Towards developing a consensus assessment framework for global emergency medicine fellowships

Background

The number of Global Emergency Medicine (GEM) Fellowship training programs are increasing worldwide. Despite the increasing number of GEM fellowships, there is not an agreed upon approach for assessment of GEM trainees.

Main body

In order to study the lack of standardized assessment in GEM fellowship training, a working group was established between the International EM Fellowship Consortium (IEMFC) and the International Federation for Emergency Medicine (IFEM). A needs assessment survey of IEMFC members and a review were undertaken to identify assessment tools currently in use by GEM fellowship programs; what relevant frameworks exist; and common elements used by programs with a wide diversity of emphases. A consensus framework was developed through iterative working group discussions. Thirty-two of 40 GEM fellowships responded (80% response). There is variability in the use and format of formal assessment between programs. Thirty programs reported training GEM fellows in the last 3 years (94%). Eighteen (56%) reported only informal assessments of trainees. Twenty-seven (84%) reported regular meetings for assessment of trainees. Eleven (34%) reported use of a structured assessment of any sort for GEM fellows and, of these, only 2 (18%) used validated instruments modified from general EM residency assessment tools. Only 3 (27%) programs reported incorporation of formal written feedback from partners in other countries. Using these results along with a review of the available assessment tools in GEM the working group developed a set of principles to guide GEM fellowship assessments along with a sample assessment for use by GEM fellowship programs seeking to create their own customized assessments.

Conclusion

There are currently no widely used assessment frameworks for GEM fellowship training. The working group made recommendations for developing standardized assessments aligned with competencies defined by the programs, that characterize goals and objectives of training, and document progress of trainees towards achieving those goals. Frameworks used should include perspectives of multiple stakeholders including partners in other countries where trainees conduct field work. Future work may evaluate the usability, validity and reliability of assessment frameworks in GEM fellowship training.

Academic Medical Support to the Ebola Virus Disease Outbreak in Liberia

During the Ebola Virus Disease (EVD) epidemic in West Africa (2014-2016), many faculty, staff, and trainees from U.S. academic medical centers (i.e., teaching hospitals and their affiliated medical schools; AMCs) wished to contribute to the response to the outbreak, but many barriers prevented their participation. Here, the authors describe a successful long-term academic collaboration in Liberia that facilitated participation in the EVD response. This Perspective outlines the role the authors played in the response (providing equipment and training, supporting the return of medical education), the barriers they faced (logistical and financial), and elements that contributed to their success (partnering and coordinating their response with both U.S. and African institutions). There is a paucity of literature discussing the role of AMCs in disaster response, so the authors discuss the lessons learned and offer suggestions about the responsibilities that AMCs have and the roles they can play in responding to disaster situations.

Guidelines for safety of trainees rotating abroad: consensus recommendations from the Global Emergency Medicine Academy of the Society for Academic Emergency Medicine, Council of Emergency Medicine Residency Directors, and the Emergency Medicine Residents' Association

The goal of a global health elective is for residents and medical students to have safe, structured, and highly educational experiences. In this article, the authors have laid out considerations for establishing a safe clinical site; ensuring a traveler's personal safety, health, and wellness; and mitigating risk during a global health rotation. Adequate oversight, appropriate mentorship, and a well-defined safety and security plan are all critical elements to a successful and safe experience.

Effect of an educational intervention on faculty and resident satisfaction with real-time feedback in the emergency department

OBJECTIVES

Effective real-time feedback is critical to medical education. This study tested the hypothesis that an educational intervention related to feedback would improve emergency medicine (EM) faculty and resident physician satisfaction with feedback.

METHODS

This was a cluster-randomized, controlled study of 15 EM residency programs in 2007-2008. An educational intervention was created that combined a feedback curriculum with a card system designed to promote timely, effective feedback. Sites were randomized either to receive the intervention or to continue their current feedback method. All participants completed a Web-based survey before and after the intervention period. The primary outcome was overall feedback satisfaction on a 10-point scale. Additional items addressed specific aspects of feedback. Responses were compared using a generalized estimating equations model, adjusting for confounders and baseline differences between groups. The study was designed to achieve at least 80% power to detect a one-point difference in overall satisfaction (α = 0.05).

RESULTS

Response rates for pre- and postintervention surveys were 65.9 and 47.3% (faculty) and 64.7 and 56.9% (residents). Residents in the intervention group reported a mean overall increase in feedback satisfaction scores compared to those in the control group (mean increase 0.96 points, standard error [SE] ± 0.44, p = 0.03) and significantly higher satisfaction with the quality, amount, and timeliness of feedback. There were no significant differences in mean scores for overall and specific aspects of satisfaction between the faculty physician intervention and control groups.

CONCLUSIONS

An intervention designed to improve real-time feedback in the ED resulted in higher resident satisfaction with feedback received, but did not affect faculty satisfaction with the feedback given.

Isolation of a new melanoma antigen, MART-2, containing a mutated epitope recognized by autologous tumor-infiltrating T lymphocytes

Using cDNA expression cloning, a cDNA encoding a novel human melanoma Ag, MART-2 (melanoma Ag recognized by T cells-2), recognized by HLA-A1-restricted CD8(+) T cells from tumor-infiltrating lymphocytes (TIL1362) was isolated from an autologous melanoma cell line, 1362 mel. Homologous sequences to the cDNA had been registered in the EST database. This gene encoded an uncharacterized protein expressed ubiquitously in most normal and cancer cells. A mutation (A to G transition) was found in the cDNA obtained from the1362 mel melanoma cell line in the sequences encoding the phosphate binding loop (P-loop) that resulted in loss of the ability to bind GTP. Transfection of NIH-3T3 with the mutated MART-2 did not result in the development of significant foci. By screening 36 various cancer cell lines using single-strand conformation polymorphism, a possible mutation in the P-loop of MART-2 was found in one squamous cell lung cancer cell line, EBC1. The T cell epitope for TIL1362, FLEGNEVGKTY, was identified to be encoded by the mutated sequence of the MART-2 Ag. The mutation substituted glycine in the normal peptide with glutamic acid at the third amino acid of the epitope, which is an important primary anchor amino acid for HLA-A1 peptide binding. The normal peptide, FLGGNEVGKTY, was not recognized by TIL1362, suggesting that this T cell response was specific for the autologous tumor. Although transforming activity was not detected in the NIH-3T3 assay, MART-2 with the mutation in the P-loop may be involved in the generation of melanoma through a loss of GTP binding activity.

Recognition of shared melanoma antigens in association with major HLA-A alleles by tumor infiltrating T lymphocytes from 123 patients with melanoma

A total of 123 tumor-infiltrating T lymphocyte (TIL) cultures established from patients with HLA-A1, -A2, -A3, -A24, or -A31 metastatic melanoma in the Surgery Branch, National Cancer Institute, were screened for recognition of shared melanoma antigens including five melanosomal proteins (tyrosinase, MART-1/melan-A, gp100, TRP1, TRP2) as well as peptides derived from MAGE-1 and MAGE-3. Examination of the specificity of these T cells indicated that 16% of HLA-A1 TIL, 57% of HLA-A2 TIL, 7% of HLA-A3 TIL, 13% of HLA-A24 TIL, and 27% of HLA-A31 TIL recognized shared melanoma antigens restricted by major histocompatibility complex class I. Melanosomal proteins were frequently recognized by these TIL, and MART-1(27-35), gp100(154-162), gp100(209-217), and gp100(280-288) represent highly immunogenic epitopes that were recognized by a high percentage of HLA-A2 restricted melanoma reactive TIL. Recognition of gp100 by HLA-A2 restricted TIL significantly correlated with clinical response to adoptive immunotherapy with TIL in 21 HLA-A2 melanoma patients (p = 0.024). Four HLA-A1, two HLA-A2, two HLA-A3, one HLA-A24, and two HLA-A31 restricted shared antigen-specific TIL did not recognize the previously identified antigens tested in this study, and may be useful for the identification of new melanoma antigens. The observation that TILs isolated from patients with metastatic melanoma recognized melanosomal proteins in the context of predominant HLA-A alleles implies that it may be possible to develop immunotherapies for patients with melanoma expressing diverse HLA types.