Motivations for a career in emergency medicine: a profile of the 1996 US applicant pool

INTRODUCTION

Although some studies have tried to assess the factors leading to choice of specialty, none have been specific to emergency medicine (EM). With a doubling of the number of EM residency programs in the past decade, an assessment of the career motivations of residents is in order.

OBJECTIVES

To identify and rank the factors that lead candidates to choose EM as a career.

METHODS

Fifty-four participating EM programs returned a total of 393 anonymous surveys completed by their 1996 National Residency Matching Program (NRMP) interviewees. The survey asked respondents to rank 12 factors on a 5-point (0-4) Likert scale.

RESULTS

Respondents ranked the 12 motivating factors in the following descending order of importance: diversity in clinical pathology, emphasis on acute care, flexibility in choice of practice location, flexibility of EM work schedules, previous work experience in EM, greater availability of EM faculty for bedside teaching, strong influence of an EM faculty advisor or mentor, relatively shorter length of training, better salaries for EM than for primary care specialties, the presence of an EM residency at the student's medical school, perception that EM residents have more time to moonlight and popularity of EM among medical students.

CONCLUSION

US applicants appear to choose a career in EM largely because of clinical factors (diversity of clinical pathology and emphasis on acute care) and practice-related factors (flexibility in practice location and schedule).

Patients' vs. Physicians' Assessments of Emergencies: The Prudent Layperson Standard

OBJECTIVE

To compare perception of the need for emergency care by emergency department (ED) patients vs. emergency physicians (EPs).

METHODS

Mailed survey to EPs and a convenience sample of ED patients. Survey rated urgency of acute sore throat, ankle injury, abdominal pain, and hemiparesis, as well as the best definition of "emergency." Responses were compared with chi-square (p < .05).

RESULTS

119/140 (85%) of EPs and 1453 ED patients responded. EPs were more likely to judge acute abdominal pain (79.8% vs. 43.4%, p < 0.001, odds ratio (OR) 5.16, 95% confidence interval (CI) 3.19-8.40) and hemiparesis (100% vs. 82.6%, p < 0.001, OR 24.9, 95% CI 3.75-94.4) as an emergency. Similar proportions of ED patients and EPs considered sore throat (12.2% vs. 7.6%, p = 0.18, OR 0.59, CI 0.27-1.23) and ankle injury (46.9% vs. 38.6%, p = 0.10, OR 0.71, CI 0.48-1.06) an emergency. EPs (35%) and ED patients (40%) agreed to a similar degree with the "prudent layperson" definition, "a condition that may result in death, permanent disability, or severe pain." (p = .36, OR 1.22, CI 0.81-1.84). EPs were more likely to add, "the condition prevented work," (27% vs. 16%, p = 0.003, OR 0.51, CI 0.33-0.81). Patients more often added, "occurred outside business hours" (15% vs. 4%, p = 0.002, OR 4.0, CI = 1.5-11.3).

CONCLUSION

For serious complaints, ED patients' thresholds for seeking care are higher than judged appropriate by EPs. Stroke is not uniformly recognized as an emergency. Absent consensus for the "correct" threshold, the prudent layperson standard is appropriate.

Second place winner. Absorption of topical ophthalmic medications presenting as lethargy and apnea in an infant

The case of a previously healthy 3-week-old infant with lethargy and apnea resulting from topical absorption of ophthalmic antiglaucoma medications is described. This case illustrates the importance of including topical drugs in medication histories and considering them as potential causes of systemic toxicity. It also emphasizes the high level of vigilance that is needed in monitoring infants and small children when prescribing concentrated topical medications that are usually given to adults.

Providing telephone advice from the emergency department

Emergency departments frequently receive telephone calls from the general public. Callers sometimes request detailed instruction or medical advice. The growth of managed care produced expanded use of telephone-based medical information as a part of managed care ED demand management. Although the suboptimal accuracy of on-site triage is well documented in the medical literature, the accuracy of telephone-based medical advice is poorly studied. Case law indicates that the expectations for the medical outcomes of those receiving telephone-based medical advice will not be significantly less than those for on-site ED triage. This American College of Emergency Physicians Policy Resource and Education Paper (PREP) explores these issues.

Utility of the CORD ECG Database in Evaluating ECG Interpretation by Emergency Medicine Residents

OBJECTIVES

Electrocardiograph (ECG) interpretation is a vital component of Emergency Medicine (EM) resident education, but few studies have formally examined ECG teaching methods used in residency training. Recently, the Council of EM Residency Directors (CORD) developed an Internet database of 395 ECGs that have been extensively peer-reviewed to incorporate all findings and abnormalities. We examined the efficacy of this database in assessing EM residents' skills in ECG interpretation.

METHODS

We used the CORD ECG database to evaluate residents at our academic three-year EM residency. Thirteen residents participated, including four first-year, four second-year, and five third-year residents. Twenty ECGs were selected using 14 search criteria representing a broad range of abnormalities, including infarction, rhythm, and conduction abnormalities. Exams were scored based on all abnormalities and findings listed in the teaching points accompanying each ECG. We assigned points to each abnormal finding based on clinical relevance.

RESULTS

Out of a total of 183 points in our clinically weighted scoring system, first-year residents scored an average of 99 points (54.1%) [91-119], second-year residents 111 points (60.4%) [97-126], and third-year residents 130 points (71.0%) [94-150], p = 0.12. Clinically relevant abnormalities, including anterior and inferior myocardial infarctions, were most frequently diagnosed correctly, while posterior infarction was more frequently missed. Rhythm abnormalities including ventricular and supraventricular tachycardias were most frequently diagnosed correctly, while conduction abnormalities including left bundle branch block and atrioventricular (AV) block were more frequently missed.

CONCLUSION

The CORD database represents a valuable resource in the assessment and teaching of ECG skills, allowing more precise identification of areas upon which instruction should be further focused or individually tailored. Our experience suggests that more focused teaching of conduction abnormalities and posterior infarctions may be beneficial. The CORD database should be considered for incorporation into an ECG curriculum during residency training.

Report from the Council of Emergency Medicine Residency Directors subcommittee on graduate medical education funding: effects of decreased medicare support

INTRODUCTION

Recent changes by the Health Care Financing Administration (HCFA) have resulted in decreased Medicare support for emergency medicine (EM) residencies.

OBJECTIVE

To determine the effects of reduced graduate medical education (GME) funding support on residency size, resident rotations, and support for a fourth postgraduate year (PGY) of training and for residents with previous training.

METHODS

A 36-question survey was developed by the Council of Emergency Medicine Residency Directors (CORD) committee on GME funding and sent to all 122 EM program directors (PDs). Responses were collected by the Society for Academic Emergency Medicine (SAEM) office and blinded with respect to the institution.

RESULTS

Of 122 programs, 109 (89%) responded, of which 78 were PGY 1-3 programs, 19 were PGY 2-4, and 12 were PGY 1-4. The PDs were asked specifically whether there were changes in program size due to changes in Medicare reimbursement. Although few programs (12%) decreased their size or planned to decrease their size, 39% had discussions regarding decreasing their size. Thirty percent of the PDs responded that other programs at their institution had already decreased their size; 26% of the PDs had problems with financing outside rotations; and 24% had a decrease in off-service residents in their emergency departments (EDs). Only seven (6%) of programs paid residents from practice plan dollars, while most (82%) were fully supported by federal GME funding. Nearly all four-year programs (97%) received full resident salary support from their institutions and 77% of programs accept residents with previous training.

CONCLUSIONS

Nearly all EM programs are fully supported by their institutions, including the fourth postgraduate year. Most programs take residents with previous training. Although few programs have reduced their size, many are discussing this. Many programs have had difficulty with funding off-service rotations and many have had decreased numbers of off-service residents in their EDs. Recent GME funding changes have had adverse effects on EM residency programs.

AAEM, CORD, and SAEM reach a landmark position: consensus recommendations to the Federation of State Medical Boards (FSMB) for revisions to the FSMB May 1998 policy statement on physician licensure. American Academy of Emergency Medicine. Council of Emergency Medicine Residency Directors. Society for Academic Medicine

As a result of months of meetings and deliberations coordinated with the Medical Board of California and chaperoned by the California Chapter of the American Academy of Emergency Medicine (CAL/AAEM), the Society for Academic Medicine (SAEM), the Council of Emergency Medicine Residency Directors (CORD), and the American Academy of Emergency Medicine (AAEM) recently reached a landmark agreement on recommendations to the Federation of State Medical Boards (FSMB) pertaining to controversial May 1998 FSMB recommendations regarding physician licensure. Endorsed unanimously by the boards of all three emergency medicine (EM) organizations, the recommendations of this consensus have been forwarded to the FSMB and await its official response. The recommendations will also be forwarded to remaining EM organizations and to the medical community for comment and to enlist their support.

Emergency medicine residency applicant educational debt: relationship with attitude toward training and moonlighting

OBJECTIVES

Heated debate persists regarding the role of resident moonlighting in emergency medicine (EM). The attitudes of EM residency applicants have not been assessed. The objectives of this study were to assess: 1) the level of educational debt among EM residency applicants, 2) their perception of increased risk potential to patients from unsupervised EM resident practice, and 3) their opposition to laws restricting moonlighting. The authors then report the relationship between the degree of indebtedness and these stated positions.

METHODS

Fifty-four EM residency programs returned 393 responses to a 1996 anonymous survey. Applicants recorded: 1) their indebtedness, 2) whether they believed that EDs should hire only physicians who have completed full training in an EM residency, and 3) whether they believed that unsupervised EM practice prior to completing EM training carries a higher risk of adverse patient outcomes. The authors used a t-test and logistic regression to determine whether there was any significant difference in debt between responders who answered yes and those who answered no to the various questions. A p-value < 0.05 was considered significant.

RESULTS

The mean +/- SD debt was $72,290 +/- 48,683 (median $70,000). Most EM applicants (84.8%) agreed that unsupervised medical care by EM residents carries a higher risk of adverse patient outcomes. Paradoxically, only half the applicants opposed a moonlighting ban. Responses did not statistically correlate with educational debt.

CONCLUSIONS

Emergency medicine residency applicant debt is large. The EM applicants' opposition to laws that would restrict moonlighting was mixed. This was inconsistent with the majority acknowledging an increased risk potential to patients. Nearly all EM applicants would still select EM as a career, even if moonlighting were to be banned.

Earthquake epidemiology: the 1994 Los Angeles Earthquake emergency department experience at a community hospital

INTRODUCTION

To assess the volume of patients and the composition of their injuries and illnesses that presented to an emergency department (ED) close to the epicenter of an earthquake that occurred in a seismically prepared area.

METHODS

A retrospective analysis of data abstracted from charts and ED logs for patient census and types of injuries and illnesses of the patients who presented in the ED of a community hospital before and after the earthquake (6.8 Richter scale) that occurred in 1994 in Los Angeles. Illnesses were classified as trauma- and non-trauma related. Data were compared with epidemiological profiles of earthquakes in seismically prepared and unprepared areas.

RESULTS

A statistically significant increase in ED patient census over baseline lasted 11 days. There was a large increase in the number of traumatic injuries such as lacerations and orthopedic injuries during the first 48 hours. Beginning on the third day after the event, primary care conditions predominated. When the effects of the LA quake were compared with those of similar Richter magnitude and disruptive capability, the ED epidemiology profile was similar to those in seismically unprepared areas, except for the total number of casualties.

CONCLUSION

The majority of patients with traumatic injuries presented within the first 48 hours. The increase relative to baseline lasted 11 days. Efforts to develop disaster response systems from resources outside the disaster-stricken area should focus on providing mostly primary care assistance. Communities in seismically prepared areas could require external medical assistance for their EDs for up to two weeks following the event.

The threat of funding cuts for graduate medical education: survey of decision makers

OBJECTIVE

To assess the potential actions of medical school deans, graduate medical education (GME) committee chairs, and hospital chief executive officers (CEOs) regarding future funding reductions for residency training. Specifically, institutions with emergency medicine (EM) residencies were surveyed to see whether EM training was disproportionally at risk for reductions.

METHODS

An anonymous 2-page survey was used. Ninety-eight EM residency programs were identified using the American Medical Association Graduate Medical Education Directory 1994-95. Seventy deans, 102 GME chairs, and 97 hospital CEOs were identified. The survey posed a hypothetical 25% forced reduction in residency positions and asked the decision makers for their responses. Options included: 1) proportional reductions of training positions from all residencies, 2) proportional reductions in either primary care or specialty residency positions, or 3) reduction or elimination of specific training programs. The survey asked for a first and second choice of residencies to be reduced or eliminated from an alphabetical list of 17. The survey elicited explanations for each program reduction.

RESULTS

200 (74%) of 269 surveys were returned. Eighty-four responders selected specific residencies to be reduced or eliminated. EM was selected 8 times, making EM the seventh most vulnerable residency to be targeted for reductions. The decision makers who selected proportional reductions chose to reduce across all residencies 32 times, among only the specialty residencies 129 times, and among only the primary care residencies 3 times.

CONCLUSIONS

In the setting of anticipated residency cuts, favored proportional reductions in specialty residencies would likely affect EM training. However, most GME decision makers with an existing EM residency program do not consider the EM residency a top choice to be reduced or eliminated.