Assessing clinical competence: a multitrait-multimethod matrix construct validity study

Education in Doctor of Medicine programs has moved towards an emphasis on clinical competency, with entrustable professional activities providing a framework of learning objectives and outcomes to be assessed within the clinical environment. While the identification and structured definition of objectives and outcomes have evolved, many methods employed to assess clerkship students' clinical skills remain relatively unchanged. There is a paucity of medical education research applying advanced statistical design and analytic techniques to investigate the validity of clinical skills assessment. One robust statistical method, multitrait-multimethod matrix analysis, can be applied to investigate construct validity across multiple assessment instruments and settings. Four traits were operationalized to represent the construct of critical clinical skills (professionalism, data gathering, data synthesis, and data delivery). The traits were assessed using three methods (direct observations by faculty coaches, clinical workplace-based evaluations, and objective structured clinical examination type clinical practice examinations). The four traits and three methods were intercorrelated for the multitrait-multimethod matrix analysis. The results indicated reliability values in the adequate to good range across the three methods with the majority of the validity coefficients demonstrating statistical significance. The clearest evidence for convergent and divergent validity was with the professionalism trait. The correlations on the same method/different traits analyses indicated substantial method effect; particularly on clinical workplace-based assessments. The multitrait-multimethod matrix approach, currently underutilized in medical education, could be employed to explore validity evidence of complex constructs such as clinical skills. These results can inform faculty development programs to improve the reliability and validity of assessments within the clinical environment.

Development of a lecture evaluation tool rooted in cognitive load theory: A modified Delphi study

Background

Didactics play a key role in medical education. There is no standardized didactic evaluation tool to assess quality and provide feedback to instructors. Cognitive load theory provides a framework for lecture evaluations. We sought to develop an evaluation tool, rooted in cognitive load theory, to assess quality of didactic lectures.

Methods

We used a modified Delphi method to achieve expert consensus for items in a lecture evaluation tool. Nine emergency medicine educators with expertise in cognitive load participated in three modified Delphi rounds. In the first two rounds, experts rated the importance of including each item in the evaluation rubric on a 1 to 9 Likert scale with 1 labeled as "not at all important" and 9 labeled as "extremely important." In the third round, experts were asked to make a binary choice of whether the item should be included in the final evaluation tool. In each round, the experts were invited to provide written comments, edits, and suggested additional items. Modifications were made between rounds based on item scores and expert feedback. We calculated descriptive statistics for item scores.

Results

We completed three Delphi rounds, each with 100% response rate. After Round 1, we removed one item, made major changes to two items, made minor wording changes to nine items, and modified the scale of one item. Following Round 2, we eliminated three items, made major wording changes to one item, and made minor wording changes to one item. After the third round, we made minor wording changes to two items. We also reordered and categorized items for ease of use. The final evaluation tool consisted of nine items.

Conclusions

We developed a lecture assessment tool rooted in cognitive load theory specific to medical education. This tool can be applied to assess quality of instruction and provide important feedback to speakers.

Clinical reasoning education in the clerkship years: A cross-disciplinary national needs assessment

Background

Improving clinical reasoning education has been identified as an important strategy to reduce diagnostic error—an important cause of adverse patient outcomes. Clinical reasoning is fundamental to each specialty, yet the extent to which explicit instruction in clinical reasoning occurs across specialties in the clerkship years remains unclear.

Method

The Alliance for Clinical Education (ACE) Clinical Reasoning Workgroup and the Directors of Clinical Skills Courses (DOCS) Clinical Reasoning Workgroup collaborated to develop a clinical reasoning needs assessment survey. The survey questionnaire covered seven common clinical reasoning topics including illness scripts, semantic qualifiers, cognitive biases and dual process theory. Questionnaires were delivered electronically through ACE member organizations, which are primarily composed of clerkship leaders across multiple specialties. Data was collected between March of 2019 and May of 2020.

Results

Questionnaires were completed by 305 respondents across the six organizations. For each of the seven clinical reasoning topics, the majority of clerkship leaders (range 77.4% to 96.8%) rated them as either moderately important or extremely important to cover during the clerkship curriculum. Despite this perceived importance, these topics were not consistently covered in respondents’ clerkships (range 29.4% to 76.4%) and sometimes not covered anywhere in the clinical curriculum (range 5.1% to 22.9%).

Conclusions

Clerkship educators across a range of clinical specialties view clinical reasoning instruction as important, however little curricular time is allocated to formally teach the various strategies. Faculty development and restructuring of curricular time may help address this potential gap.

Effect of Perceived Level of Interaction on Faculty Evaluations of 3rd Year Medical Students

INTRODUCTION

Several factors are known to affect the way clinical performance evaluations (CPEs) of medical students are completed by supervising physicians. We sought to explore the effect of faculty perceived "level of interaction" (LOI) on these evaluations.

METHODS

Our third-year CPE requires evaluators to identify perceived LOI with each student as low, moderate, or high. We examined CPEs completed during the academic year 2018-2019 for differences in (1) clinical and professionalism ratings, (2) quality of narrative comments, (3) quantity of narrative comments, and (4) percentage of evaluation questions left unrated.

RESULTS

A total of 3682 CPEs were included in the analysis. ANOVA revealed statistically significant differences between LOI and clinical ratings (p ≤ .001), with mean ratings from faculty with a high LOI significantly higher than from faculty with a moderate or low LOI (p ≤ .001). Chi-squared analysis demonstrated differences based on faculty LOI and whether questions were left unrated (p ≤ .001), quantity of narrative comments (p ≤ .001), and specificity of narrative comments (p ≤ .001).

CONCLUSIONS

Faculty who perceive higher LOI were more likely to assign that student higher ratings, complete more of the clinical evaluation and were more likely to provide narrative feedback with more specific, higher-quality comments.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s40670-021-01307-w.

The GI Simulated Clinic: A Clinical Reasoning Exercise Supporting Medical Students' Basic and Clinical Science Integration

INTRODUCTION

Cognitive integration is required to perform clinical decision-making tasks, even in the preclinical curriculum of medical school. Simulation supports students' cognitive integration by providing practical application of basic science knowledge in a relevant clinical context. To address the need for integrative activities in our curriculum, we implemented a simulated clinic exercise with cases representing gastrointestinal diseases for first-year medical students.

METHODS

Basic science and clinical skills course directors collaborated to design this simulated clinic event, during which student small groups rotated through a series of standardized patient encounters. During each encounter, one student performed the history and physical exam, following which the small group collaboratively developed a prioritized differential diagnosis. Afterwards, the gastroenterology course director debriefed students to highlight key learning points. We collected learner evaluation data following the event.

RESULTS

Two hundred eighty first-year medical students participated in the simulated clinic in 2018 and 2019. Students rated these events as effective for learning about clinical features of the diseases presented and for reinforcing skills learned in the clinical skills course. Students agreed that the small-group format, pace, and duration were appropriate and that the problem-solving aspect was intellectually stimulating. The most effective aspects were opportunities to solidify illness scripts, apply knowledge to solve a problem, and encounter diseases in a realistic clinical context.

DISCUSSION

This simulated clinic model effectively supported preclinical students' basic and clinical science integration to complete diagnostic reasoning tasks for gastrointestinal gastrointestinal conditions and was evaluated favorably by learners.

Optimizing Lectures From a Cognitive Load Perspective

Lectures are a common instructional method in medical education. Understanding the cognitive processes and theories involved in learning is essential for lecturers to be effective. Cognitive load theory is one theory that is becoming increasingly recognized in medical education and addresses the appropriate use of one's working memory. Memory is essential to knowledge acquisition. Two types of memory can be considered, working memory (processing of information) and long-term memory (storage of information). Working memory has a limited capacity. Cognitive load refers to the amount of information processing activity imposed on working memory and can be divided into three domains: intrinsic, extraneous, and germane. By attending to cognitive load, educators can promote learning. This paper highlights various ways of improving cognitive load for learners during lecture-based instruction by minimizing extraneous load, optimizing intrinsic load, and promoting germane load.

Practical Application of Assessment Principles in the Development of an Innovative Clinical Performance Evaluation in the Entrustable Professional Activity Era

Educators have been challenged to create assessments that are competency-based and grounded in accepted standards such as the entrustable professional activities (EPAs). The clinical performance evaluation (CPE) is a commonly utilized assessment modality, which allows multiple evaluators to provide feedback on a learner's performance in the clinical workplace. In this paper, we describe the relevant principles that served as a guide as we developed a new CPE for medical students that fully incorporate EPAs. This may help ease the transition for other institutions looking to introduce a new student CPE.

A Multidisciplinary Self-Directed Learning Module Improves Knowledge of a Quality Improvement Instrument: The HEART Pathway

We created and tested an educational intervention to support implementation of an institution wide QI project (the HEART Pathway) designed to improve care for patients with acute chest pain. Although online learning modules have been shown effective in imparting knowledge regarding QI projects, it is unknown whether these modules are effective across specialties and healthcare professions. Participants, including nurses, advanced practice clinicians, house staff and attending physicians (N = 486), were enrolled into an online, self-directed learning course exploring the key concepts of the HEART Pathway. The module was completed by 97% of enrollees (469/486) and 90% passed on the first attempt (422/469). Out of 469 learners, 323 completed the pretest, learning module and posttest in the correct order. Mean test scores across learners improved significantly from 74% to 89% from the pretest to the posttest. Following the intervention, the HEART Pathway was used for 88% of patients presenting to our institution with acute chest pain. Our data demonstrate that this online, self-directed learning module can improve knowledge of the HEART Pathway across specialties-paving the way for more efficient and informed care for acute chest pain patients.

Scurvy: Dietary Discretion in a Developed Country

Although the causes have changed, scurvy (vitamin C deficiency) is still diagnosed in developed countries. We report a case of an 18-year-old female who presented to our emergency department with thrombocytopenia, sinus tachycardia, hypotension, fatigue, gingival hyperplasia, knee effusion, petechiae and ecchymosis in lower extremities. The differential diagnosis included hematologic abnormalities, infectious etiologies, vasculitis and vitamin deficiency. A brief dietary history was performed revealing poor fruit and vegetable intake, thus increasing our suspicion for vitamin C deficiency. This experience illustrates the importance of a dietary history and reminds us to keep scurvy in the differential diagnosis.

Trends in NRMP Data from 2007-2014 for U.S. Seniors Matching into Emergency Medicine

INTRODUCTION

Since 1978, the National Residency Matching Program (NRMP) has published data demonstrating characteristics of applicants who have matched into their preferred specialty in the NRMP main residency match. These data have been published approximately every two years. There is limited information about trends within these published data for students matching into emergency medicine (EM). Our objective was to investigate and describe trends in NRMP data to include the following: the ratio of applicants to available EM positions; United State Medical Licensing Examination (USMLE) Step 1 and Step 2 scores (compared to the national means); number of programs ranked; and Alpha Omega Alpha Honor Medical Society (AOA) membership among U.S. seniors matching into EM.

METHODS

This was a retrospective observational review of NRMP data published between 2007 and 2016. We analyzed the data using analysis of variance (ANOVA) or Kruskal-Wallis testing, and Fischer's exact or chi-squared testing, as appropriate to determine statistical significance.

RESULTS

The ratio of applicants to available EM positions remained essentially stable from 2007 to 2014 but did increase slightly in 2016. We observed a net upward trend in overall Step 1 and Step 2 scores for EM applicants. However, this did not outpace the national trend increase in Step 1 and 2 scores overall. There was an increase in the mean number of programs ranked by EM applicants over the years studied from 7.8 (SD4.2) to 9.2 (SD5.0, p<0.001), driven predominantly by the cohort of U.S. students successful in the match. Among time intervals, there was a difference in the number of EM applicants with AOA membership (p=0.043) due to a drop in the number of AOA students in 2011. No sustained statistical trend in AOA membership was identified over the seven-year period studied.

CONCLUSION

NRMP data demonstrate trends among EM applicants that are similar to national trends in other specialties for USMLE board scores, and a modest increase in number of programs ranked. AOA membership was largely stable. EM does not appear to have become more competitive relative to other specialties or previous years in these categories.

Large Posterior Communicating Artery Aneurysm: Initial Presentation with Reproducible Facial Pain Without Cranial Nerve Deficit

Unruptured posterior communicating artery (PCOM) aneurysms can be difficult to diagnose and, when large (≥ 7mm), represent a substantial risk to the patient. While most unruptured PCOM aneurysms are asymptomatic, when symptoms do occur, clinical manifestations typically include severe headache (HA), visual acuity loss, and cranial nerve deficit. This case report describes an atypical initial presentation of a large unruptured PCOM aneurysm with symptoms mimicking trigeminal neuralgia, without other associated cranial nerve palsies or neurologic deficits. The patient returned to the emergency department four days later with a HA, trigeminal neuralgia, and a new cranial nerve III palsy. After appropriate imaging, she was found to have a large PCOM aneurysm, which was treated with surgical clipping with significant improvement in patient’s symptoms.

Combined Versus Detailed Evaluation Components in Medical Student Global Rating Indexes

Introduction

To determine if there is any correlation between any of the 10 individual components of a global rating index on an emergency medicine (EM) student clerkship evaluation form. If there is correlation, to determine if a weighted average of highly correlated components loses predictive value for the final clerkship grade.

Methods

This study reviewed medical student evaluations collected over two years of a required fourth-year rotation in EM. Evaluation cards, comprised of a detailed 10-part evaluation, were completed after each shift. We used a correlation matrix between evaluation category average scores, using Spearman’s rho, to determine if there was any correlation of the grades between any of the 10 items on the evaluation form.

Results

A total of 233 students completed the rotation over the two-year period of the study. There were strong correlations (>0.80) between assessment components of medical knowledge, history taking, physical exam, and differential diagnosis. There were also strong correlations between assessment components of team rapport, patient rapport, and motivation. When these highly correlated were combined to produce a four-component model, linear regression demonstrated similar predictive power in terms of final clerkship grade (R²=0.71, CI₉₅=0.65–0.77 and R²=0.69, CI₉₅=0.63–0.76 for the full and reduced models respectively).

Conclusion

This study revealed that several components of the evaluation card had a high degree of correlation. Combining the correlated items, a reduced model containing four items (clinical skills, interpersonal skills, procedural skills, and documentation) was as predictive of the student’s clinical grade as the full 10-item evaluation. Clerkship directors should be aware of the performance of their individual global rating scales when assessing medical student performance, especially if attempting to measure greater than four components.

Emergency medicine clerkship directors: current workforce

Introduction

The emergency medicine clerkship director serves an important role in the education of medical students. The authors sought to update the demographic and academic profile of the emergency medicine clerkship director.

Methods

We developed and implemented a comprehensive questionnaire, and used it to survey all emergency medicine clerkship directors at United States allopathic medical schools accredited by the Liaison Committee on Medical Education. We analyzed and interpreted data using descriptive statistics.

Results

One hundred seven of 133 (80.4%) emergency medicine clerkship directors completed the survey. Clerkship Director’s mean age was 39.7 years (SD-7.2), they were more commonly male 68.2%, of Caucasian racial backgrounds and at the instructor or assistant professor (71.3%) level. The mean number of years of experience as clerkship director was 5.5 (SD-4.5). The mean amount of protected time for clerkship administration reported by respondents was 7.3 hours weekly (SD-5.1), with the majority (53.8%) reporting 6 or more hours of protected time per week. However, 32.7% of emergency medicine clerkship directors reported not having any protected time for clerkship administration. Most clerkship directors (91.6%) held additional teaching responsibilities beyond their clerkship and many were involved in educational research (49.5%). The majority (79.8%), reported being somewhat or very satisfied with their job as clerkship director.

Conclusion

Most clerkship directors were junior faculty at the instructor or assistant professor rank and were involved with a variety of educational endeavors beyond the clerkship.

Medical student milestones in emergency medicine

OBJECTIVES

Medical education is a continuum from medical school through residency to unsupervised clinical practice. There has been a movement toward competency-based medical education prompted by the Accreditation Council for Graduate Medical Education (ACGME) using milestones to assess competence. While implementation of milestones for residents sets specific standards for transition to internship, there exists a need for the development of competency-based instruments to assess medical students as they progress toward internship. The objective of this study was to develop competency-based milestones for fourth-year medical students completing their emergency medicine (EM) clerkships (regardless of whether the students were planning on entering EM) using a rigorous method to attain validity evidence.

METHODS

A literature review was performed to develop a list of potential milestones. An expert panel, which included a medical student and 23 faculty members (four program directors, 16 clerkship directors, and five assistant deans) from 19 different institutions, came to consensus on these milestones through two rounds of a modified Delphi protocol. The Delphi technique builds content validity and is an accepted method to develop consensus by eliciting expert opinions through multiple rounds of questionnaires.

RESULTS

Of the initial 39 milestones, 12 were removed at the end of round 1 due to low agreement on importance of the milestone or because of redundancy with other milestones. An additional 12 milestones were revised to improve clarity or eliminate redundancy, and one was added based on expert panelists' suggestions. Of the 28 milestones moving to round 2, consensus with a high level of agreement was achieved for 24. These were mapped to the ACGME EM residency milestone competency domains, as well as the Association of American Medical Colleges (AAMC) core entrustable professional activities for entering residency to improve content validity.

CONCLUSIONS

This study found consensus support by experts for a list of 24 milestones relevant to the assessment of fourth-year medical student performance by the completion of their EM clerkships. The findings are useful for development of a valid method for assessing medical student performance as students approach residency.

State of undergraduate education in emergency medicine: a national survey of clerkship directors

BACKGROUND

The discipline of emergency medicine (EM) has rapidly changed over the past 10 years, resulting in greater involvement of the specialty in undergraduate medical education.

OBJECTIVES

The authors sought to present a review of how, when, and where EM is currently taught in U.S. medical schools and to include general program characteristics, such as number of required clerkships, clinical expectations and experiences, use of the national curriculum guide, didactic content, and methods of assessment and grading.

METHODS

The authors surveyed representatives of the 128 U.S. allopathic medical schools on medical education in 2010. Contacts were drawn from established databases, direct inquiries, and medical school websites. Up to five attempts were made to contact representatives through e-mail and telephone. Descriptive statistics were used to summarize the data.

RESULTS

The survey response rate was 83.6%. Fifty-two percent of medical schools now require students to complete EM clerkships. Required EM clerkships usually last 4 weeks and take place during the fourth year of medical school. They require students to complete a mean (±SD) of 14.3 (±2.8) shifts, which average 8.9 (±1.4) hours in length. Programs include a mean (±SD) of 18 (±10.4) hours of didactics. Approximately 60% of respondents report that both residents and attending physicians precept students. Assessments of students primarily include written clinical performance assessments and end-of-rotation written tests. These assessments contribute 66.8 and 24.5%, respectively, to the clerkship grade.

CONCLUSIONS

Currently more than half of all U.S. medical schools require EM clerkships in their undergraduate medical curricula. This article reports an overview of EM programs at the undergraduate level.

Increasing Faculty Attendance at Emergency Medicine Resident Conferences: Does CME Credit Make a Difference?

BACKGROUND

Faculty involvement in resident teaching events is beneficial to resident education, yet evidence about the factors that promote faculty attendance at resident didactic conferences is limited.

OBJECTIVE

To determine whether offering continuing medical education (CME) credits would result in an increase in faculty attendance at weekly emergency medicine conferences and whether faculty would report the availability of CME credit as a motivating factor.

METHODS

Our prospective, multi-site, observational study of 5 emergency medicine residency programs collected information on the number of faculty members present at CME and non-CME lectures for 9 months and collected information from faculty on factors influencing decisions to attend resident educational events and from residents on factors influencing their learning experience.

RESULTS

Lectures offering CME credit on average were attended by 5 additional faculty members per hour, compared with conferences that did not offer CME credit (95% confidence interval [CI], 3.9-6.1; P < .001). Faculty reported their desire to "participate in resident education" was the most influential factor prompting them to attend lectures, followed by "explore current trends in emergency medicine" and the lecture's "specific topic." Faculty also reported that "clinical/administrative duties" and "family responsibilities" negatively affected their ability to attend. Residents reported that the most important positive factor influencing their conference experience was "lectures given by faculty."

CONCLUSIONS

Although faculty reported that CME credit was not an important factor in their decision to attend resident conferences, offering CME credit resulted in significant increases in faculty attendance. Residents reported that "lectures given by faculty" and "faculty attendance" positively affected their learning experience.

Developing and assessing initiatives designed to improve clinical teaching performance

To improve the teaching performance of emergency physicians, it is necessary to understand the attributes of expert teachers and the optimal methods to deliver faculty development. A working group of medical educators was formed to review the literature, summarize what is known on the topic, and provide recommendations for future research. This occurred as a track of the 2012 Academic Emergency Medicine (AEM) consensus conference "Education Research in Emergency Medicine: Opportunities, Challenges, and Strategies for Success." The group concluded that the current state of research on these topics is limited. Improvement in understanding will come through research focusing on Kirkpatrick's higher levels of evaluation (behavior and results).

Developing a third-year emergency medicine medical student curriculum: a syllabus of content

Emergency medicine (EM) educators have published several curricular guides designed for medical student rotations and experiences. These guides primarily provided brief overviews of opportunities to incorporate EM into all 4 years of the medical student curriculum, with one specific to the fourth year. However, there are no published guidelines specific to third-year medical students rotating in EM. Given the differences between third-year and fourth-year students in terms of clinical experience, knowledge, and skills, the Clerkship Directors in Emergency Medicine (CDEM) established the Third-year EM Medical Student Curriculum Work Group to create a third-year curriculum. The work group began this process by developing consensus-based recommendations for the content of a third-year medical student EM rotation, which are presented in this syllabus.

Dealing with the difficult student in emergency medicine

Dealing with a student who is perceived as difficult to work with or teach is inevitable in any academic physician's career. This paper will outline the basic categories of these difficulties pertinent to Emergency Medicine rotations in order to facilitate appropriate identification of problems. Strategies for evaluation and reporting of the difficult student are presented. Remediation, based on the type of difficulty, is addressed. Timeliness of reporting, evaluation, and feedback are invaluable to allow for appropriate assessment of the outcome of the remediation plan.

Expectations of an emergency medicine clerkship director

The clerkship director (CD) serves as a faculty leader within a school of medicine and plays a vital role in the hierarchy of undergraduate medical education. Collectively, CDs across specialties serve a multitude of roles and are responsible for clerkship administration, curricular development, teaching, mentoring, and advising students. The emergency medicine (EM) CD has a vitally important role to play in the future development of medical students. EM CDs should be valued and supported, because they often represent our specialty within the medical school and play a vital role in training the physicians of tomorrow. Opportunities and resources must be made available to CDs to run and maintain a successful EM clerkship, while also balancing their clinical duties and academic endeavors. In addition, EM CDs need support from their respective medical schools and departments to run highly successful medical student rotations. This article was prepared with the objective of establishing the importance of the EM CD, defining the job description of the CD, explaining the importance of adequate release time to perform the role of the CD, and describing the necessary resources and support for the position. With EM becoming an increasingly popular and integral rotation for medical students, it is likely that additional emphasis will be placed on the role of the EM CD. This reference document serves as a template for the job description and expectations of an EM CD.

Emergency medicine in the medical school curriculum

Emergency medicine (EM) is a dynamic specialty that continues to define itself as a fertile training ground for medical students. Throughout the years, a number of U.S. medical schools have incorporated topics germane to EM training (basic cardiac life support, principles of wound care, splinting, basic procedural skills training, etc.) into the medical school curriculum. By virtue of their broad-based training and the unique patient care environment that they practice in, EM specialists can serve a multitude of educational roles in the medical school. Whether serving as a problem-based learning facilitator, collaborating with basic scientists, or teaching medical history-taking and physical examination skills in the emergency department (ED), EM faculty can effectively teach future physicians in training. Although opportunities for teaching will vary by institution, often all it takes to get involved is asking. Teaching can take place in the ED, classroom, or simulation center, both in the preclinical and in the clinical curriculum. EM faculty may be well suited to help teach procedural skills to students as they enter their clinical clerkships. A formal rotation in EM can also assist the medical school in achieving their institutional objectives or in identifying ways to satisfy the Liaison Committee on Medical Education's objectives. Patients presenting to the ED span the entire spectrum: young and old, sick and not sick. It is this variety of cases that makes the ED a truly valuable setting for educating students.

Anatomy of a clerkship test

Written examinations are frequently used to assess medical student performance. Within emergency medicine (EM), a National Board of Medical Examiners (NBME) subject examination for EM clerkships does not exist. As a result, clerkship directors frequently generate examinations within their institution. This article reviews the literature behind the use of standardized examinations in evaluating medical student performance, describes methods for generating well-written test questions, reviews the statistical concepts of reliability and validity that are necessary to evaluate an examination, and proposes future directions for testing EM students.

Emergency medicine clerkship curriculum: an update and revision

In 2006, the latest version of a national curriculum for the fourth-year emergency medicine (EM) clerkship was published. Over the past several years, that curriculum has been implemented across multiple clerkships. The previous curriculum was found to be too long and detailed to cover in 4 weeks. As well, updates to the Liaison Committee on Medical Education (LCME)'s form and function document, which guides the structure of a clerkship, have occurred. Combining experience, updated guidelines, and the collective wisdom of members of the national organization of the Clerkship Directors in Emergency Medicine (CDEM), an update and revision of the fourth-year EM clerkship educational syllabi has been developed.

Off-service resident education in the emergency department: outline of a national standardized curriculum

Although many residency programs mandate at least one rotation in emergency medicine (EM), to the best of our knowledge, a standardized curriculum for emergency department (ED) rotations for "off-service" residents has not been developed. As a result, the experiences of these residents in the ED tend to vary during their rotations. To design an off-service EM curriculum, we adopted Kern's six-step approach to curriculum development as a conceptual framework. The resulting program encompasses clinical experience and didactic sessions through which residents are trained in core topics and skills. This knowledge will be applicable in the clinical settings in which residents will continue to train and ultimately practice their specialty. It is flexible enough to be applicable and implementable without being limited by resource availability or faculty strengths.

Faculty physicians and new physicians disagree about which procedures are essential to learn in medical school

BACKGROUND

Clinical procedures taught in the undergraduate medical curriculum are important for subsequent residency training and clinical practice. Published reports suggest that medical schools may not be adequately teaching procedures. This study identifies procedures considered essential by residents completing internship and by medical school faculty, and determines agreement on their importance for medical student education.

METHODS

Two hundred and thirty-five physicians (184 new physicians who recently completed internship and 51 medical school teaching faculty) categorized 31 clinical procedures based on the importance for internship. New physicians who had completed internship reported the level of training received in medical school for each procedure.

RESULTS

Survey responses were 76% (faculty) and 70% (new physicians who had completed internship). The faculty majority identified 14 procedures as 'Must Know.' New physicians disagreed on 8 of these and categorized an additional 5 as essential. There was 32% concordance for the 19 procedures identified by either group. New physicians reported 'Limited Hands-On Training' for all 19 procedures but 'Comprehensive Hands-On Training' for only two.

CONCLUSIONS

New physicians who have completed internship and medical school faculty do not agree on procedures essential for internship. A core educational list of 19 procedures was identified using the responses from these two groups.

The Centers for Medicare and Medicaid Services (CMS) community-acquired pneumonia core measures lead to unnecessary antibiotic administration by emergency physicians

OBJECTIVES

The objectives were to assess emergency physician (EP) understanding of the Centers for Medicare and Medicaid Services (CMS) core measures for community-acquired pneumonia (CAP) guidelines and to determine their self-reported effect on antibiotic prescribing patterns.

METHODS

A convenience sample of EPs from five medical centers in North Carolina was anonymously surveyed via a Web-based instrument. Participants indicated their level of understanding of the CMS CAP guidelines and the effects on their prescribing patterns for antibiotics.

RESULTS

A total of 121 EPs completed the study instrument (81%). All respondents were aware of the CMS CAP guidelines. Of these, 95% (95% confidence interval [CI] = 92% to 98%) correctly understood the time-based guidelines for antibiotic administration, although 24% (95% CI = 17% to 31%) incorrectly identified the onset of this time period. Nearly all physicians (96%; 95% CI = 93% to 99%) reported institutional commitment to meet these core measures, and 84% (95% CI = 78% to 90%) stated that they had a department-based CAP protocol. More than half of the respondents (55%; 95% CI = 47% to 70%) reported prescribing antibiotics to patients they did not believe had pneumonia in an effort to comply with the CMS guidelines, and 42% (95% CI = 34% to 50%) of these stated that they did so more than three times per month. Only 40% (95% CI = 32% to 48%) of respondents indicated a belief that the guidelines improve patient care. Of those, this was believed to occur by increasing pneumonia awareness (60%; 95% CI = 52% to 68%) and improving hospital processes when pneumonia is suspected (86%; 95% CI = 80% to 92%).

CONCLUSIONS

Emergency physicians demonstrate awareness of the current CMS CAP guidelines. Most physicians surveyed reported the presence of institutional protocols to increase compliance. More than half of EPs reported that they feel the guidelines led to unnecessary antibiotic usage for patients who are not suspected to have pneumonia. Only 40% of EPs believe that CAP awareness and expedient care resulting from these guidelines has improved overall pneumonia-related patient care. Outcome-based data for non-intensive care unit CAP patients are lacking, and EPs report that they prescribe antibiotics when they may not be necessary to comply with existing guidelines.

Clerkship directors in emergency medicine: statement of purpose

The Academy of Clerkship Directors in Emergency Medicine (CDEM) provides a forum for the collaborative exchange of ideas among emergency medicine (EM) medical student educators, a platform for the advancement of education, research, and faculty development, and establishes for the first time a national voice for undergraduate medical education within our specialty. CDEM plans to take a leading role in providing medical student educators with additional educational resources and opportunities for faculty development and networking. CDEM will work to foster the professional growth and development of undergraduate medical educators within our specialty. The advancement of undergraduate education within our specialty and beyond will come primarily from the support, hard work, and dedication of the educators. To accomplish our goals, at the departmental, medical school, and national level, we must come together to further promote our specialty across the spectrum of undergraduate medical education. The first step has already been taken with the formation of the Academy of CDEM.

A skin abscess model for teaching incision and drainage procedures

BACKGROUND

Skin and soft tissue infections are increasingly prevalent clinical problems, and it is important for health care practitioners to be well trained in how to treat skin abscesses. A realistic model of abscess incision and drainage will allow trainees to learn and practice this basic physician procedure.

METHODS

We developed a realistic model of skin abscess formation to demonstrate the technique of incision and drainage for educational purposes. The creation of this model is described in detail in this report.

RESULTS

This model has been successfully used to develop and disseminate a multimedia video production for teaching this medical procedure. Clinical faculty and resident physicians find this model to be a realistic method for demonstrating abscess incision and drainage.

CONCLUSION

This manuscript provides a detailed description of our model of abscess incision and drainage for medical education. Clinical educators can incorporate this model into skills labs or demonstrations for teaching this basic procedure.

The state of the clerkship: a survey of emergency medicine clerkship directors

OBJECTIVES

An emergency medicine (EM) clerkship can provide a medical student with a unique educational experience. The authors sought to describe the current experiential curriculum of the EM clerkship, along with methods of evaluation, feedback, and grading.

METHODS

A descriptive survey was utilized. Clerkship directors at EM residency programs accredited by the Accreditation Council for Graduate Medical Education completed an online questionnaire. Data were analyzed using descriptive statistics.

RESULTS

Ninety-two (70%) of 132 EM clerkship directors completed the survey. Sixty institutions (65%) accepted only fourth-year medical students, and 35% accepted both third- and fourth-year students. The median number of didactic lecture hours provided during each rotation block for students was ten (interquartile range [IQR], 6-16). The average length of a student's clinical shift was eight hours, while the median number of clinical shifts reported per rotation was 15 (IQR, 14-16). The median number of hours worked weekly by a medical student was 40 (IQR, 35-43). Fifty-four EM clerkship directors (59%) incorporated the Accreditation Council for Graduate Medical Education six core competencies into their evaluation process. Seventy-one clerkship directors (77%) used a shift evaluation card to evaluate the clinical performance of medical students. Fifty-four (59%) incorporated an end-of-rotation written examination to determine the final rotation grade for a medical student.

CONCLUSIONS

Medical students are exposed to a variety of didactic lectures and procedure labs but have similar experiences regarding shift length and work hours. Methods of evaluation of clinical performance vary across clinical sites.

Report of the Task Force on National Fourth Year Medical Student Emergency Medicine Curriculum Guide

This manuscript reports recommendations of the National Fourth Year Medical Student Emergency Medicine Curriculum Guide Task Force. This task force was convened by 6 major emergency medicine organizations to develop a standardized curriculum for fourth year medical students. The structure of the curriculum is based on clerkship curricula from other specialties such as internal medicine and pediatrics. The report contains a historical context, global and targeted needs assessment, goals and objectives, recommended educational strategies, implementation guidelines, and suggestions on feedback and evaluation.

Impact of the Liaison Committee on Medical Education requirements for emergency medicine education at U.S. schools of medicine

The Liaison Committee on Medical Education (LCME) accredits complete and independent medical education programs leading to the MD degree. The LCME standards for accreditation are described in the online document "Functions and Structure of a Medical School." There are ongoing minor and major changes to these standards. This article examines how the newest LCME requirements may affect emergency medicine (EM) rotations. The descriptions focus on 1) how the LCME requirements affect EM educational activities and 2) how the department of EM can help the school of medicine meet the LCME requirements. The recommendations focus on the general areas of the instructional setting, components of the educational program, resources for medical students, and faculty development. The department of EM can provide the students at the school of medicine with a number of key experiences and opportunities through its educational offerings and graduate medical education programs that will help satisfy the LCME standards. The new LCME standards will also have a significant impact on the way EM educators/clerkship directors develop curricula, assess students, provide feedback, and develop their own faculty/residents as teachers. The leadership of EM should recognize their increasingly important role within the school of medicine and be sensitive to additional requirements for faculty development and scholarship.

Referral of emergency department patients for pneumococcal vaccination

OBJECTIVES

To determine what proportion of eligible patients, when referred to a primary care physician for pneumococcal vaccination with a prescription, actually obtain the vaccination. To ascertain the number of eligible patients who would receive the vaccination in the emergency department (ED), if available.

METHODS

The authors surveyed a convenience sample of patients presenting to an urban ED during a four-month period. Eligible patients were referred to specific sites with a prescription to be immunized. Data on those referred were collected by review of medical record and telephone follow-up.

RESULTS

A total of 2,299 surveys were distributed; 338 patients declined to participate, yielding an 85% response rate. The total number of patients identified as having an indication for the pneumovax was 711 (36%). Of these, 411 were not previously vaccinated; 167 of the 411 had a contraindication to vaccination. The remaining 244 qualified for referral to receive the pneumococcal vaccine. One hundred thirty-one of these accepted referral prescription. Of the patients given prescriptions, 12 followed up and received the vaccine, 81 did not follow up, and 38 were lost to follow-up. Seventy-four percent of patients would have received the pneumovax in the ED if it had been available.

CONCLUSIONS

The percentage of ED patients who used prescription referral to the primary care network for pneumococcal vaccination was approximately 10%. The use of a referral by prescription method in this setting was not a reliable means of increasing the number of patients receiving the pneumococcal vaccination.

A comparison of oral, tympanic, and rectal temperature measurement in the elderly

This cross-sectional study enrolled 95 elderly Emergency Department patients aged 60 years or more to determine if rectal temperatures identify fevers more often than oral or tympanic temperatures when the chief complaint suggests an infection. A fever was defined as a temperature greater than 38 degrees C (100.4 degrees F). Discordance was defined as any patient with an oral or tympanic temperature of 38 degrees C or less but manifesting a rectal temperature greater than 38 degrees C and 0.5 degrees C (1 degrees F) greater than the oral or tympanic temperature. Rectal thermometry identified a fever in 14 of 95 (14.7%) patients who were afebrile orally and in 11 of 90 (12.2%) patients who were afebrile tympanically. Five of 90 (5.6%) patients were febrile rectally but were afebrile by both oral and tympanic thermometry. Thus, rectal thermometry identified fevers missed orally and tympanically in elderly patients whose presentation suggested infection. To identify these febrile patients with possible infection, clinicians must be attentive to elderly patients' vague clinical presentation.

Nephrolithiasis

This article covers the diagnosis and management of renal colic. New imaging modalities will be reviewed using evidence-based medicine. The disposition of the patient with renal colic will be addressed. Additionally, special groups with nephrolithiasis will be discussed.

Pediatric case of accidental oral overdose of methotrexate

Methotrexate is a chemotherapy antimetabolite, folic acid antagonist, that inhibits the enzyme dihydrofolate reductase resulting in decreased levels of tetrahydrofolate in the cells. This in turn blocks synthesis of thymidylate, a nucleotide necessary for DNA synthesis. It is readily absorbed from the gastrointestinal tract. Toxicity from overdose can affect multiple organ systems including bone marrow, liver, intestinal tract, kidneys, lungs, skin, and blood vessels, resulting in death in severe cases. Methotrexate is widely used to treat neoplastic disease, dermatologic disorders (psoriasis), and rheumatologic disorders (severe rheumatoid arthritis). As its indications for use increase, more accidental overdoses can be expected. We present the treatment and clinical course of one such case, that of a 2-year-old who accidentally took her grandmother's arthritis pills. Her initial serum level was 10 times greater than that needed to cause toxicity. She was treated with gastric lavage, activated charcoal, leucovorin rescue, and ICU admission. Her clinical course was unremarkable, and the only evidence of toxicity was a mild elevation in a liver-associated enzyme that resolved without any clinical sequela. Leucovorin at a dose equal to or greater than the possible ingestion should be given as soon as possible in methotrexate overdoses.

Tension hydrothorax due to ventriculopleural shunting

Tension hydrothorax is rare, with few cases reported in the literature dating back to the late 1960s. We report a case of tension hydrothorax in a patient with a ventriculopleural shunt who improved dramatically after thoracentesis. The discussion includes a brief review of ventriculopleural shunts and pleural physiology.

Ultrasound versus radiography in the detection of soft-tissue foreign bodies

STUDY OBJECTIVE

To determine the usefulness of ultrasound and radiography in detecting foreign bodies in soft-tissue models closely duplicating puncture-wound trauma and hand anatomy.

METHODS

In this randomized, blinded descriptive study, two radiologists independently evaluated 120 chicken thighs for foreign bodies with the use of standard two-view radiography and 7.5-MHz transducer ultrasonography. All chicken thighs were manipulated with hemostats to ensure uniform tissue damage. In 60 thighs, one foreign body had been inserted (10 each: gravel, metal, glass, cactus spine, wood, and plastic).

RESULTS

The sensitivity of ultrasound in detecting gravel was 40%, that for metal was 45%, that for glass was 50%, that for cactus spine was 30%, that for wood was 50%, and that for plastic was 40%. The overall sensitivity, specificity, and false-negative and false-positive rates for ultrasound were 43%, 70%, 50%, and 30%, respectively. No individual foreign body had an ultrasound detection rate of 50%. Radiography detected foreign bodies generally considered radiopaque (gravel, glass, metal) 98% of the time, but it never detected bodies considered radiolucent (wood, plastic, cactus spine). The false-negative and false-positive rates for radiography were 50% and 1.6%, respectively.

CONCLUSION

Ultrasound detection of foreign bodies by skilled operators in this animal model revealed poor sensitivity and specificity. Radiographic detection was highly sensitive for foreign bodies considered radiopaque. Our data suggest that ultrasound should not be relied on to rule out the possibility of a retained foreign body in the distal extremities.

Halo traction device

A thorough understanding of the underlying diseases and of the halo pin traction device will allow for appropriate treatment of complications. Consultation or referral to the neurosurgeon is advised to prevent serious sequelae. The following points should be remembered: 1. Pins should only be tightened during the first 24-hour period after application. 2. Pin infection is treated by local wound care in most cases. 3. CT scan cannot completely exclude the presence of an abscess secondary to artifact, but MRI may be compatible with the newer devices. 4. Pin penetration of the inner table of the skull requires admission. 5. Any suspected loss of alignment or reduction of the cervical spine requires C-spine immobilization. 5. Nasotracheal or fiberoptic intubation or emergent cricothyroidotomy should be used if orotracheal intubation proves difficult due to the device. 7. The anterior portion of the vest is removable for cardiopulmonary resuscitation without compromising the stability of the device.