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Greenberger SM, Finnell JT, Chang BP, Garg N, Quinn SM, Bird S, Diercks DB, Doty CI, Gallahue FE, Moreira ME, Ranney ML, Rives L, Kessler CS, Lo B, Schmitz G. Changes to the ACGME Common Program Requirements and Their Potential Impact on Emergency Medicine Core Faculty Protected Time. AEM Educ Train 2020; 4:244-253. [PMID: 32704594 PMCID: PMC7369497 DOI: 10.1002/aet2.10421] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 11/18/2019] [Accepted: 11/20/2019] [Indexed: 06/11/2023]
Abstract
The Accreditation Council for Graduate Medical Education (ACGME), which regulates residency and fellowship training in the United States, recently revised the minimum standards for all training programs. These standards are codified and published as the Common Program Requirements. Recent specific revisions, particularly removing the requirement ensuring protected time for core faculty, are poised to have a substantial impact on emergency medicine training programs. A group of representatives and relevant stakeholders from national emergency medicine (EM) organizations was convened to assess the potential effects of these changes on core faculty and the training of emergency physicians. We reviewed the literature and results of surveys conducted by EM organizations to examine the role of core faculty protected time. Faculty nonclinical activities contribute greatly to the academic missions of EM training programs. Protected time and reduced clinical hours allow core faculty to engage in education and research, which are two of the three core pillars of academic EM. Loss of core faculty protected time is expected to have detrimental impacts on training programs and on EM generally. We provide consensus recommendations regarding EM core faculty clinical work hour limitations to maintain protected time for educational activities and scholarship and preserve the quality of academic EM.
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Affiliation(s)
- Sarah M. Greenberger
- Department of Emergency MedicineUniversity of Arkansas for Medical SciencesLittle RockAR
| | - John T. Finnell
- The Regenstrief InstituteIndiana University School of MedicineIndianapolisIN
| | - Bernard P. Chang
- Department of Emergency MedicineColumbia University Medical CenterNew YorkNY
| | - Nidhi Garg
- Department of Emergency MedicineSouthside HospitalNew Hyde ParkNY
| | - Shawn M. Quinn
- Department of Emergency MedicineLehigh Valley Health NetworkAllentownPA
| | - Steven Bird
- Department of Emergency MedicineUniversity of MassachusettsWorcesterMA
| | - Deborah B. Diercks
- Department of Emergency MedicineUniversity of Texas Southwestern Medical CenterDallasTX
| | | | - Fiona E. Gallahue
- Harborview Medical CenterDepartment of Emergency MedicineThe University of WashingtonSeattleWA
| | - Maria E. Moreira
- Department of Emergency MedicineDenver Health and Hospital AuthorityDenverCO
| | | | - Loren Rives
- American College of Emergency PhysiciansIrvingTX
| | | | - Bruce Lo
- Eastern Virginia Medical SchoolNorfolkVA
| | - Gillian Schmitz
- San Antonio Military Medical CenterUniformed Services University of the Health SciencesSan AntonioTX
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Love JN, Doty CI, Smith JL, Deiorio NM, Jordan J, Van Meter MW, Edens MA, Hegarty CB. The Emergency Medicine Group Standardized Letter of Evaluation as a Workplace-based Assessment: The Validity Is in the Detail. West J Emerg Med 2020; 21:600-609. [PMID: 32421507 PMCID: PMC7234706 DOI: 10.5811/westjem.2020.3.45077] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Accepted: 03/27/2020] [Indexed: 11/11/2022] Open
Abstract
Introduction Interest is growing in specialty-specific assessments of student candidates based on clinical clerkship performance to assist in the selection process for postgraduate training. The most established and extensively used is the emergency medicine (EM) Standardized Letter of Evaluation (SLOE), serving as a substitute for the letter of recommendation. Typically developed by a program’s leadership, the group SLOE strives to provide a unified institutional perspective on performance. The group SLOE lacks guidelines to direct its development raising questions regarding the assessments, processes, and standardization programs employ. This study surveys EM programs to gather validity evidence regarding the inputs and processes involved in developing group SLOEs. Methods A structured telephone interview was administered to assess the input data and processes employed by United States EM programs when generating group SLOEs. Results With 156/178 (87.6%) of Accreditation Council of Graduate Medical Education-approved programs responding, 146 (93.6%) reported developing group SLOEs. Issues identified in development include the following: (1) 84.9% (124/146) of programs limit the consensus process by not employing rigorous methodology; (2) several stakeholder groups (nurses, patients) do not participate in candidate assessment placing final decisions at risk for construct under-representation; and (3) clinical shift assessments don’t reflect the task-specific expertise of each stakeholder group nor has the validity of each been assessed. Conclusion Success of the group SLOE in its role as a summative workplace-based assessment is dependent upon valid input data and appropriate processes. This study of current program practices provides specific recommendations that would strengthen the validity arguments for the group SLOE.
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Affiliation(s)
- Jeffrey N Love
- Georgetown University Hospital, Department of Emergency Medicine, Washington, District of Columbia
| | - Christopher I Doty
- University of Kentucky College of Medicine, Department of Emergency Medicine, Lexington, Kentucky
| | - Jessica L Smith
- Alpert Medical School, Brown University, Department of Emergency Medicine, Providence, Rhode Island
| | - Nicole M Deiorio
- Virginia Commonwealth University School of Medicine, Department of Emergency Medicine, Richmond, Virginia
| | - Jaime Jordan
- David Geffen School of Medicine, Harbor UCLA Medical Center, Department of Emergency Medicine, Torrance, California
| | - Michael W Van Meter
- McGovern Medical School, University of Texas-Houston, Department of Emergency Medicine, Houston, Texas
| | - Mary Ann Edens
- Louisiana State University School of Medicine-Shreveport, Department of Emergency Medicine, Shreveport, Louisiana
| | - Cullen B Hegarty
- University of Minnesota-HealthPartners Institute/Region Hospital, Department of Emergency Medicine, Saint Paul, Minnesota
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Moreira ME, Doty CI, Gallahue FE. We Need Our Village: CORD's Response to the ACGME's Common Program Requirements. West J Emerg Med 2019; 20:538-540. [PMID: 31316690 PMCID: PMC6625687 DOI: 10.5811/westjem.2019.7.44138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 07/01/2019] [Accepted: 07/01/2019] [Indexed: 11/21/2022]
Affiliation(s)
- Maria E Moreira
- Denver Health and Hospital Authority, Department of Emergency Medicine, Denver, Colorado.,University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado
| | - Christopher I Doty
- University of Kentucky-Chandler Medical Center, Department of Emergency Medicine, Lexington, Kentucky
| | - Fiona E Gallahue
- The University of Washington, Harborview Medical Center, Department of Emergency Medicine, Seattle, Washington
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Jones M, Scarduzio J, Mathews E, Holbrook P, Welsh D, Wilbur L, Carr D, Cary LC, Doty CI, Ballard JA. Individual and Team-Based Medical Error Disclosure: Dialectical Tensions Among Health Care Providers. Qual Health Res 2019; 29:1096-1108. [PMID: 30957639 DOI: 10.1177/1049732319837224] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Researchers from disciplines of education, health communication, law and risk management, medicine, nursing, and pharmacy examined communication tensions among interprofessional (IP) health care providers regarding medical error disclosure utilizing patient simulation. Using relational dialectics theory, we examined how communication tensions manifested in both individual-provided medical error disclosure and IP team-based disclosure. Two dialectical tensions that health care providers experienced in disclosure conversations were identified: (a) leadership and support, and (b) transparency and protectionism. Whereas these tensions were identified in an IP education setting using simulation, findings support the need for future research in clinical practice, which may inform best practices for various disclosure models. Identifying dialectical tensions in disclosure conversations may enable health communication experts to effectively engage health care providers, risk management, and patient care teams in terms of support and education related to communicating about medical errors.
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Affiliation(s)
- Mandy Jones
- 1 University of Kentucky, Lexington, Kentucky, USA
| | | | | | | | | | - Lee Wilbur
- 2 Catholic Health Initiative St. Vincent Infirmary, Little Rock, Arkansas, USA
| | - Douglas Carr
- 3 Indiana University School of Medicine at Bloomington, Bloomington, Indiana, USA
| | - L Curtis Cary
- 4 University of Tennessee at Chattanooga, Chattanooga, Tennessee, USA
| | | | - James A Ballard
- 5 Indiana University School of Medicine, Indianapolis, Indiana, USA
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Battaglioli N, Ankel F, Doty CI, Chung A, Lin M. Executive Summary from the 2017 Emergency Medicine Resident Wellness Consensus Summit. West J Emerg Med 2018; 19:332-336. [PMID: 29560062 PMCID: PMC5851507 DOI: 10.5811/westjem.2017.9.36182] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 08/25/2017] [Accepted: 09/22/2017] [Indexed: 11/25/2022] Open
Abstract
Introduction Physician wellness has recently become a popular topic of conversation and publication within the house of medicine and specifically within emergency medicine (EM). Through a joint collaboration involving Academic Life in Emergency Medicine’s (ALiEM) Wellness Think Tank, Essentials of Emergency Medicine (EEM), and the Emergency Medicine Residents’ Association (EMRA), a one-day Resident Wellness Consensus Summit (RWCS) was organized. Methods The RWCS was held on May 15, 2017, as a pre-day event prior to the 2017 EEM conference in Las Vegas, Nevada. Seven months before the RWCS event, pre-work began in the ALiEM Wellness Think Tank, which was launched in October 2016. The Wellness Think Tank is a virtual community of practice involving EM residents from the U.S. and Canada, hosted on the Slack digital-messaging platform. A working group was formed for each of the four predetermined themes: wellness curriculum development; educator toolkit resources for specific wellness topics; programmatic innovations; and wellness-targeted technologies. Results Pre-work for RWCS included 142 residents from 100 different training programs in the Wellness Think Tank. Participants in the actual RWCS event included 44 EM residents, five EM attendings who participated as facilitators, and three EM attendings who acted as participants. The four working groups ultimately reached a consensus on their specific objectives to improve resident wellness on both the individual and program level. Conclusion The Resident Wellness Consensus Summit was a unique and novel consensus meeting, involving residents as the primary stakeholders. The summit demonstrated that it is possible to galvanize a large group of stakeholders in a relatively short time by creating robust trust, communication, and online learning networks to create resources that support resident wellness.
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Affiliation(s)
| | - Felix Ankel
- HealthPartners Institute, Department of Emergency Medicine, University of Minnesota Medical School, St Paul, Minnesota
| | - Christopher I Doty
- University of Kentucky, Department of Emergency Medicine, Lexington, Kentucky
| | - Arlene Chung
- Icahn School of Medicine at Mount Sinai, Department of Emergency Medicine, New York, New York
| | - Michelle Lin
- University of California San Francisco, Department of Emergency Medicine, San Francisco, California
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Doty CI, Roppolo LP, Asher S, Seamon JP, Bhat R, Taft S, Graham A, Willis J. How Do Emergency Medicine Residency Programs Structure Their Clinical Competency Committees? A Survey. Acad Emerg Med 2015; 22:1351-4. [PMID: 26473693 DOI: 10.1111/acem.12804] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 05/04/2015] [Accepted: 06/10/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND The Accreditation Council for Graduate Medical Education (ACGME) recently has mandated the formation of a clinical competency committee (CCC) to evaluate residents across the newly defined milestone continuum. The ACGME has been nonproscriptive of how these CCCs are to be structured in order to provide flexibility to the programs. OBJECTIVES No best practices for the formation of CCCs currently exist. We seek to determine common structures of CCCs recently formed in the Council of Emergency Medicine Residency Directors (CORD) member programs and identify unique structures that have been developed. METHODS In this descriptive study, an 18-question survey was distributed via the CORD listserv in the late fall of 2013. Each member program was asked questions about the structure of its CCC. These responses were analyzed with simple descriptive statistics. RESULTS A total of 116 of the 160 programs responded, giving a 73% response rate. Of responders, most (71.6%) CCCs are chaired by the associate or assistant program director, while a small number (14.7%) are chaired by a core faculty member. Program directors (PDs) chair 12.1% of CCCs. Most CCCs are attended by the PD (85.3%) and selected core faculty members (78.5%), leaving the remaining committees attended by any core faculty. Voting members of the CCC consist of the residency leadership either with the PD (53.9%) or without the PD (36.5%) as a voting member. CCCs have an average attendance of 7.4 members with a range of three to 15 members. Of respondents, 53.1% of CCCs meet quarterly while 37% meet monthly. The majority of programs (76.4%) report a system to match residents with a faculty mentor or advisor. Of respondents, 36% include the resident's faculty mentor or advisor to discuss a particular resident. Milestone summaries (determination of level for each milestone) are the primary focus of discussion (93.8%), utilizing multiple sources of information. CONCLUSIONS The substantial variability and diversity found in our CORD survey of CCC structure and function suggest that there are myriad strategies that residency programs can use to match individual program needs and resources to requirements of the ACGME. Identifying a single protocol for CCC structure and development may prove challenging.
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Affiliation(s)
| | - Lynn P. Roppolo
- Department of Emergency Medicine; University of Texas; Southwestern Medical Center; Dallas TX
| | - Shellie Asher
- Department of Emergency Medicine; Albany Medical Center; Albany NY
| | - Jason P. Seamon
- Department of Emergency Medicine; Grand Rapids Medical Education Partners/Michigan State University; Grand Rapids MI
| | - Rahul Bhat
- Department of Emergency Medicine; Georgetown University; Washington DC
| | - Stephanie Taft
- Department of Emergency Medicine; East Carolina University; Greenville NC
| | - Autumn Graham
- Department of Emergency Medicine; Georgetown University; Washington DC
| | - James Willis
- Department of Emergency Medicine; SUNY Downstate Medical Center; Brooklyn NY
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Joshi NK, Yarris LM, Doty CI, Lin M. Social media responses to the Annals of Emergency Medicine residents' perspective article on multiple mini-interviews. Ann Emerg Med 2014; 64:320-5. [PMID: 25149965 DOI: 10.1016/j.annemergmed.2014.07.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Revised: 07/17/2014] [Accepted: 07/17/2014] [Indexed: 11/19/2022]
Abstract
In May 2014, Annals of Emergency Medicine continued a successful collaboration with an academic Web site, Academic Life in Emergency Medicine (ALiEM) to host an online discussion session featuring the 2014 Annals Residents' Perspective article "Does the Multiple Mini-Interview Address Stakeholder Needs? An Applicant's Perspective" by Phillips and Garmel. This dialogue included Twitter conversations, a live videocast with the authors and other experts, and detailed discussions on the ALiEM Web site's comment section. This summary article serves the dual purpose of reporting the qualitative thematic analysis from a global online discussion and the Web analytics for our novel multimodal approach. Social media technologies provide a unique opportunity to engage with a diverse audience to detect existing and new emerging themes. Such technologies allow rapid hypothesis generation for future research and enable more accelerated knowledge translation.
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Affiliation(s)
- Nikita K Joshi
- Department of Surgery, Division of Emergency Medicine, Stanford University; MedEdLIFE Research Collaborative, San Francisco, CA.
| | - Lalena M Yarris
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR
| | - Christopher I Doty
- Department of Emergency Medicine, University of Kentucky-Chandler Medical Center, Lexington, KY
| | - Michelle Lin
- MedEdLIFE Research Collaborative, San Francisco, CA; Department of Emergency Medicine, University of California, San Francisco, CA
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Love JN, Smith J, Weizberg M, Doty CI, Garra G, Avegno J, Howell JM. Council of Emergency Medicine Residency Directors' standardized letter of recommendation: the program director's perspective. Acad Emerg Med 2014; 21:680-7. [PMID: 25039553 DOI: 10.1111/acem.12384] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Revised: 12/19/2013] [Accepted: 12/20/2013] [Indexed: 10/25/2022]
Abstract
OBJECTIVES The standardized letter of evaluation (SLOE) was created in 1997 to provide residency program directors (PDs) with a summative evaluation that incorporates normative grading (i.e., comparisons to peers applying to emergency medicine [EM] training). Although the standard letter of recommendation (SLOR) has become increasingly popular and important in decision-making, it has not been studied in the past 12 years. To assess the SLOR's effectiveness and limitations, the perspective of EM PDs was surveyed in this study. METHODS After validation of the questionnaire by 10 retired PDs, the survey was sent to the PD of each of the 159 EM residencies that existed at that time. The survey was circulated via the Council of Emergency Medicine Residency Directors' (CORD) listserv from January 24, 2013, to February 13, 2013. Weekly e-mail reminders to all PDs served to increase participation. RESULTS A total of 150 of 159 PDs (94.3%) completed the questionnaire. Nearly all respondents (149 of 150; 99.3%) agreed that the SLOR is an important evaluative tool and should continue to be used. In the application process, 91 of 150 (60.7%) programs require one or more SLORs, and an additional 55 (36.7%) recommend but do not require a SLOR to be considered for interview. When asked to identify the top three factors in deciding who should be interviewed, the SLOR was ranked first (139 of 150; 92.7%), with EM rotation grades ranked second (73 of 150; 48.7%). The factors that were most often identified as the top three that diminish the value of the SLOR in order were 1) "inflated evaluations" (121 of 146; 82.9%), 2) "inconsistency between comments and grades" (106 of 146; 72.6%), and 3) "inadequate perspective on candidate attributes in the written comments" and "inexperienced authors" (60 of 146; 41.1% each). CONCLUSIONS The SLOR appears to be the most important tool in the EM PD's armamentarium for determining which candidates should be interviewed for residency training. Although valuable, the SLOR's potential utility is hampered by a number of factors, the most important of which is inflated evaluations. Focused changes in the SLOR template should be mindful that it appears, in general, to be successful in its intended purpose.
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Affiliation(s)
- Jeffrey N. Love
- Medstar Georgetown University Hospital/Medstar Washington Hospital Center; Washington DC
| | | | | | | | | | - Jennifer Avegno
- The Louisiana State University Health Sciences Center; New Orleans LA
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Hegarty CB, Lane DR, Love JN, Doty CI, DeIorio NM, Ronan-Bentle S, Howell J. Council of emergency medicine residency directors standardized letter of recommendation writers' questionnaire. J Grad Med Educ 2014; 6:301-6. [PMID: 24949136 PMCID: PMC4054731 DOI: 10.4300/jgme-d-13-00299] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Revised: 01/02/2014] [Accepted: 01/15/2014] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The Council of Emergency Medicine Residency Directors (CORD) Standardized Letter of Recommendation (SLOR) has become the primary tool used by emergency medicine (EM) faculty to evaluate residency candidates. A survey was created to describe the training, beliefs, and usage patterns of SLOR writers. METHODS The SLOR Task Force created the survey, which was circulated to the CORD listserv in 2012. RESULTS Forty-six percent of CORD members (320 of 695) completed the survey. Of the respondents, 39% (125 of 320) had fewer than 5 years of experience writing SLOR letters. Most were aware of published guidelines, and most reported they learned how to write a SLOR on their own (67.4%, 182 of 270). Sixty-eight percent (176 of 258) admitted to not following the instructions for certain questions. Self-reported grade inflation occurred "rarely" 36% (97 of 269) of the time and not at all 40% (107 of 269) of the time. CONCLUSIONS The CORD SLOR has become the primary tool used by EM faculty to evaluate candidates applying for residency in EM. The SLOR has been in use in the EM community for 16 years. However, our study has identified some problems with its use. Those issues may be overcome with a revised format for the SLOR and with faculty training in the writing and use of this document.
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Love JN, DeIorio NM, Ronan-Bentle S, Howell JM, Doty CI, Lane DR, Hegarty C. Characterization of the Council of Emergency Medicine Residency Directors' standardized letter of recommendation in 2011-2012. Acad Emerg Med 2013; 20:926-32. [PMID: 24050799 DOI: 10.1111/acem.12214] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Revised: 03/16/2013] [Accepted: 03/29/2013] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The Council of Emergency Medicine Residency Directors (CORD) introduced the standardized letter of recommendation (SLOR) in 1997, and it has become a critical tool for assessing candidates for emergency medicine (EM) training. It has not itself been evaluated since the initial studies associated with its introduction. This study characterizes current SLOR use to evaluate whether it serves its intended purpose of being standardized, concise, and discriminating. METHODS This retrospective, multi-institutional study evaluated letters of recommendation from U.S. allopathic applicants to three EM training programs during the 2011-2012 Electronic Residency Application Service (ERAS) application cycle. Distributions of responses to each question on the SLOR were calculated, and the free-text responses were analyzed. Two pilots, performed on five applicants each, assisted in developing a strategy for limiting interrater reliability. RESULTS Each of the three geographically diverse programs provided a complete list of U.S. allopathic applicants to their program. Upon randomization, each program received a list of coded applicants unique to their program randomly selected for data collection. The number of applicants was selected to reach a goal of approximately 200 SLORs per site (n = 602). Among this group, comprising 278 of 1,498 applicants (18.6%) from U.S. allopathic schools, a total of 1,037 letters of recommendation were written, with 724 (69.8%) written by emergency physicians. SLORs represented 57.9% (602/1037) of all LORs (by any kind of author) and 83.1% (602/724) of letters written by emergency physicians. Three hundred ninety-two of 602 SLORs had a single author (65.1%). For the question on "global assessment," students were scored in the top 10% in 234 of 583 of applications (40.1%; question not answered by some), and 485 of 583 (83.2%) of the applicants were ranked above the level of their peers. Similarly, >95% of all applicants were ranked in the top third compared to peers, for all but one section under "qualifications for emergency medicine." For 405 of 602 of all SLORs (67.2%), one or more questions were left unanswered, while 76 of all SLORs (12.6%) were "customized" or changed from the standard template. Finally, in 291 of 599 of SLORs (48.6%), the word count was greater than the recommended maximum of 200 words. CONCLUSIONS Grade inflation is marked throughout the SLOR, limiting its ability to be discriminating. Furthermore, template customization and skipped questions work against the intention to standardize the SLOR. Finally, it is not uncommon for comments to be longer than guideline recommendations. As an assessment tool, the SLOR could be more discerning, concise, and standardized to serve its intended purpose.
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Affiliation(s)
- Jeffrey N. Love
- Medstar Georgetown University Hospital/Medstar Washington Hospital Center; Washington DC
| | | | | | | | | | - David R. Lane
- Medstar Georgetown University Hospital/Medstar Washington Hospital Center; Washington DC
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MacVane CZ, Doty CI. Clinicopathological conference: a deadly cause of seizures in a 67-year-old alcoholic. Acad Emerg Med 2011; 18:e77-83. [PMID: 21883639 DOI: 10.1111/j.1553-2712.2011.01146.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Casey Z MacVane
- Department of Emergency Medicine, Maine Medical Center, Portland, USA.
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Sinert R, Doty CI. Update: Prevention of Contrast-Induced Nephropathy in the Emergency Department. Ann Emerg Med 2009; 54:e1-5. [DOI: 10.1016/j.annemergmed.2008.08.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2008] [Revised: 08/14/2008] [Accepted: 08/15/2008] [Indexed: 11/30/2022]
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Sinert R, Doty CI, Brown MD. Bicarbonate to Prevent Contrast-Induced Nephropathy in the Emergency Department: Does the Brar Study Change Recommendations? Ann Emerg Med 2009; 54:e6-7. [DOI: 10.1016/j.annemergmed.2008.10.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2008] [Revised: 10/17/2008] [Accepted: 10/31/2008] [Indexed: 10/21/2022]
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Sinert R, Doty CI. Prevention of Contrast-Induced Nephropathy in the Emergency Department. Ann Emerg Med 2007; 50:335-45, 345.e1-2. [PMID: 17512638 DOI: 10.1016/j.annemergmed.2007.01.023] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2006] [Revised: 01/13/2007] [Accepted: 01/26/2007] [Indexed: 12/31/2022]
Abstract
STUDY OBJECTIVE Contrast-induced nephropathy is the third leading cause of hospital-acquired acute renal failure. Expanded use of contrast-enhanced imaging exposes an ever-widening number of patients to this renal toxin. We perform an evidence-based emergency medicine review comparing different therapies to prevent contrast-induced nephropathy. We limit our review to prophylactic therapies that are practical for an emergency department setting. METHODS We searched MEDLINE, EMBASE, and the Cochrane Library for randomized trials comparing a wide range of medications to prevent contrast-induced nephropathy. We defined contrast-induced nephropathy by a commonly used surrogate measure of renal failure: a 25% or 0.5 mg/dL absolute increase in serum creatinine level from baseline 48 to 72 hours postcontrast. We limited our review to only trials for patients with baseline renal insufficiency, who are most at risk for contrast-induced nephropathy. We excluded prophylactic protocols requiring more than 2 hours precontrast to initiate and any trials of experimental medications or those that required invasive monitoring. We used standard criteria to appraise the quality of published trials. RESULTS We found 7 randomized trials; 3 using N-acetylcysteine, 2 using theophylline, and 1 each using bicarbonate and ascorbic acid. Although many of these trials showed statistically significant reductions in the risk for contrast-induced nephropathy, none were sufficiently powered to detect reductions in mortality rate or the need for dialytic therapy. CONCLUSION Evidence from randomized trials shows that these interventions (theophylline, bicarbonate, and ascorbic acid) under review were appropriate to an ED setting and decreased the risk of contrast-induced nephropathy. The case for the effectiveness (N-acetylcysteine) was less certain.
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Affiliation(s)
- Richard Sinert
- Department of Emergency Medicine, State University of New York-Downstate Medical Center, Brooklyn, NY 11203, USA.
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Sinert R, Spencer MT, Wilson R, Silverberg M, Patel M, Doty CI, Sapan A, Baron BJ. The effect of hypertension on uncontrolled hemorrhage in a rodent model. Acad Emerg Med 2002; 9:767-74. [PMID: 12153879 DOI: 10.1111/j.1553-2712.2002.tb02162.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
UNLABELLED Patients with essential hypertension (EH) have higher mortality rates from hemorrhage. How the complex physiologic changes seen in EH affect the response to uncontrolled hemorrhage has yet to be adequately described. OBJECTIVE To test the null hypothesis that there would be no difference in the hemorrhage volumes and hemodynamic responses to uncontrolled hemorrhage between hypertensive rats (SHRs) and normotensive rats (WKYs). METHODS Twenty-four adult rats (12 WKYs and 12 SHRs) were anesthetized with althesin via the intra-peritoneal route. The femoral artery was cannulated by cutdown for mean arterial pressure (MAP) measurement and blood gas sampling. Twelve rats (6 WKYs and 6 SHRs) underwent uncontrolled hemorrhage by 50% tail amputation. Twelve rats (6 WKYs and 6 SHRs) served as non-hemorrhage controls. The MAP, base excess (BE), and cumulative blood loss were measured pre-hemorrhage and then every 15 minutes post-hemorrhage for 90 minutes. Data were reported as mean +/- standard error of the mean. Comparisons between control and uncontrolled hemorrhage groups were analyzed by analysis of variance (ANOVA) with repeated-measures post-hoc testing by Bonferroni. Statistical significance was defined by an alpha = 0.05. RESULTS Mortality rates were significantly higher (p < 0.05) for the SHRs (100%) as compared with the WKYs (33%). Changes in time-averaged MAP post-hemorrhage were significantly greater (p < 0.001) in the SHR group (88 +/- 10 mm Hg) as compared with the WKY group (48 +/- 4 mm Hg). Hemorrhage volume was significantly lower (p = 0.02) in the SHR group (3.7 +/- 0.5 mL) as compared with the WKY group (6.1 +/- 0.7 mL). CONCLUSIONS Hypertensive rats had a higher mortality rate than normotensives from a comparable vascular injury with lower hemorrhage volumes.
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Affiliation(s)
- Richard Sinert
- Department of Emergency Medicine, State University of New York Downstate Medical Center, Brooklyn, NY 11203, USA.
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Abstract
A 51-year-old woman presented to the emergency department (ED) of another institution with sudden onset of blindness in the left eye. The patient was found to have no light perception in the left eye and a marked chemosis occurring several days after a fall. She was transferred to the hospital for ophthalmologic evaluation. Upon careful history and physical examination, the diagnosis of rhinocerebral mucormycosis was considered and urgent ophthalmology and otolaryngology consults were obtained. The patient underwent extensive surgical debridement and pharmacologic treatment. The diagnosis was confirmed by pathological specimens. In this case report, the clinical presentation, pathogenesis, diagnostic workup, and ED management of mucormycosis are discussed, highlighting the possible diagnostic and therapeutic pitfalls that are most pertinent to the emergency physician.
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Affiliation(s)
- C I Doty
- Department of Emergency Medicine, Kings County Hospital Center and State University of New York, Health Science Center at Brooklyn, 11203, USA.
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