Teaching Trainees Effective Patient Communication Skills in the Clinical Environment: Best Practices Under Crisis Conditions

ABSTRACT

Communication within the health care setting has significant implications for the safety, engagement, and well-being of patients and physicians. Evidence shows that communication training is variable or lacking in undergraduate and graduate medical education. Physician-patient communication presents a vulnerable point in patient care, which was heightened by the COVID-19 pandemic and its aftermath. Physicians have to adapt their strategies to meet new challenges, including communicating through the necessary barriers of personal protective equipment and telecommunication platforms. They also face uncharted challenges of facilitating discussions around proactive planning and scarce resources. Medical educators must be equipped to provide trainees with the skills needed to maintain empathy, facilitate trust and connection, and adapt communication behaviors under such crisis conditions. Using the Calgary-Cambridge model as a framework, the authors describe 3 new challenges to effective physician-patient communication for which COVID-19 was the impetus-face masks, visitor restrictions, and resource allocation/proactive planning discussions-and propose educational solutions.

Measuring and Predicting Faculty Consensus Rankings of Standardized Letters of Evaluation

Background Standardized letters of evaluation (SLOE) are becoming more widely incorporated into the residency application process to make the letter of recommendation, an already critical component in a residency application packet, more objective. However, it is not currently known if the reviewers of these letters share consensus regarding the strength of an applicant determined by their SLOE. Objective We measured the level of faculty agreement regarding applicant competitiveness as determined by SLOEs and the ability of 2 algorithms to predict faculty consensus rankings. Methods Using data from the 2021-2022 Match cycle from the Council of Residency Directors in Emergency Medicine SLOE Database as a blueprint, authors created 50 fictional SLOEs representative of the national data. Seven faculty then rated these SLOEs in order of applicant competitiveness, defined as suggested rank position. Consensus was evaluated using cutoffs established a priori, and 2 prediction models, a point-based system and a linear regression model, were tested to determine their ability to predict consensus rankings. Results There was strong faculty consensus regarding the interpretation of SLOEs. Within narrow windows of agreement, faculty demonstrated similar ranking patterns with 83% and 93% agreement for "close" and "loose" agreement, respectively. Predictive models yielded a strong correlation with the consensus ranking (point-based system r=0.97, linear regression r=0.97). Conclusions Faculty displayed strong consensus regarding the competitiveness of applicants via SLOEs, adding further support to the use of SLOEs for selection and advising. Two models predicted consensus competitiveness rankings with a high degree of accuracy.

Racial disparities in emergency medicine: Implementation of a novel educational module in the emergency medicine clerkship

Objectives

Despite decades of literature recognizing racial disparities (RDs) in emergency medicine (EM), published curricula dedicated to addressing them are sparse. We present details of our novel RD curriculum for EM clerkships and its educational outcomes.

Methods

We created a 30-min interactive didactic module on the topic designed for third- and fourth-year medical students enrolled in our EM clerkships. Through a modified Delphi process, education faculty and content experts in RD developed a 10-question multiple-choice test of knowledge on RD that the students completed immediately prior to and 2 weeks following the activity. Students also completed a Likert-style learner satisfaction survey. Median pre- and posttest scores were compared using a paired Wilcoxon signed-rank test and presented using medians and 95% confidence intervals (CIs). Satisfaction survey responses were dichotomized into favorable and neutral/not favorable.

Results

For the 36 students who completed the module, the median pretest score was 40% (95% CI 36%-50%) and the posttest score was 70% (95% CI 60%-70%) with a p-value of <0.001. Thirty-five of the 36 students improved on the posttest with a mean increase of 24.2% (95% CI 20.2-28.2). The satisfaction survey also showed a positive response, with at least 83% of participants responding favorably to all statements (overall mean favorable response 93%, 95% CI 90%-96%).ConclusionsThis EM-based module on RD led to improvement in students' knowledge on the topic and positive reception by participants. This is a feasible option for educating students in EM on the topic of RD.

The next generation of researchers: One-year outcome data from the SAEM Advanced Research Methodology Evaluation and Design in Medical Education (ARMED MedEd) program

Introduction

As the field of medical education evolves, there is a need to increase the quality of education scholarship and develop a cadre of research scholars; however, clinician educators (CEs) considering this career transition have limited formal training in education research methodology to heed this call. Therefore, a program that provides more advanced training in education scholarship for CEs without the financial and resource barriers of fellowships and masters programs is needed.

Methods

The SAEM Advanced Research Methodology Evaluation and Design in Medical Education (ARMED MedEd) program is a longitudinal program for the beyond-beginner CE, seeking advanced training in education research. The program was created using a comprehensive needs assessment and included longitudinal training; small-group projects; dedicated project mentors; and integrated diversity, equity, and inclusion initiatives. Program participants applied for a grant upon program completion.

Results

Twenty-one participants completed the course with 100% completing the baseline survey and 67% (14/21) completing the end-of-program survey. Participants reported improved perception of knowledge across all of the topics with a medium to large effect size, ranging from 0.40 to 0.62. When asked about impact on their network of potential collaborators, participants reported a median of 7 (interquartile range [IQR] 5-8) out of 9. When asked about the impact on their community of practice, participants reported a median of 7 (IQR 5-7) out of 9. When asked about the impact on their professional identity, participants reported a median of 7 (IQR 4-9) out of 9. Participants also reported an increase in both the quantity (mean of 2 ± 1 new mentors) and the quality (median score 7 [IQR 5-8] out of 9) of new research mentorship as a result of the program. Open-ended feedback was generally positive, with 100% reporting they would advise others to take this program.

Conclusions

The SAEM ARMED MedEd program represents a proof of concept for an advanced education research program seeking to fill the research training gap for the beyond-beginner Clinician educators.

Sensitivity of diffusion-weighted magnetic resonance imaging in transient global amnesia as a function of time from symptom onset

BACKGROUND

The objective was to systematically evaluate the sensitivity of diffusion-weighted magnetic resonance imaging (DW-MRI) for transient global amnesia (TGA) across various time frames compared to the reference-standard clinical criteria.

METHODS

All indexed publications related to TGA and MRI through June 2020 were retrieved by a medical librarian. Two independent reviewers identified original research studies of adults with a clinical diagnosis of TGA using Caplan and Hodges and Warlow criteria (reference standard) who were evaluated with DW-MRI. Pooled estimates and its 95% confidence intervals (CI) for the proportion of acute TGA patients with positive DW-MRI (i.e., sensitivity) were obtained using random-effects meta-analysis for various time frames. Quality assessment was performed using the revised Quality of Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool.

RESULTS

After screening 665 reports, we identified 81 potentially relevant studies. Twenty-three studies representing 1688 patients met eligibility criteria, but not all studies had data available for meta-analysis. The pooled sensitivity (also described as positivity rate) of DW-MRI was 15.6% (95% CI = 2.6%-35.0%) between 0 and 12 h from symptom onset, 23.1% (95% CI = 6.1%-45.7%) at 0-24 h, 72.8% (95% CI = 40.8%-96.3) at 12-24 h, 68.8% (95% CI = 44.8%-88.8%) at 24-36 h, 72.4% (95% CI = 59.8%-83.5%) at 36-48 h, 82.8% (95% CI = 54.7%-99.6%) at 48-60 h, 66.9% (95% CI = 47.5%-83.9%) at 60-72 h, and 72.0% (95% CI = 30.1%-100.0%) at 72-96 h. There was significant concern for risk of bias in the QUADAS-2 domains of patient selection and index test, yielding a low level of certainty in the pooled estimates.

CONCLUSION

DW-MRI lesions are uncommon in patients with TGA early after symptom onset, but the sensitivity (i.e., positivity rate) of DW-MRI increases with time. Despite the limited quality of existing evidence, obtaining an early DW-MRI in patients with clinical diagnosis of TGA in the acute setting is likely a low-yield test.

Design and Evaluation of a Curriculum on Intimate Partner Violence for Medical Students in an Emergency Medicine Clerkship

PURPOSE

Intimate partner violence (IPV) is a widespread public health issue that is relevant to all areas of medicine. Patients who suffer from IPV often contact the health care system via the emergency department, making this a particularly important but too often overlooked issue in this setting. Education on IPV varies in medical schools and emergency medicine (EM) educational programs, and evidence suggests that a barrier to assessing for IPV is a lack of adequate training of clinicians. In this study, we sought to design, implement and evaluate the efficacy of a curriculum on IPV geared towards medical students on an EM clerkship.

METHODS

We assembled a multi-disciplinary team of EM education faculty, a resident content expert on IPV, and social workers to design a two-part curriculum that was administered to medical students on an EM clerkship. The curriculum involved a 20-minute narrated slide presentation viewed asynchronously, followed by a 1-hour case-based discussion session. The curriculum was evaluated using a 13-item self-assessment survey on knowledge, comfort level and skill in managing victims of IPV, administered electronically before and after the curriculum. Survey results were compared pre- and post-curriculum using Wilcoxon signed-rank test.

RESULTS

Thirty-four students completed the curriculum and 26 completed both the pre and post self-assessment surveys. A statistically significant improvement in knowledge, comfort level and skills was observed in 11 of the 13 survey elements.

CONCLUSION

Based on the self-assessment survey results, this curriculum was well received and successfully increased participants' comfort, knowledge and skill level regarding assessment of patients for IPV. This is a focused and feasible curriculum that can be easily incorporated into an EM clerkship to provide effective education on a relevant but often overlooked topic.

A Simulation-Based Prospective Cohort Study on Teaching Best Practices in Firearms Safety

BACKGROUND

Gun violence in the United States is a significant public health concern. The high rate of weapons carriage by Americans places medical providers at risk for exposure to firearms in the workplace and provides an opportunity for patient safety counseling. Few curricular interventions have been published on teaching firearms safety principles to medical providers. Given the risk of encountering firearms in the workplace and the opportunity to engage patients in firearms safety counseling, providers may benefit from dedicated training on safely handling firearms.

METHODS

This was a prospective cohort pilot study of a simulation-based educational intervention for third- and fourth-year medical students enrolled in an emergency medicine subinternship and emergency medicine bootcamp elective. Before undergoing the educational intervention, students completed a preintervention simulation case during which they discovered a model firearm in the patient's belongings and were asked to remove it. Students then received the intervention that included a discussion and demonstration on how to safely remove a firearm in the clinical setting. Two weeks later, the students were presented with a model firearm in a different simulation case, which they needed to remove. During the preintervention and postintervention simulations, students were evaluated on their performance of the critical actions in firearm removal using an 8-item checklist. Students' scores on this checklist were compared.

RESULTS

Fifty-three students participated in the study, 25 of whom completed the postintervention assessment. The median number of correctly performed critical actions preintervention was 5 (interquartile range = 4-6) and postintervention was 7 (interquartile range = 6-8, P < 0.001). Students showed particular improvement in 4 steps: holding the firearm by the grip only, pointing the firearm in a safe direction at all times, removing the firearm from the immediate patient care area and placing it in a safe area, and ensuring that the firearm is monitored and untouched until police or security personnel arrive to secure it.

CONCLUSIONS

This educational intervention is the first to formally teach students about the safe handling of firearms found in the clinical care space. This low-cost pilot project is easily transferrable to other training centers for teaching principles of safe firearms handling.

Addressing gender inequities: Creation of a multi-institutional consortium of women physicians in academic emergency medicine

Gender inequity is pervasive in medicine, including emergency medicine (EM), and is well documented in workforce representation, leadership, financial compensation, and resource allocation. The reasons for gender inequities in medicine, including academic EM, are multifactorial and include disadvantageous institutional parental, family, and promotion policies; workplace environment and culture; implicit biases; and a paucity of women physician leader role models, mentors, and sponsors. To address some of the challenges of gender inequities and career advancement for women in academic EM, we established an innovative, peer-driven, multi-institutional consortium of women EM faculty employed at four distinct hospitals affiliated with one medical school. The consortium combined financial and faculty resources to execute gender-specific programs not feasible at an individual institution due to limited funding and faculty availability. The programs included leadership skill-building and negotiation seminars for consortium members. The consortium created a collaborative community designed specifically to enrich career development for women in academic EM, with a formal organizational structure to connect faculty from four hospitals under one academic institution. The objective of this report is to describe the creation of this cross-institutional consortium focused on career development, academic productivity, and networking and sharing best practices for work-life integration for academic EM women faculty. This consortium-building model could be used to enhance existing institutional career development structures for women and other physician communities in academic medicine with unique career advancement challenges.

Correlation of attending and patient assessment of resident communication skills in the emergency department

BACKGROUND

Communication and interpersonal skills are one of the Accreditation Council for Graduate Medical Education's six core competencies. Validated methods for assessing these among trainees are lacking. Educators have developed various communication assessment tools from both the supervising attending and the patient perspectives. How these different assessment methods and tools compare with each other remains unknown. The goal of this study was to determine the degree of agreement between attending and patient assessment of resident communication skills.

METHODS

This was a retrospective study of emergency medicine (EM) residents at an academic medical center. From July 2017 to June 2018, residents were assessed on communication skills during their emergency department shifts by both their supervising attending physicians and their patients. The attendings rated residents' communication skills with patients, colleagues, and nursing/ancillary staff using a 1 to 5 Likert scale. Patients completed the modified Communication Assessment Tool (CAT), a 14-item questionnaire based on a 1 to 5 Likert scale. Mean attending ratings and patient CAT scores were calculated for each resident. Means were divided into tertiles due to nonparametric distribution of scores. Agreement between attending and patient ratings of residents were measured using Cohen's kappa for each attending evaluation question. Scores were weighted to assign adjacent tertiles partial agreement.

RESULTS

During the study period, 1,097 attending evaluations and 952 patient evaluations were completed for 26 residents. Attending scores and CAT scores of the residents showed slight to fair agreement in the following three domains: patient communication (κ = 0.21), communication with colleagues (κ = 0.21), and communication with nursing/ancillary staff (κ = 0.26).

CONCLUSIONS

Attending and patient ratings of EM residents' communication skills show slight to fair agreement. The use of different types of raters may be beneficial in fully assessing trainees' communication skills.

Early, awake proning in emergency department patients with COVID-19

Objective

Proning has been shown to improve oxygenation and mortality in certain populations of intubated patients with acute respiratory distress syndrome. Small observational analyses of COVID-19 patients suggest awake proning may lead to clinical improvement. Data on safety and efficacy is lacking. We sought to describe the effect of proning on oxygenation in nonintubated COVID-19 patients. We also evaluated feasibility, safety, and other physiological and clinical outcomes associated with this intervention.

Methods

We conducted a prospective, observational cohort study of nonintubated patients with COVID-19 who underwent proning per an Emergency Department (ED) clinical protocol. Patients with mild to moderate respiratory distress were included. We calculated change in oxygenation by comparing the oxygen saturation to fraction of inspired oxygen ratio (SpO2:FiO2) during the five minutes prior to proning and first 30 min of proning. We also captured data on respiratory rate, duration of proning, need for intubation, intensive care unit admission, survival to discharge.

Results

Fifty-two patients were enrolled. Thirty were excluded for not meeting protocol inclusion criteria or missing baseline oxygenation data, leaving 22 for analysis. The SpO2:FiO2 ratio increased by a median of 5 (IQR: 0–15) in the post-proning period compared to the pre-proning period (median: 298 (IQR: 263–352) vs 295 (IQR: 276–350), p = 0.01). Respiratory rate did not change significantly between time periods. No immediate adverse events occurred during proning. Five patients (23%) were intubated within 48 h of admission.

Conclusion

Early, awake proning may be feasible in select COVID-19 patients and was associated with improved oxygenation.

Diagnosis and Initial Emergency Department Management of Subarachnoid Hemorrhage

Atraumatic subarachnoid hemorrhage represents a small proportion of strokes, but is a true medical emergency that results in significant morbidity and mortality. Making the diagnosis can be challenging and misdiagnosis can result in devastating consequences. There are several time-dependent diagnostic and management considerations for emergency physicians and other frontline providers. This article reviews the most up-to-date literature on the diagnostic workup of subarachnoid hemorrhage, avoiding misdiagnosis, and initial emergency department management recommendations.

Standardized Video Interview Scores Correlate Poorly with Faculty and Patient Ratings

The Standardized Video Interview (SVI) was developed by the Association of American Medical Colleges to assess professionalism, communication, and interpersonal skills of residency applicants. How SVI scores compare with other measures of these competencies is unknown. The goal of this study was to determine whether there is a correlation between the SVI score and both faculty and patient ratings of these competencies in emergency medicine (EM) applicants. This was a retrospective analysis of a prospectively collected dataset of medical students. Students enrolled in the fourth-year EM clerkship at our institution and who applied to the EM residency Match were included. We collected faculty ratings of the students’ professionalism and patient care/communication abilities as well as patient ratings using the Communication Assessment Tool (CAT) from the clerkship evaluation forms. Following completion of the clerkship, students applying to EM were asked to voluntarily provide their SVI score to the study authors for research purposes. We compared SVI scores with the students’ faculty and patient scores using Spearman’s rank correlation. Of the 43 students from the EM clerkship who applied in EM during the 2017–2018 and 2018–2019 application cycles, 36 provided their SVI scores. All 36 had faculty evaluations and 32 had CAT scores available. We found that SVI scores did not correlate with faculty ratings of professionalism (rho = 0.09, p = 0.13), faculty assessment of patient care/communication (rho = 0.12, p = 0.04), or CAT scores (rho = 0.11, p = 0.06). Further studies are needed to validate the SVI and determine whether it is indeed a predictor of these competencies in residency.

Gender differences in funding among grant recipients in emergency medicine: A multicenter analysis

OBJECTIVE

To describe differences in funded grants between male and female faculty in two academic emergency departments.

METHODS

This was a retrospective analysis of grant funding at two academic emergency departments from January 2012-September 2018. We queried the grants department databases at each institution and obtained records of all funded grants for emergency medicine (EM) faculty. We extracted the following information for each award: gender of the principal investigator (PI), PI academic rank, grant mechanism (government, institutional, industry, organizational), and percent effort. Differences by gender were compared using Chi-square or Fisher's exact test and Wilcoxon-rank sum.

RESULTS

One-hundred and thirty grants were awarded to EM faculty at the two institutions during the study period. Of the funded grants, 35 (27%) of recipients were female. Among grant recipients, females held lower academic ranking than males (p-value < 0.001): Instructor (49% vs 51%), Assistant Professor (36% vs 64%), Associate Professor (9% vs 91%), and Professor (0% vs 100%), respectively. Organizational grants were dispersed equally between funded faculty, but females received a fewer government, industry, and institutional grants (p-value = 0.007). Female grant recipients were awarded a higher median percent of effort compared to males (14% [IQR: 3-51] vs 8% [IQR: 1-15], respectively, p-value = 0.023).

CONCLUSION

In this multicenter analysis, gender discrepancies exist among funded grants of EM faculty. Male recipients had higher academic ranking than their female counterparts. Female recipients were less likely to have government, institutional, and industry grants but received a greater percent effort on funding that was awarded.

A Multimodal Curriculum With Patient Feedback to Improve Medical Student Communication: Pilot Study

Introduction

Despite the extraordinary amount of time physicians spend communicating with patients, dedicated education strategies on this topic are lacking. The objective of this study was to develop a multimodal curriculum including direct patient feedback and assess whether it improves communication skills as measured by the Communication Assessment Tool (CAT) in fourth-year medical students during an emergency medicine (EM) clerkship.

Methods

This was a prospective, randomized trial of fourth-year students in an EM clerkship at an academic medical center from 2016–2017. We developed a multimodal curriculum to teach communication skills consisting of 1) an asynchronous video on communication skills, and 2) direct patient feedback from the CAT, a 15-question tool with validity evidence in the emergency department setting. The intervention group received the curriculum at the clerkship midpoint. The control group received the curriculum at the clerkship’s end. We calculated proportions and odds ratios (OR) of students achieving maximum CAT score in the first and second half of the clerkship.

Results

A total of 64 students were enrolled: 37 in the control group and 27 in the intervention group. The percentage of students achieving the maximum CAT score was similar between groups during the first half (OR 0.70, p = 0.15). Following the intervention, students in the intervention group achieved a maximum score more often than the control group (OR 1.65, p = 0.008).

Conclusion

Students exposed to the curriculum early had higher patient ratings on communication compared to the control group. A multimodal curriculum involving direct patient feedback may be an effective means of teaching communication skills.

Diagnostic error, quality assurance, and medical malpractice/risk management education in emergency medicine residency training programs

Background

Diagnostic errors in emergency medicine (EM) can lead to patient harm as well as potential malpractice claims and quality assurance (QA) reviews. It is therefore essential that these topics are part of the core education of trainees. The methods training programs use to educate residents on these topics are unknown. The goal of this study was to identify the current methods used to teach EM residents about diagnostic errors, QA, and malpractice/risk management and determine the amount of educational teaching time EM programs dedicate to these topics.

Methods

An 11-item questionnaire pertaining to resident education on diagnostic errors, QA, and malpractice was sent through the Council of Emergency Medicine Residency Directors (CORD) listserv. Differences in the proportions of responses by duration of training program were analyzed using chi-squared or Fisher’s exact tests.

Results

Fifty-four percent (91/168) of the EM programs responded. There was no difference in prevalence of formal education on these topics among 3- and 4-year programs. The majority of programs (59.5%) offer fewer than 4 h per year of additional QA education beyond morbidity and mortality rounds; a minority of the programs (18.8%) offer more than 4 h per year of medical malpractice/risk management education.

Conclusions

This needs assessment demonstrated that there is a lack of dedicated educational time devoted to these topics. A more formalized and standard curricular approach with increased time allotment may enhance EM resident education about diagnostic errors, QA, and malpractice/risk management.

Critical Appraisal of Emergency Medicine Educational Research: The Best Publications of 2016

OBJECTIVES

The objectives were to critically appraise the emergency medicine (EM) medical education literature published in 2016 and review the highest-quality quantitative and qualitative studies.

METHODS

A search of the English language literature in 2016 querying MEDLINE, Scopus, Education Resources Information Center (ERIC), and PsychInfo identified 510 papers related to medical education in EM. Two reviewers independently screened all of the publications using previously established exclusion criteria. The 25 top-scoring quantitative studies based on methodology and all six qualitative studies were scored by all reviewers using selected scoring criteria that have been adapted from previous installments. The top-scoring articles were highlighted and trends in medical education research were described.

RESULTS

Seventy-five manuscripts met inclusion criteria and were scored. Eleven quantitative and one qualitative papers were the highest scoring and are summarized in this article.

CONCLUSION

This annual critical appraisal series highlights the best EM education research articles published in 2016.

Fourth-year medical students do not perform a focused physical examination during a case-based simulation scenario

BACKGROUND

The art of physical examination is one of the most valuable diagnostic tools bestowed upon new generations of medical students. Despite traditional educational techniques and significant attention on a national level, both trainees and educators have noticed a decrease in physical examination proficiency. Simulation has been identified as a potential way to improve physical examination techniques within undergraduate medical education. We sought to determine the utility of a cardiac case-based simulation scenario to assess physical examination performance of fourth-year medical students during an emergency medicine (EM) clerkship.

MATERIALS AND METHODS

Fourth-year medical students enrolled in a 4-week EM clerkship were prospectively evaluated during a case-based scenario using a simulation mannequin (Laerdal SimMan^®). The case involved a patient presenting with chest pain that evolved into cardiac arrest. All simulations were video recorded and two emergency physicians reviewed each video. The reviewers recorded whether or not each student completed the essential components of a focused physical examination.

RESULTS

Twenty-seven students participated in the simulation. The percentage of students completing each of the four components of the physical examination was as follows: cardiac auscultation 33.3% (95% CI 18.5-52.3), lung auscultation 29.6% (95% CI 15.7-48.7), pulse and extremity examination 55.6% (95% CI 37.3-72.4), and abdominal examination 3.70% (95% CI 0-19.8). None of the students completed all four of these components.

CONCLUSION

Our study showed that fourth-year medical students did not uniformly perform components of a focused physical examination during a high-acuity chest pain simulation scenario. Although our study showed limited physical examination performance, simulation allows evaluators to observe and provide constructive feedback and may lead to an improvement in these skills. These findings call for improved technology to increase authenticity of simulators and continued faculty development for more creative, meaningful integration of physical examination skills into high-acuity simulation cases.

Cultural Competency Training in Emergency Medicine

BACKGROUND

The Emergency Department is widely regarded as the epicenter of medical care for diverse and largely disparate types of patients. Physicians must be aware of the cultural diversity of their patient population to appropriately address their medical needs. A better understanding of residency preparedness in cultural competency can lead to better training opportunities and patient care.

OBJECTIVE

The objective of this study was to assess residency and faculty exposure to formal cultural competency programs and assess future needs for diversity education.

METHODS

A short survey was sent to all 168 Accreditation Council for Graduate Medical Education program directors through the Council of Emergency Medicine Residency Directors listserv. The survey included drop-down options in addition to open-ended input. Descriptive and bivariate analyses were used to analyze data.

RESULTS

The response rate was 43.5% (73/168). Of the 68.5% (50/73) of residency programs that include cultural competency education, 90% (45/50) utilized structured didactics. Of these programs, 86.0% (43/50) included race and ethnicity education, whereas only 40.0% (20/50) included education on patients with limited English proficiency. Resident comfort with cultural competency was unmeasured by most programs (83.6%: 61/73). Of all respondents, 93.2% (68/73) were interested in a universal open-source cultural competency curriculum.

CONCLUSIONS

The majority of the programs in our sample have formal resident didactics on cultural competency. Some faculty members also receive cultural competency training. There are gaps, however, in types of cultural competency training, and many programs have expressed interest in a universal open-source tool to improve cultural competency for Emergency Medicine residents.

Distribution of Honors Grades Across Fourth-year Emergency Medicine Clerkships

BACKGROUND

Medical student grades during emergency medicine (EM) rotations are a key factor in resident selection. The variability in grading among EM clerkships is not well understood.

OBJECTIVE

The objective was to describe the current grade distribution of fourth-year EM clerkships.

METHODS

This was an observational study at an EM residency program. We identified grade distributions by reviewing the standard letter of evaluation from individuals applying to our residency program for the 2016 match. Descriptive statistics of proportions, standard deviations (SDs), and p-values were calculated.

RESULTS

A total of 1,075 applications from 236 individual clerkships were reviewed. Thirty-four programs did not give an honors grade during the previous year. Four of these programs distributed a highest grade of "high pass" and 30 gave only "pass" and/or "fail." Of the remaining 202 programs, the percentage of grades that were given as honors ranged from 1% to 87% with a mean (±SD) of 25% (±17.2%). Of the 202 programs that granted honors grades, 63 (31.2%) sites gave between 1 and 14.9% honors grades, 69 (34.2%) gave 15% to 29.9% honors grades, 27 (13.4%) gave 30% to 44.9% honors grades, and 24 (11.9%) programs granted honors to greater than 45% of their students. Medical schools required an EM rotation at 82 (40.6%) sites. Among these programs, honors grades were given to 24% (±16.7%) of students with a range of 4% to 85% while programs that did not require clerkships gave a mean (±SD) of 26% (±17.5%) with a range of 1% to 87% and a p-value of 0.54.

CONCLUSIONS

Honor grade distribution varies markedly across U.S. fourth-year EM clerkship sites. Requiring EM clerkships does not affect honor percentages. A minority of sites only give pass/fail grades. Program directors should consider this marked variation in grades when reviewing EM residency applications.

Faculty Evaluations Correlate Poorly with Medical Student Examination Performance in a Fourth-Year Emergency Medicine Clerkship

BACKGROUND

Clerkship directors routinely evaluate medical students using multiple modalities, including faculty assessment of clinical performance and written examinations. Both forms of evaluation often play a prominent role in final clerkship grade. The degree to which these modalities correlate in an emergency medicine (EM) clerkship is unclear.

OBJECTIVE

We sought to correlate faculty clinical evaluations with medical student performance on a written, standardized EM examination of medical knowledge.

METHODS

This is a retrospective study of fourth-year medical students in a 4-week EM elective at one academic medical center. EM faculty performed end of shift evaluations of students via a blinded online system using a 5-point Likert scale for 8 domains: data acquisition, data interpretation, medical knowledge base, professionalism, patient care and communication, initiative/reliability/dependability, procedural skills, and overall evaluation. All students completed the National EM M4 Examination in EM. Means, medians, and standard deviations for end of shift evaluation scores were calculated, and correlations with examination scores were assessed using a Spearman's rank correlation coefficient.

RESULTS

Thirty-nine medical students with 224 discrete faculty evaluations were included. The median number of evaluations completed per student was 6. The mean score (±SD) on the examination was 78.6% ± 6.1%. The examination score correlated poorly with faculty evaluations across all 8 domains (ρ 0.074-0.316).

CONCLUSION

Faculty evaluations of medical students across multiple domains of competency correlate poorly with written examination performance during an EM clerkship. Educators need to consider the limitations of examination score in assessing students' ability to provide quality patient clinical care.

Pasteurella multocida Epiglottitis

Epiglottitis is an uncommon but life-threatening disease. While the most common infectious causes are the typical respiratory pathogens, Pasteurella multocida is a rare causative organism. We present a case of P. multocida epiglottitis diagnosed by blood culture. The patient required intubation but was successfully treated medically. P. multocida is a rare cause of epiglottitis; this is the ninth reported case in the literature. Most diagnoses are made from blood culture and patients usually have an exposure to animals.

Hospital ward transfer to intensive care unit as a quality marker in emergency medicine

BACKGROUND

Minimizing and preventing adverse events and medical errors in the emergency department (ED) is an ongoing area of quality improvement. Identifying these events remains challenging.

OBJECTIVE

To investigate the utility of tracking patients transferred to the ICU within 24h of admission from the ED as a marker of preventable errors and adverse events.

METHODS

From November 2011 through June 2016, we prospectively collected data for all patients presenting to an urban, tertiary care academic ED. We utilized an automated electronic tracking system to identify ED patients who were admitted to a hospital ward and then transferred to the ICU within 24h. Reviewers screened for possible error or adverse event and if discovered the case was referred to the departmental Quality Assurance (QA) committee for deliberations and consensus agreement.

RESULTS

Of 96,377 ward admissions, 921 (1%) patients were subsequently transferred to the ICU within 24h of ED presentation. Of these 165 (19%) were then referred to the QA committee for review. Total rate of adverse events regardless of whether or not an error occurred was 2.1%, 19/921 (95% CI 1.4% to 3.0%). Medical error on the part of the ED was 2.2%, 20/921 (95% CI 1.5% to 3.1%) and ED Preventable Error in 1.1%, 10/921 (95% CI 0.6% to 1.8%).

CONCLUSION

Tracking patients admitted to the hospital from the ED who are transferred to the ICU <24h after admission may be a valuable marker for adverse events and preventable errors in the ED.

Sensitivity of Early Brain Computed Tomography to Exclude Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis

BACKGROUND AND PURPOSE

Emerging evidence demonstrating the high sensitivity of early brain computed tomography (CT) brings into question the necessity of always performing lumbar puncture after a negative CT in the diagnosis of spontaneous subarachnoid hemorrhage (SAH). Our objective was to determine the sensitivity of brain CT using modern scanners (16-slice technology or greater) when performed within 6 hours of headache onset to exclude SAH in neurologically intact patients.

METHODS

After conducting a comprehensive literature search using Ovid MEDLINE, Ovid EMBASE, Web of Science, and Scopus, we conducted a meta-analysis. We included original research studies of adults presenting with a history concerning for spontaneous SAH and who had noncontrast brain CT scan using a modern generation multidetector CT scanner within 6 hours of symptom onset. Our study adheres to the preferred reporting items for systematic reviews and meta-analyses (PRISMA).

RESULTS

A total of 882 titles were reviewed and 5 articles met inclusion criteria, including an estimated 8907 patients. Thirteen had a missed SAH (incidence 1.46 per 1000) on brain CTs within 6 hours. Overall sensitivity of the CT was 0.987 (95% confidence intervals, 0.971-0.994) and specificity was 0.999 (95% confidence intervals, 0.993-1.0). The pooled likelihood ratio of a negative CT was 0.010 (95% confidence intervals, 0.003-0.034).

CONCLUSIONS

In patients presenting with thunderclap headache and normal neurological examination, normal brain CT within 6 hours of headache is extremely sensitive in ruling out aneurysmal SAH.

Types of diagnostic errors in neurological emergencies in the emergency department

Neurological emergencies often pose diagnostic challenges for emergency physicians because these patients often present with atypical symptoms and standard imaging tests are imperfect. Misdiagnosis occurs due to a variety of errors. These can be classified as knowledge gaps, cognitive errors, and systems-based errors. The goal of this study was to describe these errors through review of quality assurance (QA) records.

This was a retrospective pilot study of patients with neurological emergency diagnoses that were missed or delayed at one urban, tertiary academic emergency department. Cases meeting inclusion criteria were identified through review of QA records. Three emergency physicians independently reviewed each case and determined the type of error that led to the misdiagnosis. Proportions, confidence intervals, and a reliability coefficient were calculated.

During the study period, 1168 cases were reviewed. Forty-two cases were found to include a neurological misdiagnosis and twenty-nine were determined to be the result of an error. The distribution of error types was as follows: knowledge gap 45.2% (95% CI 29.2, 62.2), cognitive error 29.0% (95% CI 15.9, 46.8), and systems-based error 25.8% (95% CI 13.5, 43.5). Cerebellar strokes were the most common type of stroke misdiagnosed, accounting for 27.3% of missed strokes.

All three error types contributed to the misdiagnosis of neurological emergencies. Misdiagnosis of cerebellar lesions and erroneous radiology resident interpretations of neuroimaging were the most common mistakes. Understanding the types of errors may enable emergency physicians to develop possible solutions and avoid them in the future.

Implementation of an emergency department sign-out checklist improves transfer of information at shift change

BACKGROUND

Transitions of care are ubiquitous in the emergency department (ED) and inevitably introduce the opportunity for errors. Few emergency medicine residency programs provide formal training or a standard process for patient handoffs. Checklists have been shown to be effective quality-improvement measures in inpatient settings and may be a feasible method to improve ED handoffs.

OBJECTIVE

To determine if the use of a sign-out checklist improves the accuracy and efficiency of resident sign-out in the ED.

METHODS

A prospective pre-/postinterventional study of residents rotating in the ED at a tertiary academic medical center. Trained research assistants observed resident sign-out during shift change over a 2-week period and completed a data collection tool to indicate whether or not key components of sign-out occurred and time to sign out each patient. An electronic sign-out checklist was implemented using a multi-faceted educational effort. A 2-week postintervention observation phase was conducted. Proportions, means, and nonparametric comparison tests were calculated using STATA.

RESULTS

One hundred fifteen sign-outs were observed prior to checklist implementation and 114 were observed after. Significant improvements were seen in four sign-out components: reporting of history of present illness increased from 81% to 99%, ED course increased from 75% to 86%, likely diagnosis increased from 60% to 77%, and team awareness of plan increased from 21% to 41%. Use of the repeat-back technique decreased from 13% to 5% after checklist implementation and time to sign-out showed no significant change.

CONCLUSION

Implementation of a checklist improved the transfer of information without increasing time to sign-out.

Ultrasound interest group: a novel method of expanding ultrasound education in medical school

Purpose

Ultrasound technology and clinical applications are advancing across many medical specialties and there exists an increasing need for ultrasound education in medical school. Few institutions, however, have incorporated this into the 4-year curriculum and barriers to curricular change remain. The Ultrasound Interest Group (USIG) is an alternative, extracurricular way for future operators to gain ultrasound exposure throughout all four years of medical school and develop the skill sets necessary to emerge as leaders in sonography.

Methods

The USIG was designed using a student organization infrastructure. The mission is to promote ultrasound education and student leadership across the medical school, outside the required curriculum. Participation is voluntary and open to all medical students. Leadership consists of defined positions held by junior and senior medical students. The USIG holds four meetings per year, organizes clinical and scanning opportunities for students, sponsors ultrasound events, and distributes a newsletter.

Results

The USIG has been an active student interest group for three academic years and had three sets of student leaders. Participants in USIG activities included first through fourth-year medical students each year. To date, the USIG had 12 meetings including 2 national and 4 local guest speakers. The USIG has organized scanning opportunities for students, sponsored events, and established a vertical model of structured mentorship.

Conclusion

The USIG is a feasible method of promoting ultrasound education and student leadership among medical students. This model may be implemented at other medical schools as a centralized, organizing body for extracurricular ultrasound education.