Utilizing Post-Clerkship Surveys to Optimize Emergency Medicine Program Outcomes in the Match

Purpose

The Match for Emergency Medicine residency has presented new challenges over the past 2 years (2022-2023). Use of a post-clerkship survey given to clerkship students could improve outcomes in The Match by helping the program identify its different strengths and weaknesses.

Methods

A post-clerkship survey, sent after The Match, was sent to Emergency Medicine bound students who completed our Emergency Medicine clerkship. This data was then collected and analyzed and, in collaboration with our faculty and residents, changes were made to the clerkship and residency program with the intention that these changes would improve our program and therefore our competitiveness in the upcoming cycle of The Match. These changes were analyzed in the subsequent post-clerkship survey. The survey included questions that asked students to reflect on their experiences with various aspects of the program and how these experiences influenced their personal ranking of our program compared to other emergency medicine residency programs they might have interacted with.

Results

Results from the initial post-clerkship survey revealed that students found our faculty and residents (55% ranked higher), County hospital (55% ranked higher), and SLOE transparency (64% ranked higher) as the main aspects of our program that led them to rank the program higher. Living in Lubbock, TX was found to be the biggest drawback for students, with 55% ranking our program lower. The 2023 post-clerkship survey revealed that the changes we made to our clerkship and program were effective, with an overall decrease of 10 points in students who ranked our program lower based on "Living in Lubbock, TX". We also were able to keep 4 of our rotators, as opposed to 2 the year before. Lastly, we also did not need to go as far down our rank list in the 2023 cycle of The Match.

Conclusion

Using a post-clerkship survey to evaluate strengths and weaknesses of a program through a student's perspective can be an effective tool to help programs in their outcomes from The Match. Further study is necessary to validate these findings.

Antihypertensive use for stroke in United States emergency departments

OBJECTIVE

Timely emergency department (ED) control of hypertension in the acute phase of stroke is associated with improved outcomes. It is unclear how emergency physicians use antihypertensive medications to treat severe hypertension associated with stroke. We sought to determine national patterns of antihypertensive use associated with ED visits for stroke in the United States.

METHODS

We analyzed data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) 2008-2017. We included ED visits associated with ischemic stroke (ICD9 433-434, ICD10 I630-I639) or hemorrhagic stroke (ICD9 430-432, ICD10 I600-I629). We estimated the number and proportions of stroke ED visits with triage blood pressure meeting treatment thresholds (triage systolic blood pressure [SBP] ≥180 mm Hg). We identified the frequency of antihypertensive use, as well as the most commonly used agents.

RESULTS

Between 2008-2017, of a total 135,012,819 ED visits, 619,791 were associated with stroke (78.3% ischemic strokes and 21.7% hemorrhage strokes). Of all stroke visits, 21.8% received antihypertensive medications. Of the identified visits, 9.0% (95% confidence interval [CI] = 6.0%, 13.1%) ischemic stroke visits and 58.2% (95% CI = 49.0%, 66.9%) hemorrhagic stroke visits met criteria for BP reduction. A total of 47.6% (95% CI = 29.1%, 66.7%) of eligible ischemic stroke visits and 41.5% (95% CI = 30.5%, 53.3%) of eligible hemorrhagic strokes visits received antihypertensives. The most common agents used in ischemic stroke were beta-blockers, calcium-channel blockers, and ACE inhibitors. The most common agents used in hemorrhagic stroke included calcium-channel blockers, beta-blockers, and vasodilators.

CONCLUSION

In this national sample, less than half of strokes presenting to the ED with hypertension received antihypertensive therapy.

Utilization of prescription medications and ancillary pharmacy services among rural elders in west Texas: distance barriers and implications for telepharmacy

We examine the relationship between distance and access to prescription medications and ancillary pharmacy services among rural elders in west Texas. Further understanding this relationship is important because programs such as telepharmacy are largely justified on the basis of reducing distance barriers. We use data from the Texas Tech 5000 survey to evaluate the relationship between distance and access. In addition, we examine whether regulations that prohibit competition between independent pharmacies and telepharmacies create a distance barrier to prescription medication. Our findings suggest that distance is a barrier to access, but telepharmacy regulations in Texas do not exacerbate the impact of distance.

State-level variations in income-related inequality in health and health achievement in the US

The objective of this study was to examine state-level variations in income-related inequality in health and overall health achievement in the US. Data that were representative of the US and each state in 2001 were extracted from the Current Population Survey 2001. Income-related inequality in health and health achievement were measured by Health Concentration and Health Achievement Indices, respectively. Significant variations were found across states in income-related inequality in health and health achievement. In particular, states in the south and east regions, on average, experienced a higher degree of health inequality and lower health achievement. About 80% of the state-level variation in health achievement could be explained by demographics, economic structure and performance, and state and local government spending and burden. In contrast, medical care resource indicators were not found to contribute to health achievement in states. States with better health achievement were more urbanized, had lower proportions of minority groups, females and the elderly, fewer individuals below the poverty line, larger primary industry, and lower unemployment rates. Also, per capita state and local government spending, particularly the proportion spent on public health, was positively associated with better health achievement. Because of the direct implications of health level and distribution in resource allocation and social norms, states with a lower level of health achievement need to prioritize efforts in increasing and reallocating resources to diminish health inequality and to improve population health.

Comparison of Colvard pupillometer and infrared digital photography for measurement of the dark-adapted pupil diameter

PURPOSE

To investigate the accuracy of pupil diameter measurement using the Colvard pupillometer and to determine the learning curve for inexperienced examiners.

SETTING

Texas Tech University Health Sciences Center, Lubbock, Texas, USA.

METHODS

In this population study, subjects with normal pupillary behavior were tested by 1 of 2 investigators (examiner A, examiner B). After 5 minutes of dark adaptation at 1 lux, digital infrared pupil photography of the right eye was performed, followed by measurement of the horizontal pupil diameter and vertical pupil diameter with the Colvard pupillometer. The photographs were digitally analyzed to determine the horizontal and vertical pupil diameters. During phase I of the study, examiners were masked to the results of infrared pupil photography; during phase II, they reviewed the infrared pupil photography results after each testing session. Bland-Altman plots were created to detect measurement bias; results were graphed by subject test sequence to assess learning. A test difference of less than +/-0.5 mm was considered clinically acceptable.

RESULTS

Fifty-nine subjects were tested in phase I, of whom 39 had adequate infrared pupil photography for analysis; 40 were tested in phase II, of whom 34 were included. The mean age of the analyzed subjects was 27 years (range 18 to 44 years). For all subjects, the infrared pupil photography median horizontal pupil diameter was 7.09 mm +/- 0.75 (SD) (range 5.44 to 8.79 mm); the median vertical pupil diameter was 7.22 +/- 0.79 mm (range 5.45 to 9.10 mm). Examiner A initially had a negative bias (Colvard pupillometer value less than infrared pupil photography value) for both horizontal and vertical pupil diameter measurements, which resolved during phase I after 23 subjects were tested; 18 of the final 19 subjects tested (11 phase I, 8 phase II) showed a test difference of less than 0.5 mm for all readings. The pupil diameter did not affect the bias. Examiner B had a strong positive bias that persisted throughout the study. Testing 26 subjects in 5 sessions during phase II did not improve the accuracy. During the final testing session, 3 of 8 subjects had a test difference of 0.5 mm or more in at least 1 dimension. The pupil diameter did not affect the bias.

CONCLUSION

The Colvard pupillometer is susceptible to user errors causing unidirectional bias and seems to have a steep and variable learning curve.

Six-month variability of the dark-adapted pupil diameter

PURPOSE

To determine the individual variability of the dark-adapted pupil diameter over 6 months using a standardized dark-adaptation protocol.

SETTING

Texas Tech University Health Sciences Center, Lubbock, Texas, USA.

METHODS

This prospective observational cohort study comprised volunteers with no history of ocular disease, surgery, or injury other than requirement for refractive correction. The right eye was tested. A standardized dark-adaptation protocol was used that controlled for accommodation and patient alertness. Infrared, still digital photographs were taken after 10 minutes of dark adaptation at 1 lux and were analyzed using digital image software. Testing was performed at baseline in the afternoon, at 3 months in the afternoon, and at 6 months in the morning. Lifestyle factors such as diet and exercise were not controlled.

RESULTS

Mean intersession differences were 0.04 mm (95% confidence interval [CI]: -0.68-0.146), 0.15 mm (95% CI: -0.001-0.297), and 0.09 mm (95% CI: -0.048-0.236) for baseline-3 month, baseline-6 month, and 3 month-6 month comparisons, respectively. None of these differences was significantly different from zero (P>.05, 2-tailed Student t tests). The likelihood that the mean intersession difference was >.25 mm was negligible for all comparisons (P=.9996, .9099, and .9829 respectively, 1-tailed Student t tests).

CONCLUSION

When a consistent dark-adaptation protocol that controls for alertness and accommodation is used, normal young individuals showed no significant variation in the dark-adapted pupil diameter over a 6-month period.

Visual field changes after laser in situ keratomileusis

PURPOSE

To determine whether laser in situ keratomileusis (LASIK) affects the central 30-degree visual field.

SETTING

University-based ophthalmology practice.

METHODS

This nonrandomized clinical trial comprised 14 normal patients (27 eyes) scheduled to have LASIK for myopia or myopic astigmatism. Automated static perimetry was performed before and 6 months after surgery using the Octopus 1-2-3 perimeter and the Dynamic-32 test strategy. Patient data included sex, age, preoperative and postoperative refractive errors, preoperative and postoperative best corrected visual acuity, preoperative corneal thickness, programmed optical zone, programmed total ablation diameter, and duration of microkeratome suction. All surgery was performed using the same Alcon LADARVision 4000 excimer laser. The main outcome measures were the mean sensitivity (MS) change in the central 15-degree visual field and the MS change in the 15- to 30-degree visual field. A multivariate analysis of the MS change as a function of preoperative clinical parameters was performed.

RESULTS

There was no significant change in the MS in the central 15-degree visual field; between 15 and 30 degrees, there was a statistically significant decrease of -0.82 dB +/- 1.40 (SD) (P=.01, 2-tailed t test). The decline in MS was positively correlated with refractive error and corneal thickness; it was negatively correlated with the programmed optical zone diameter.

CONCLUSIONS

Automatic static perimetry can detect decreased sensitivity in the midperipheral visual field after myopic LASIK. It may be a useful quantitative subjective test for measuring the effects of future improvements in surgical technique on vision quality.

Factors associated with health-related quality of life among an older population in a largely rural western region

CONTEXT

As elderly people become a larger proportion of the rural population, it is important to identify those at risk for poor health. Predictors of health-related quality of life can be useful in designing interventions.

PURPOSE

One objective of the present study was to profile the health-related quality of life of community-dwelling, elderly people in a southwestern region of the United States. A related objective was to identify the principal factors associated with health-related quality of life, thereby identifying population subgroups in greatest need of health or social services.

METHODS

A telephone survey of approximately 5,000 individuals 65 years and older collected data on need for assistance with activities of daily living, physical and mental health-related quality of life, and worry about health status measures. A modified version of the Behavioral Model was used to more clearly distinguish the different groups at risk for poor health.

FINDINGS

Those groups of community-dwelling, elderly people in the poorest health were older than 75 years, had less than a high school education, were retired or unemployed, and had low household income. No differences were found by urban, rural, and frontier residence.

CONCLUSIONS

To maintain the physical, social, and psychological health of older people residing in rural and urban areas, social services, medical care, and supportive services are needed, particularly among the most socially and economically disadvantaged.

Effects of weight status on the recommendations of and adherence to lifestyle modifications among hypertensive adults

Overweight and obese hypertensive patients can greatly benefit from high adherence rates for lifestyle modifications. The objectives of this paper were to investigate how patients' weight status affected physicians' recommendations of lifestyle modifications and patients' adherence after they received the recommendations. The patients were adults (18+ years of age) with hypertension (prehypertension, Stage I and Stage II hypertension). The National Health and Nutrition Examination Survey (NHANES) 1999-2000 was used. Weight status was categorized as normal/underweight, overweight and obese. Physicians' recommendations of and patients' adherence to lifestyle modifications (weight control, exercise, sodium intake reduction, alcohol intake reduction) were examined using descriptive and multivariate analyses, controlling for weight status, hypertension stage, comorbidities and demographic characteristics. About 57.0% of the US adult population in 1999-2000 had prehypertension, Stages I or II hypertension. Among the hypertensive adults, 30.3% were normal/underweight, 32.6% were overweight and 37.2% were obese. We found that physicians were more aggressive in recommending lifestyle modification for obese patients. In contrast, obese hypertensive patients were not found to be more likely than normal/underweight patients to adhere to lifestyle modification recommendations. In addition, adherence rates for sodium and alcohol consumption reduction were higher than that for either exercise or weight control. In conclusion, more aggressive approaches should be taken by physicians to educate obese patients about the benefits of lifestyle modifications and to improve adherence to enhance the effects of antihypertensive medications.

Patient involvement in medical decision-making and pain among elders: physician or patient-driven?

Background

Pain is highly prevalent among older adults, but little is known about how patient involvement in medical decision-making may play a role in limiting its occurrence or severity. The purpose of this study was to evaluate whether physician-driven and patient-driven participation in decision-making were associated with the odds of frequent and severe pain.

Methods

A cross-sectional population-based survey of 3,135 persons age 65 and older was conducted in the 108-county region comprising West Texas. The survey included self-reports of frequent pain and, among those with frequent pain, the severity of pain.

Results

Findings from multivariate logistic regression analyses showed that higher patient-driven participation in decision-making was associated with lower odds (OR, 0.82; 95% CI, 0.75–0.89) of frequent pain, but was not significantly associated with severe pain. Physician-driven participation was not significantly associated with frequent or severe pain.

Conclusions

The findings suggest that patients may need to initiate involvement in medical decision-making to reduce their chances of experiencing frequent pain. Changes to other modifiable health care characteristics, including access to a personal doctor and health insurance coverage, may be more conducive to limiting the risk of severe pain.

Canine ovariohysterectomy and orchiectomy increases the prevalence of ACL injury

To determine whether canine ovariohysterectomy or orchiectomy affects the prevalence of anterior cruciate ligament injury, we compared injury rates of anterior cruciate ligaments of animals that had gonadectomy and animals that were sexually intact as a function of gender, breed, or size. Records of 3218 dogs treated in one orthopaedic veterinary practice during a 2-year period were retrospectively reviewed. Anterior cruciate ligament injury, diagnosed by a history of acute hind limb lameness and by positive anterior drawer test, was confirmed at the time of surgery. The prevalence of anterior cruciate ligament rupture in all dogs was 3.48%. Females that had ovariohysterectomy and males that had orchiectomy had a significantly higher prevalence of anterior cruciate ligament rupture than the sexually intact dogs. Larger dogs had an increased prevalence of anterior cruciate ligament injury compared with smaller or medium-sized dogs, with the increased rupture rates for sterilized animals holding across breeds and sizes. Sterilization of either gender increased the prevalence of anterior cruciate ligament injury, suggesting a potential effect of gonadal gender on prevalence of injury of this ligament.

Normal values for a clinical test of letter-recognition contrast thresholds

PURPOSE

To investigate the contrast thresholds (CTs) in normal subjects using a high-luminance, letter-recognition task under clinically relevant testing conditions.

SETTING

Texas Tech University Health Sciences System, Lubbock, Texas, USA.

METHODS

Sixty normal subjects aged 20 to 49 years with a best corrected visual acuity of 20/20 or better in both eyes participated. M & S Technologies software was used to display black-on-white Sloan letters at contrast levels of 25%, 20%, 15%, 12%, and 10% through 1% in 1% decrements. The effects of age, sex, optotype size, eye dominance, ambient illumination level (bright = 625 - 630 lux; dim = <3 lux), and direction of approach to threshold were analyzed using a multivariate, ordinary, least-squares analysis.

RESULTS

Age and sex did not influence CTs. Ascending versus descending testing was not statistically significant (P>.5). The effects of room illumination and eye dominance were significant (P<.01). Significant differences were found between 20/30 and 20/50, 20/30 and 20/70, and 20/50 and 20/70 optotype sizes (P<.01 for all comparisons).

CONCLUSIONS

A commercially available, computer-based test of CTs was easy to administer and apparently easy for inexperienced subjects to perform. The results suggest criteria for detecting visual problems concerned with familiar but complex spatial-image shapes. This information might be used to assess the effects of treatments such as laser refractive surgery on recognition contrast. Further study is warranted.

Parents' reports of children's medical care access: are there Mexican-American versus non-Hispanic white disparities?

OBJECTIVES

We investigated whether there were Mexican-American versus non-Hispanic white disparities in parents' reports of problems with 4 dimensions of children's medical care access after controlling for a range of demographic, social, economic, and health status factors.

METHODS

Data were collected through a telephone survey of 5941 parents residing in Texas. The survey questionnaire included measures of the parent's demographic and socioeconomic status and the child's health-related quality of life. The behavioral model was used to guide the inclusion of factors in multivariate logistic regression analyses of parents' reports of their children's ability to obtain an appointment for routine/regular care, obtain care for illness/injury, obtain help/advice over the phone when calling the doctor's office, and having to wait more than 15 minutes in the doctor's office.

RESULTS

Mexican-American parents had worse reports of all 4 dimensions of their children's access even after controlling for predisposing, enabling, and need factors. Among Mexican-Americans, there were no differences between those who primarily spoke English versus Spanish. Other factors that were significantly associated with at least 2 reports of access were household income, the child's insurance status, and the child's health-related quality of life.

CONCLUSIONS

Mexican-American children face problems accessing medical care in a timely manner that are not fully explained by parents' demographic, social, and economic status or children's health-related quality of life. Health policy makers, managers, and clinicians should further consider how they could reduce the inequity of access to medical services among Mexican-American children.

Day to day variability of the dark-adapted pupil diameter

PURPOSE

To determine the individual variability of the dark-adapted pupil diameter over 2 testing sessions using a standardized dark-adaptation protocol.

SETTING

Texas Tech University Health Sciences Center, Lubbock, Texas, USA.

METHODS

In this prospective observational cohort study, 40 volunteers with no history of ocular disease, surgery, or injury other than requirement for refractive correction were included. The right eye was tested. A standardized dark-adaptation protocol was used that controlled for accommodation and patient alertness. Infrared, still digital photographs were taken after 5 and 10 minutes of dark adaptation and analyzed independently by 2 investigators using digital-image software. Two test sessions were performed 1 to 7 days apart. Lifestyle factors such as sleep, diet, and exercise were not controlled.

RESULTS

The mean subject age was 31.5 years (range 20 to 49 years). There were 20 men; 27 subjects wore correction for myopia, and 13 wore no correction. The mean interval between test sessions was 2 days (range 1 to 7 days). The mean difference and 95% confidence intervals for pupil diameter difference between sessions were as follows: 5-minute readings, +0.032 mm (-0.030 to +0.094); 10-minute readings, -0.006 mm (-0.059 to +0.047); mean of 5- and 10-minute readings, +0.013 mm (-0.038 to +0.064). Using the paired t test, the pupil diameter did not differ significantly between sessions in 5-minute dark adaptation (P =.2980), 10-minute dark adaptation (P =.8263), or the mean (P =.6049).

CONCLUSION

Using a consistent dark-adaptation protocol that controlled for alertness, individuals aged 20 to 49 years showed no significant variation in dark-adapted pupil diameter when tested twice in 1 week.

Prevalence and correlates of paediatric asthma and wheezing in a largely rural USA population

OBJECTIVE

The prevalence of asthma among children has been increasing in the United States and it is estimated that there are approximately 5 million children with asthma. This cross-sectional survey sought to estimate the prevalence of asthma and asthma symptoms and potential risk factors among children aged 16 and younger, in a largely rural population in the USA.

METHODS

This study was a telephone survey of 1500 households in the South Plains/Panhandle region of Texas. Parents of children were interviewed with a response rate of 64%. Having been diagnosed with asthma by a physician and a report of wheezing in the last 12 months were used as dependent variables in multivariate logistic regressions with several sociodemographic and environmental factors as potential confounders.

RESULTS

The age-adjusted prevalence of asthma and wheezing among children were approximately 15 and 18%, respectively. The prevalence of asthma was highest (20%) among children aged 11-16 (P < 0.001). Living in urban areas was associated significantly with asthma and wheezing. Non-Hispanic blacks reported significantly increased odds of asthma in their children (adjusted odds ratio (OR) = 2.04, 95%CI 1.02-4.08), whereas Mexican-Americans reported significantly reduced odds of asthma (adjusted OR = 0.48, 95%CI 0.29-0.78) and wheezing (adjusted OR = 0.58, 95%CI 0.37-0.89) in their children. The odds of asthma (adjusted OR = 1.78, 95%CI 1.09-2.92) and wheezing (adjusted OR = 2.45, 95%CI 1.52-3.95) was highest among children in the highest body mass index quartile. No significant association with pet ownership and exposure to second-hand smoke with asthma and wheezing was observed in this study.

CONCLUSION

Urban residence, non-Hispanic black and Mexican-American race/ethnicity, and being overweight were significantly associated with the increased risk of asthma and/or wheezing.

Duration of heart disease visits by elderly patients: productivity versus quality

A balance should be reached between physician productivity and clinical quality, since the first comes at the expense of the second. The study described here used the National Ambulatory Medical Care Survey (NAMCS) to demonstrate that visit length for elderly heart disease patients is related to both appropriate (i.e. clinical) patient differences and to less justifiable factors. Both demand management and managerial control strategies should be considered.

Are rural residents and Hispanics less satisfied with medical care? Evidence from the Permian Basin

Few population-based studies of consumers' perceptions of health care quality have included both rural residents and Hispanics. Using data collected through a random-digit telephone survey of households in the Permian Basin region of west Texas, an area with a relatively high percentage of Mexican Americans, we tested for rural/urban and ethnic differences in satisfaction with medical care. The study had several limitations, but the findings suggest that rural residents of this region rate the quality of their medical care overall more negatively than do their urban counterparts. No ethnic differences were found when controlling for demographic, social, economic, and health-status characteristics. Other factors, including part-time employment, a lack of continuous health insurance coverage, and poor health status appear to have a stronger, negative relationship with satisfaction. The collection and reporting of more specific measures of interpersonal and technical quality would further enable policy-makers, managers, and clinicians to better serve their patient populations.