency Department

Objectives

Academic emergency physicians must find ways to teach residents, medical students, and advanced practice providers amidst the myriad demands on their time during clinical shifts. In this study, we sought to characterize in detail what types of teaching occurred, how often they occurred, and how attending teaching styles differed at one academic emergency department (ED).

Methods

We conducted this observational study in a large, urban, quaternary care, academic Level I trauma center with an emergency medicine (EM) residency. The on-shift activities of EM attending physicians (attendings) were observed and recorded over 42 hours by a fourth-year EM resident with co-observations by an EM education fellow. Teaching categories were identified, developed iteratively, and validated by the study team. We then characterized the distribution of teaching activities during shifts through the coding of attending activities every 30 seconds during observations. Teaching archetypes were then developed through the synthesis of notes taken during observations.

Results

Attendings spent a mean of 25% (standard deviation 7%) of their time engaging in teaching activities during shifts. Of this teaching time 36% consisted of explicit instruction, while the remaining 64% of teaching occurred implicitly through the discussion of cases with learners. The time distribution of on-shift activities varied greatly between attendings, but three archetypes emerged for how attendings coupled patient care and teaching: “in-series”; “in-parallel modeling”; and “in-parallel supervision.”

Conclusions

Teaching in this academic ED took many forms, most of which arose organically from patient care. The majority of on-shift teaching occurred through implicit means, rather than explicit instruction. Attendings also spent their time in markedly different ways and embodied distinct teaching archetypes. The impact of this variability on both educational and patient care outcomes warrants further study.

Impact of COVID-19 on digital medical education: compatibility of digital teaching and examinations with integrity and ethical principles

The COVID-19 (coronavirus disease 2019) pandemic in 2020 has had a lasting impact on all areas of personal life. However, the political, economic, legal and healthcare system, as well as the education system have also experienced the effects. Universities had to face new challenges and requirements in teaching and examinations as quickly as possible in order to be able to guarantee high-quality education for their students.

This study aims to examine how the German-speaking medical faculties of the Umbrella Consortium of Assessment Network (UCAN) have dealt with the challenges but also the opportunities that the outbreak of the COVID-19 pandemic created in medical education and whether digitalisation has been driven forward as a result. In an initial online-survey we focused our questions on the current teaching situation with regard to digitised teaching content, the support or establishment of adequate framework conditions by the medical faculties and IT facilities and also the execution of examinations during the summer semester 2020.

Between August and September 2020, a total of 88 examiners, educators, dean of study and/or technical admins from 32 partner faculties took part in the survey. Students were not included in our survey. Most respondents stated that a switch to a digital semester had worked, the use of e-learning increased compared to previous semesters and that most courses could be converted, with the exception of practical courses, which were largely cancelled. The respondents also indicated that most examinations could still be taken, with the exception of practical examination formats, like Objective Structured Clinical Examinations (OSCEs). However, in the case of face-to-face examinations, strict distance and hygiene conditions had to be obeyed or there had to be a switch to distance-online examinations, which raised many open issues such as equal opportunities of students (technical equipment, internet access, premises) and attempts at deception (third-party help with the exam, mutual exchange between students, web search).

In conclusion, we identified several issues regarding the rapid transition to a digital semester due to COVID-19 which were categorised into the following topics: Face-to-face teaching could not take place, (2) know-how of educators, (3) integrity aspects, (4) technical aspects, (5) additional personnel required, (6) additional time and effort required for implementation of digital teaching. Our study shows that a switch to digital teaching and distance online examinations is feasible, but many problems were encountered concerning academic integrity and basic ethical principles still need to be solved. In order to investigate whether above mentioned issued could be solved one year after the transition to a digital semester, we conducted a second survey in which the 32 initially surveyed institutions were questioned again.

Design and Implementation of a Curriculum for Emergency Medicine Residents to Address Medications and Treatment Referral for Opioid Use Disorder

Background: Medications for Opioid Use Disorder (MOUD) are recognized as successful treatments for Opioid Use Disorder (OUD). The Emergency Department is well situated to initiate MOUD and begin the referral process. Unfortunately, uptake of this practice among Emergency Medicine (EM) physicians has been slow. EM physicians may feel inadequately prepared to provide MOUD and addiction referral services due to lack of previous training and experience. The goal of this pilot study was to create, implement, and evaluate an OUD management curriculum for EM residents and measure impact on knowledge, practice, and empathy. Methods: A 4.5-hour curriculum was developed, incorporating the Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment mission statement as well as the Accreditation Council for Graduate Medical Education and the American Board of Emergency Medicine resident physician milestones. The curriculum was inserted into an existing EM residency didactic block at an urban, tertiary care, residency program. Surveys were obtained pre- and post-intervention. Results: Post curriculum surveys demonstrated improved knowledge of buprenorphine/naloxone including indications, clinical effects and side-effects (p < 0.05). Surveys also noted increased comfort prescribing buprenorphine/naloxone for opioid withdrawal and misuse and instructing patients on home induction (p < 0.05). Additionally, residents responded positively regarding the impact of the curriculum on their understanding of the topic and their subsequent confidence in managing patients with OUD in the ED setting. Conclusion: A dedicated brief MOUD and referral curriculum can be effectively integrated into EM resident education to provide valuable clinical knowledge that may affect clinical practice.

Clinical Teaching: An Evidence-based Guide to Best Practices from the Council of Emergency Medicine Residency Directors

Clinical teaching is the primary educational tool use to train learners from day one of medical school all the way to the completion of fellowship. However, concerns over time constraints and patient census have led to a decline in bedside teaching. This paper provides a critical review of the literature on clinical teaching with a focus on instructor teaching strategies, clinical teaching models, and suggestions for incorporating technology. Recommendations for instructor-related teaching factors include adequate preparation, awareness of effective teacher attributes, using evidence-based-knowledge dissemination strategies, ensuring good communication, and consideration of environmental factors. Proposed recommendations for potential teaching strategies include the Socratic method, the One-Minute Preceptor model, SNAPPS, ED STAT, teaching scripts, and bedside presentation rounds. Additionally, this article will suggest approaches to incorporating technology into clinical teaching, including just-in-time training, simulation, and telemedical teaching. This paper provides readers with strategies and techniques for improving clinical teaching effectiveness.

Characteristics of Effective Teachers of Invasive Bedside Procedures: A Multi-institutional Qualitative Study

BACKGROUND

Faculty supervision of invasive bedside procedures (IBPs) in the ICU may enhance procedural education and ensure patient safety. However, there is limited research on teaching effectiveness in the ICU, and there are no best teaching practices regarding the supervision of IBPs.

RESEARCH QUESTION

We conducted a multi-institutional qualitative study of pulmonary and critical care medicine faculty and fellows to better understand characteristics of effective IBP teachers.

STUDY DESIGN AND METHODS

Separate focus groups (FGs) were conducted with fellows and faculty at four large academic institutions that were geographically distributed across the United States. FGs were facilitated by a trained investigator, audio-recorded, and transcribed verbatim for analysis. Themes were identified inductively and compared with constructs from social and situated learning theories. Data were analyzed between and across professional groups. Qualitative research software (NVivo; QSR International) was used to facilitate data organization and create an audit trail of the analysis. A multidisciplinary research team was engaged to minimize interpretive bias.

RESULTS

Thirty-three faculty and 30 fellows participated. Inductive analysis revealed three categories of themes among successful IBP teachers: traits, behaviors, and context. Traits included calm demeanor, trust, procedural competence, and effective communication. Behaviors included leading preprocedure huddles to assess learners' experiences and define expectations; debriefing to provide feedback; and allowing appropriate autonomy. Context included learning climate, levels of distraction, patient acuity, and institutional culture.

INTERPRETATION

We identified specific traits and behaviors of effective IBP teachers that intersect with the practice environment, which highlights the challenge of teaching IBPs. Notably, FG participants emphasized interpersonal, more than technical, aspects of successful IBP teachers. These findings should inform future curricula on teaching IBPs in the ICU, standardize IBP teaching for pulmonary and critical care medicine fellows, and reduce patient injury from procedural complications.

Developing Physical Exam Skills in Residency: Comparing the Perspectives of Residents and Faculty About Values, Barriers, and Teaching Methods

BACKGROUND

The physical examination (PE) skills of residents are often not improved since medical school. Unfortunately, how residents learn PE is not well understood. There is a paucity of research on the factors involved and the differences between resident and faculty perspectives. The authors sought to determine resident and faculty perceptions about the value of PE, the major barriers to learning PE, and the most effective teaching methods.

METHODS

Based on a rigorous process of literature review and semi-structured interviews, the authors developed an online survey which was sent to 406 internal medicine residents and 93 faculty at 3 institutions. Residents and faculty answered questions about both their own opinions and about their perception of the other group's opinions.

RESULTS

About 283 residents (70%) and 61 faculty (66%) completed the survey. Both residents and faculty rated the importance of PE similarly. Residents rated being too busy, followed by a lack of feedback, as the most significant barriers to learning PE. Faculty rated a lack of feedback, followed by a lack of resident accountability, as the most significant barriers. Both groups rated the availability of abnormal findings as the least significant barrier. Both groups agreed that faculty demonstration at the bedside was the most effective teaching method.

CONCLUSION

This survey can serve as a needs assessment for educational interventions to improve the PE skills of residents by focusing on areas of agreement between residents and faculty, specifically faculty demonstration at the bedside combined with feedback about residents' skills.

Impact of a Dedicated Teaching Attending Experience on a Required Emergency Medicine Clerkship

Introduction

One published strategy for improving educational experiences for medical students in the emergency department (ED) while maintaining patient care has been the implementation of dedicated teaching attending shifts. To leverage the advantages of the ED as an exceptional clinical educational environment and to address the challenges posed by the rapid pace and high volume of the ED, our institution developed a clerkship curriculum that incorporates a dedicated clinical educator role – the teaching attending – to deliver quality bedside teaching experiences for students in a required third-year clerkship. The purpose of this educational innovation was to determine whether a dedicated teaching attending experience on a third-year required emergency medicine (EM) clerkship would improve student-reported clinical teaching evaluations and student-reported satisfaction with the overall quality of the EM clerkship.

Methods

Using a five-point Likert-type scale (1 - poor to 5 - excellent), student-reported evaluation ratings and the numbers of graduating students matching into EM were trended for 10 years retrospectively from the inception of the clerkship for the graduating class of 2009 through and including the graduating class of 2019. We used multinomial logistic regression to evaluate whether the presence of a teaching attending during the EM clerkship improved student-reported evaluation ratings for the EM clerkship. We used sample proportion tests to assess the differences between top-box (4 or 5 rating) proportions between years when the teaching attending experience was present and when it was not.

Results

For clinical teaching quality, when the teaching attending is present the estimated odds of receiving a rating of 5 is 77.2 times greater (p <0.001) than when the teaching attending is not present and a rating of 4 is 27.5 times greater (p =0.0017). For overall clerkship quality, when the teaching attending is present, the estimated odds of receiving a rating of 5 is 13 times greater (p <0.001) and a rating of 4 is 5.2 times greater (p=0.0086) than when the teaching attending is not present.

Conclusion

The use of a dedicated teaching attending shift is a successful educational innovation for improving student self-reported evaluation items in a third-year required EM clerkship.

Resident Supervision and Patient Care: A Comparative Time Study in a Community-Academic Versus a Community Emergency Department

OBJECTIVE

The objective was to compare attending emergency physician (EP) time spent on direct and indirect patient care activities in emergency departments (EDs) with and without emergency medicine (EM) residents.

METHODS

We performed an observational, time-motion study on 25 EPs who worked in a community-academic ED and a nonacademic community ED. Two observations of each EP were performed at each site. Average time spent per 240-minute observation on main-category activities are illustrated in percentages. We report descriptive statistics (median and interquartile ranges) for the number of minutes EPs spent per subcategory activity, in total and per patient. We performed a Wilcoxon two-sample test to assess differences between time spent across two EDs.

RESULTS

The 25 observed EPs executed 34,358 tasks in the two EDs. At the community-academic ED, EPs spent 14.2% of their time supervising EM residents. Supervision activities included data presentation, medical decision making, and treatment. The time spent on supervision was offset by a decrease in time spent by EPs on indirect patient care (specifically communication and electronic health record work) at the community academic ED compared to the nonacademic community ED. There was no statistical difference with respect to direct patient care time expenditure between the two EDs. There was a nonstatistically significant difference in attending patient load between sites.

CONCLUSIONS

EPs in our study spent 14.2% of their time (8.5 minutes/hour) supervising residents. The time spent supervising residents was largely offset by time savings related to indirect patient care activities rather than compromising direct patient care.

Advances in Medical Education and Implications for the Pediatric Emergency Department

The learning environment of the pediatric emergency department is composed of many layers that provide opportunity for intervention to improve the education of residents and medical students. Creating an intentional plan of targeted interventions at the levels of learner, teacher, and department can create a culture where education is highly regarded. This article briefly defines the learning environment and explores strategies for improving clinical teaching at these various levels through improved teacher-learner relationships, entrustment, and the implementation of teaching strategies that can be easily incorporated into the busy and time-stretched work of the pediatric emergency department.

Emergency Medicine Resident Self-assessment of Clinical Teaching Compared to Student Evaluation Using a Previously Validated Rubric

PURPOSE

The quality of clinical teaching in the emergency department from the students' perspective has not been previously described in the literature. Our goals were to assess senior residents' teaching ability from the resident/teacher and student/learner viewpoints for any correlation, and to explore any gender association. The secondary goal was to evaluate the possible impact of gender on the resident/student dyad, an interaction that has previously been studied only in the faculty/student pairing.

METHODS

After approval by an institutional review board, a 1-year, grant-funded, single-site, prospective study was implemented at a regional medical campus that sponsors a 4-year dually approved emergency medicine residency. The residency hosts both medical school students (MSs) and physician's assistant students (PAs). Each student and senior resident working concurrently completed a previously validated ER Scale, which measured residents' teaching performance in 4 categories: Didactic, Clinical, Approachable, and Helpful. Students evaluated residents' teaching, while residents self-assessed their performance. The participants' demographic characteristics gathered included prior knowledge of or exposure to clinical teaching models. Gender was self-reported by participants. The analysis accounted for multiple observations by comparing participants' mean scores.

FINDINGS

Ninety-nine subjects were enrolled; none withdrew consent. Thirty-seven residents (11 women) and 62 students (39 women) from 25 MSs and 6 PA schools were enrolled, completing 517 teaching assessments. Students evaluated residents more favorably in all ER Scale categories than did residents on self-assessments (P < 0.0001). This difference was significant in all subgroup comparisons (types of school versus postgraduate years [PGYs]). Residents' evaluations by type of student (MS vs PA) did not show a significant difference. PGY 3 residents assessed themselves higher in all categories than did PGY 4 residents, with Approachability reaching significance (P = 0.0105). Male residents self-assessed their teaching consistently higher than did female residents, significantly so on Clinical (P = 0.0300). Students' evaluations of the residents' teaching skills by residents' gender did not reveal gender differences.

IMPLICATIONS

MS and PA students evaluated teaching by EM senior residents statistically significantly higher than did EM residents on self-evaluation when using the ER Scale. Students did not evaluate residents' teaching with any difference by gender, although male residents routinely self-assessed their teaching abilities more positively than did female residents. These findings suggest that, if residency programs utilize resident self-evaluation for programmatic evaluation, the gender of the resident may impact self-scoring. This cohort may inform future study of resident teaching in the emergency department, such as the design of future resident-as-teacher curricula.

Teaching Methods Utilized During Medical Resuscitations in an Academic Emergency Department

Introduction

One important skill that an emergency medicine trainee must learn is the resuscitation of the critically ill patient. There is research describing clinical teaching strategies used in the emergency department (ED), but less is known about specific methods employed during actual medical resuscitations. Our objective was to identify and describe the teaching methods used during medical resuscitations.

Methods

This was a prospective study involving review of 22 videotaped, medical resuscitations. Two teams of investigators first each reviewed and scored the amount and types of teaching observed for the same two videos. Each team then watched and scored 10 different videos. We calculated a Cohen's kappa statistic for the first two videos. For the remaining 20 videos, we determined means and standard deviations, and we calculated independent two-tailed t-tests to compare means between different demographic and clinical situations.

Results

The Cohen's kappa statistic was K=0.89 with regard to number of teaching events and K=0.82 for types of teaching observed. Of the resuscitations reviewed, 12 were in coding patients. We identified 148 episodes of teaching, for an average of 7.4 per resuscitation. The amount of teaching did not vary with regard to whether the patient was coding or not (p=0.97), nor based on whether the primary learner was a junior or senior resident (p=0.59). Questioning, affirmatives and advice-giving were the most frequently observed teaching methods.

Conclusion

Teachers use concise teaching methods to instruct residents who lead medical resuscitations. Further research should focus on the effectiveness of these identified strategies.

Fantastic Learning Moments and Where to Find Them

Introduction

Experiential learning is crucial for the development of all learners. Literature exploring how and where experiential learning happens in the modern clinical learning environment is sparse. We created a novel, web-based educational tool called "Learning Moment" (LM) to foster experiential learning among our learners. We used data captured by LM as a research database to determine where learning experiences were occuring within our emergency department (ED). We hypothesized that these moments would occur more frequently at the physician workstations as opposed to the bedside.

Methods

We implemented LM at a single ED's medical student clerkship. The platform captured demographic data including the student's intended specialty and year of training as well as "learning moments," defined as logs of learner self-selected learning experiences that included the clinical "pearl," clinical scenario, and location where the "learning moment" occurred. We presented data using descriptive statistics with frequencies and percentages. Locations of learning experiences were stratified by specialty and training level.

Results

A total of 323 "learning moments" were logged by 42 registered medical students (29 fourth-year medical students (MS 4) and 13 MS 3 over a six-month period. Over half (52.4%) intended to enter the field of emergency medicine (EM). Of these "learning moments," 266 included optional location data. The most frequently reported location was patient rooms (135 "learning moments", 50.8%). Physician workstations hosted the second most frequent "learning moments" (67, 25.2%). EM-bound students reported 43.7% of "learning moments" happening in patient rooms, followed by workstations (32.8%). On the other hand, non EM-bound students reported that 66.3% of "learning moments" occurred in patient rooms and only 8.4% at workstations (p<0.001).

Conclusion

LM was implemented within our ED as an innovative, web-based tool to fulfill and optimize the experiential learning cycle for our learners. In our environment, patient rooms represented the most frequent location of "learning moments," followed by physician workstations. EM-bound students were considerably more likely to document "learning moments" occurring at the workstation and less likely in patient rooms than their non EM-bound colleagues.

Literature review of teaching skills programs for junior medical officers

OBJECTIVE

The aim of this review was to assess the current evidence regarding the efficacy of teaching skills programs for junior medical officers. We aimed to compare and contrast these results with findings from previous literature reviews, the last of which were published in 2009.

METHODS

In order to capture studies since the last published literature reviews, five databases and grey literature were searched for publications from January 2008 to January 2015. A search for literature reviews without using the timeframe limitation was also performed.

RESULTS

The search from January 2008 to January 2015 resulted in the inclusion of 12 studies. Five systematic reviews of the topic were found which included 39 individual studies that were also analysed. Nearly all studies reported positive effects. Twenty nine studies reported change in attitudes, 28 reported modification in knowledge, 28 reported change in behaviour, 6 reported change in the organisation and two reported change in program participant's students. There were substantial threats of bias present.

CONCLUSIONS

The literature reviewed demonstrated many positive effects of teaching skills programs, which supports their utilization. However, high level outcomes need to be evaluated over longer periods of time to establish their true impact. An organisation specific approach to these programs needs to occur using sound course design principles, and they need to be reported in evaluation trials that are designed with robust methodology.

Quality of bedside teaching in internal wards of Qaem and Imam Reza hospitals in Mashhad

Background:

Bedside teaching is a patient-based teaching method in medical education. The present study has been conducted with the aim of investigating the quality of bedside teaching in the internal wards of Qaem and Imam Reza Educational Hospitals.

Methods:

This study follows a mixed qualitative-quantitative approach using checklists on educational clinical rounds in Imam Reza and Qaem Hospitals in Mashhad. In the first stage consisting of qualitative study, the parts related to the quality of bedside teaching were recognized and a checklist was designed in three domains of patient comfort (8 questions), targeted teaching (14 questions) and group dynamics (8 questions), and its reliability and validity were verified. In the next step, data were collected and then analyzed using SPSS 16 software through statistical techniques of independent t-test, one-way ANOVA and variance analysis.

Results:

In total, 113 educational rounds were investigated in this study. Among them, 59 (52.2%) and 54 (47.8%) educational rounds have been investigated in Imam Reza and Qaem Hospitals, respectively. The average total score of bedside teaching was 180.8 out of 300 in the internal wards of both Imam Reza and Qaem Hospitals.

Conclusion:

The results of this study showed that generally the quality of bedside teaching in Imam Reza and Qaem Hospitals of Mashhad is low according to the qualitative standards considered in this study. Holding educational workshops along with more familiarity of the professors with effective bedside teaching strategies could be effective in improving the quality of educational rounds.

Three-year emergency medicine training program in The Netherlands: first evaluation from the residents' perspective

BACKGROUND

The Netherlands' 3-year training in Emergency Medicine (EM) was formally approved and introduced in November 2008. To identify areas for improvement, we conducted the first evaluation of this curriculum from the residents' perspective.

METHODS

A questionnaire was composed on ten aspects of the curriculum. It contained multiple-choice, open and opinion questions; answers to the latter were classified using the Likert scale. The questionnaires were mailed to all enrolled residents.

RESULTS

We mailed questionnaires to all 189 enrolled residents, and 105 responded (55.6%). Although they were satisfied with their training overall, 96.2% thought it was currently too short: 18.3% desired extension to 4 years, 76.0% to 5 and 1.9% to 6 years. Nevertheless, residents expected that they would function effectively as emergency physicians (EPs) after finishing their 3-year training program. Bedside teaching was assessed positively by 35.2%. All rotations were assessed positively, with the general practice rotation seen as contributing the least to the program. According to 43.7%, supervising EPs were available for consultation; 40.7% thought that, in a clinical capacity, the EP was sufficiently present during residents' shifts. When EPs were present, 82.5% found them to be easily accessible, and 66.6% viewed them as role models. In the Emergency Medicine Departments (EDs) with a higher number of EPs employed, residents tended to perceive better supervision and were more likely to see their EPs as role models. While residents were stimulated to do research, actual support and assistance needed to be improved.

CONCLUSION

Although overall, the current training program was evaluated positively, the residents identified four areas for improvement: (1) in training hospitals, trained EPs should be present more continuously for clinical supervision; (2) bedside teaching should be improved, (3) scientific research should be facilitated more and (4) the training program should be extended.

Significant improvement of a clinical training course in physical examination after basic structural changes in the teaching content and methods

Background: Regular student evaluations at the Technical University Munich indicate the necessity for improvement of the clinical examination course. The aim of this study was to examine if targeted measures to restructure and improve a clinical examination course session lead to a higher level of student satisfaction as well as better self-assessment of the acquired techniques of clinical examination.

Methods: At three medical departments of the Technical University Munich during the 2010 summer semester, the quantitative results of 49 student evaluations (ratings 1-6, German scholastic grading system) of the clinical examination course were compared for a course before and a course after structured measures for improvement. These measures included structured teaching instructions, handouts and additional material from the Internet.

Results: 47 evaluations were completed before and 34 evaluations after the measures for improvement. The measures named above led to a significant improvement of the evaluative ratings in the following areas: short introduction to the topic of each clinical examination course (from 2.4±1.2 to1.7±1.0; p=0.0020) and to basic measures of hygiene (from 3.8±1.9 to 2.5±1.8; p=0.004), structured demonstration of each clinical examination step (from 2.9±1.5 to 1.8±1.0; p=0.001), sufficient practice of each clinical examination step (from 3.1±1.8 to 2.2±1.4; p=0.030) structured feedback on each clinical examination step (from 3.0±1.4 to 2.3±1.0; p=0.0070), use of handouts (from 5.2±1.4 to 1.8±1.4; p<0.001), advice on additional learning material (from 5.0±1.4 to 3.4±2.0; p<0.001), general learning experience (from 2.4±0.9 to 1.9±0.8; p=0.017), and self-assessment of the acquired techniques of clinical examination (from 3.5±1.3 to 2.5±1.1; p<0.01).

Conclusion: Structured changes led to significant improvement in the evaluative ratings of a clinical examination course session concerning preparation of the tutors, structure of the course, and confidence in performing physical examinations.

Influence of clinical experience and productivity on emergency medicine faculty teaching scores

BACKGROUND

Commonly cited barriers to effective teaching in emergency medicine include lack of time, competing demands for patient care, and a lack of formal teaching experience. Teaching may be negatively affected by demands for increased clinical productivity, or positively influenced by clinical experience.

OBJECTIVE

To examine the association between faculty teaching scores and clinical productivity, years of clinical experience, and amount of clinical contact with resident physicians.

METHODS

We conducted a retrospective, observational study with existing data on full-time faculty at a high-volume, urban emergency medicine residency training program for academic year 2008-2009. Residents rated faculty on 9 domains of teaching, including willingness to teach, enthusiasm for teaching, medical knowledge, preparation, and communication. Clinical productivity data for relative value units per hour and number of patients per hour, years of clinical experience, and annual clinical hours were obtained from existing databases.

RESULTS

For the 25 core faculty members included in the study, there was no relationship between faculty teaching scores and clinical productivity measures (relative value units per hour: r (2)  =  0.01, P  =  .96, patients per hour: r (2)  =  0.00, P  =  .76), or between teaching scores and total clinical hours with residents (r (2)  =  0.07, P  =  .19). There was a significant negative relationship between years of experience and teaching scores (r (2)  =  0.27, P < .01).

CONCLUSIONS

Our study demonstrated that teaching scores for core emergency medicine faculty did not correlate with clinical productivity or amount of clinical contact with residents. Teaching scores were inversely related to number of years of clinical experience, with more experienced faculty earning the lowest teaching scores. Further study is necessary to determine if there are clinical measures that identify good educators.

Learning clinical versus leadership competencies in the emergency department: strategies, challenges, and supports of emergency medicine residents

BACKGROUND

Emergency medicine residents are expected to master 6 competencies that include clinical and leadership skills. To date, studies have focused primarily on teaching strategies, for example, what attending physicians should do to help residents learn. Residents' own contributions to the learning process remain largely unexplored. The purpose of this study was to explore what emergency medicine residents believe helps them learn the skills required for practice in the emergency department.

METHODS

This qualitative study used semistructured interviews with emergency medicine residents at a major academic medical center. Twelve residents participated, and 11 additional residents formed a validation group. We used phenomenologic techniques to guide the data analysis and techniques such as triangulation and member checks to ensure the validity of the findings.

RESULTS

We found major differences in the strategies residents used to learn clinical versus leadership skills. Clinical skill learning was approached with rigor and involved a large number of other physicians, while leadership skill learning was unplanned and largely relied on nursing personnel. In addition, with each type of skills, different aspects of the residents' personalities, motivation, and past nonclinical experiences supported or challenged their learning process.

CONCLUSION

The approaches to learning leadership skills are not well developed among emergency medicine residents and result in a narrow perspective on leadership. This may be because of the lack of formal leadership training in medical school and residency, or it may reflect assumptions regarding how leadership skills develop. Substantial opportunity exists for enhancing emergency medicine residents' learning of leadership skills as well as the teaching of these skills by the attending physicians and nurses who facilitate their learning.

The return of bedside rounds: an educational intervention

BACKGROUND

Bedside rounds have decreased in frequency on teaching services. Perceived barriers toward bedside rounds are inefficiency and patient and house staff lack of preference for this mode of rounding.

OBJECTIVES

To evaluate the impact of a bedside rounding intervention on the frequency of bedside rounding, duration of patient encounters and rounding sessions, and patient and resident attitudes toward bedside rounds.

DESIGN

A pre- and postintervention design, with a bedside rounding workshop midway through two consecutive internal medicine rotations, with daily resident interviews, patient surveys, and an end-of-the-year survey given to all Medicine house staff.

PARTICIPANTS

Medicine house staff and medicine patients.

MEASURES

Frequency of bedside rounds, duration of new patient encounters and rounding sessions, and patient and house staff attitudes regarding bedside rounds.

RESULTS

Forty-four residents completed the bedside rounding workshop. Comparing the preintervention and postintervention phases, bedside rounds increased from <1% to 41% (p < 0.001). The average duration of walk rounding encounters was 16 min, and average duration of bedside rounding encounters was 15 min (p = 0.42). Duration of rounds was 95 and 98 min, respectively (p = 0.52). Patients receiving bedside rounds preferred bedside rounds (99% vs. 83%, p = 0.03) and perceived more time spent at the bedside by their team (p < 0.001). One hundred twelve house staff (71%) responded, with 73% reporting that bedside rounds are better for patient care. House staff performing bedside rounds were less likely to believe that bedside rounds were more educational (53% vs. 78%, p = 0.01).

CONCLUSIONS

Bedside rounding increased after an educational intervention, and the time to complete bedside rounding encounters was similar to alternative forms of rounding. Patients preferred bedside rounds and perceived more time spent at the bedside when receiving bedside rounds. Medicine residents performing bedside rounds were less likely to believe bedside rounds were more educational, but all house staff valued the importance of bedside rounding for the delivery of patient care.

Making sense: duty hours, work flow, and waste in graduate medical education

Parsimony, and not industry, is the immediate cause of the increase of capital. Industry, indeed, provides the subject which parsimony accumulates. But whatever industry might acquire, if parsimony did not save and store up, the capital would never be the greater.Adam Smith, The Wealth of Nations, book 2, chapter 31In 2003, the Accreditation Council for Graduate Medical Education implemented resident duty hour limits that included a weekly limit and limits on continuous hours. Recent recommendations for added reductions in resident duty hours have produced concern about concomitant reductions in future graduates' preparedness for independent practice. The current debate about resident hours largely does not consider whether all hours residents spend in the educational and clinical-care environment contribute meaningfully either to residents' learning or to effective patient care. This may distract the community from waste in the current clinical-education model. We propose that use of "lean production" and quality improvement methods may assist teaching institutions in attaining a deeper understanding of work flow and waste. These methods can be used to assign value to patient- and learner-centered activities and outputs and to optimize the competing and synergistic aspects of all desired outcomes to produce the care the Institute of Medicine recommends: safe, effective, efficient, patient-centered, timely, and equitable. Finally, engagement of senior clinical faculty in determining the culture of the care and education system will contribute to an advanced social-learning and care network.

Service versus education: finding the right balance: a consensus statement from the Council Of Emergency Medicine Residency Directors 2009 Academic Assembly "Question 19" working group

Many emergency medicine (EM) residency programs have recently received citations for their residents' responses to Question 19 of the Accreditation Council on Graduate Medical Education annual survey, which asks residents to rate their program's emphasis on clinical education over service obligations. To the best of our knowledge, no prior investigations or consensus statements exist that specifically address the appropriate balance between educational activity and clinical service in EM residency training. The objective of this project was to create a consensus statement based on the shared insights of academic faculty and educators in EM, with specific recommendations to improve the integration of education with clinical service in EM residency training programs. More than 80 EM program directors (PDs), associate and assistant PDs, and other academic EM faculty attending an annual conference of EM educators met to address this issue in a discussion session and working group. Participants examined the current literature on resident service and education and shared with the conference at large their collective insight and experience and possible solutions to this challenge. A consensus statement of specific recommendations and effective educational techniques aimed at balancing service and education requirements was created, based on the contributions of a diverse group of academic emergency physicians. Recommendations included identifying the teachable moment in all clinical service; promoting resident understanding of program goals and expectations from the beginning; educating residents about the ACGME resident survey; and engaging hospitals, institutional graduate medical education departments, and residents in finding solutions.

Direct observation of residents in the emergency department: a structured educational program

OBJECTIVES

The objective was to describe the implementation of a program of structured direct observation of emergency medicine (EM) residents during clinical shifts in the emergency department (ED).

METHODS

The authors developed a program in which an observer spent 4 to 5 hours with each resident, without intervening in the clinical encounters. A structured data form was developed to document the resident's performance in a number of defined clinical areas relevant to patient care and mastery of the core competencies. Individual strengths and weaknesses were noted, and the observer provided directed feedback at the end of the session.

RESULTS

Over an 18-month period, 32 EM residents were observed during their ED shifts. The sessions not only provided specific information on individual residents' performances, but also identified areas where the residency program curriculum could be enhanced and provided a means of assessing mastery of the core competencies. In addition, the program provided an opportunity to give detailed and timely directed feedback to residents. Both residents and attending staff found the sessions acceptable and useful.

CONCLUSIONS

Implementation of a structured direct observation program was feasible and well received and provided insight into the strengths and weaknesses of residents both individually and as a group.

The effect of emergency department crowding on education: blessing or curse?

Emergency department (ED) crowding is a national crisis that contributes to medical error and system inefficiencies. There is a natural concern that crowding may also adversely affect undergraduate and graduate emergency medicine (EM) education. ED crowding stems from a myriad of factors, and individually these factors can present both challenges and opportunities for education. Review of the medical literature demonstrates a small body of evidence that education can flourish in difficult clinical environments where faculty have a high clinical load and to date does not support a direct deleterious effect of crowding on education. To provide a theoretical framework for discussing the impact of crowding on education, the authors present a conceptual model of the effect of ED crowding on education and review possible positive and negative effects on each of the six recognized Accreditation Council for Graduate Medical Education (ACGME) core competencies.

Emergency medicine in India: why are we unable to 'walk the talk'?

The largest democracy on earth, the second most populous country and one of the most progressive countries in the globe, India, has advanced tremendously in most conventional fields of Medicine. However, emergency medicine (EM) is a nascent specialty and is yet to receive an identity. Today, it is mostly practised by inadequately trained clinicians in poorly equipped emergency departments (EDs), with no networking. Multiple factors such as the size of the population, variation in standards of medical education, lack of pre-hospital medical systems and non-availability of health insurance schemes are some of the salient causes for this tardy response. The Indian medical system is governed by a central, regulatory body which is responsible for the introduction and monitoring of all specialties--the Medical Council of India (MCI). This organisation has not recognized EM as a distinct specialty, despite a decade of dogged attempts. Bright young clinicians who once demonstrated a keen interest in EM have eventually migrated to other conventional branches of medicine, due to the lack of MCI recognition and the lack of specialty status. The Government of India has launched a nationwide network of transport vehicles and first aid stations along the national highways to expedite the transfer of patients from a crash site. However, this system cannot be expected to decrease morbidity and mortality, unless there is a concurrent development of EDs. The present article intends to highlight factors that continue to challenge the handful of dedicated, full time emergency physicians who have tenaciously pursued the cause for the past decade. A three-pronged synchronous development strategy is recommended: (i) recognise the specialty of EM as a distinct and independent basic specialty; (ii) initiate postgraduate training in EM, thus enabling EDs in all hospitals to be staffed by trained Emergency physicians; and (iii) ensure that EMs are staffed by trained ambulance officers. The time is ripe for a paradigm shift, since the country is aware that emergency care is the felt need of the hour and it is the right of the citizen.