Gender Differences in Emergency Medicine Attending Physician Comments to Residents: A Qualitative Analysis.

Importance: Prior studies have revealed gender differences in the milestone and clinical competency committee assessment of emergency medicine (EM) residents. Objective: To explore gender disparities and the reasons for such disparities in the narrative comments from EM attending physicians to EM residents. Design, Setting, and Participants: This multicenter qualitative analysis examined 10 488 narrative comments among EM faculty and EM residents between 2015 to 2018 in 5 EM training programs in the US. Data were analyzed from 2019 to 2021. Main Outcomes and Measures: Differences in narrative comments by gender and study site. Qualitative analysis included deidentification and iterative coding of the data set using an axial coding approach, with double coding of 20% of the comments at random to assess intercoder reliability (κ, 0.84). The authors reviewed the unmasked coded data set to identify emerging themes. Summary statistics were calculated for the number of narrative comments and their coded themes by gender and study site. χ2 tests were used to determine differences in the proportion of narrative comments by gender of faculty and resident. Results: In this study of 283 EM residents, of whom 113 (40%) identified as women, and 277 EM attending physicians, of whom 95 (34%) identified as women, there were notable gender differences in the content of the narrative comments from faculty to residents. Men faculty, compared with women faculty, were more likely to provide either nonspecific comments (115 of 182 [63.2%] vs 40 of 95 [42.1%]), or no comments (3387 of 10 496 [32.3%] vs 1169 of 4548 [25.7%]; P < .001) to men and women residents. Compared with men residents, more women residents were told that they were performing below level by men and women faculty (36 of 113 [31.9%] vs 43 of 170 [25.3%]), with the most common theme including lack of confidence with procedural skills. Conclusions and Relevance: In this qualitative study of narrative comments provided by EM attending physicians to residents, multiple modifiable contributors to gender disparities in assessment were identified, including the presence, content, and specificity of comments. Among women residents, procedural competency was associated with being conflated with procedural confidence. These findings can inform interventions to improve parity in assessment across graduate medical education.

A Randomized Controlled Trial to Improve the Success of Women Assistant Professors.

BACKGROUND: Given the persistent disparity in the advancement of women compared with men faculty in academic medicine, it is critical to develop effective interventions to enhance women's careers. We carried out a cluster-randomized, multifaceted intervention to improve the success of women assistant professors at a research-intensive medical school. MATERIALS AND METHODS: Twenty-seven departments/divisions were randomly assigned to intervention or control groups. The three-tiered intervention included components that were aimed at (1) the professional development of women assistant professors, (2) changes at the department/division level through faculty-led task forces, and (3) engagement of institutional leaders. Generalized linear models were used to test associations between assignment and outcomes, adjusting for correlations induced by the clustered design. RESULTS: Academic productivity and work self-efficacy improved significantly over the 3-year trial in both intervention and control groups, but the improvements did not differ between the groups. Average hours worked per week declined significantly more for faculty in the intervention group as compared with the control group (-3.82 vs. -1.39 hours, respectively, p = 0.006). The PhD faculty in the intervention group published significantly more than PhD controls; however, no differences were observed between MDs in the intervention group and MDs in the control group. CONCLUSIONS: Significant improvements in academic productivity and work self-efficacy occurred in both intervention and control groups, potentially due to school-wide intervention effects. A greater decline in work hours in the intervention group despite similar increases in academic productivity may reflect learning to "work smarter" or reveal efficiencies brought about as a result of the multifaceted intervention. The intervention appeared to benefit the academic productivity of faculty with PhDs, but not MDs, suggesting that interventions should be more intense or tailored to specific faculty groups.

Culture matters: the pivotal role of culture for women's careers in academic medicine.

PURPOSE: Women in academic medicine are not achieving the same career advancement as men, and face unique challenges in managing work and family alongside intense work demands. The purpose of this study was to investigate how a supportive department/division culture buffered women from the impact of work demands on work-to-family conflict. METHOD: As part of a larger intervention trial, the authors collected baseline survey data from 133 women assistant professors at the University of Pennsylvania Perelman School of Medicine in 2010. Validated measures of work demands, work-to-family conflict, and a department/division culture were employed. Pearson correlations and general linear mixed modeling were used to analyze the data. Authors investigated whether work culture moderated the association between work demands and work-to-family conflict. RESULTS: Heavy work demands were associated with increased levels of work-to-family conflict. There were significant interactions between work demands, work-to-family conflict, and department/division culture. A culture conducive to women's academic success significantly moderated the effect of work hours on time-based work-to-family conflict and significantly moderated the effect of work overload on strain-based work-to-family conflict. At equivalent levels of work demands, women in more supportive cultures experienced lower levels of work-to-family conflict. CONCLUSIONS: The culture of the department/division plays a crucial role in women's work-to-family conflict and can exacerbate or alleviate the impact of extremely high work demands. This finding leads to important insights about strategies for more effectively supporting the careers of women assistant professors.

Factors impacting the departure rates of female and male junior medical school faculty: evidence from a longitudinal analysis.

BACKGROUND: High rates of attrition have been documented nationally in assistant professor faculty of U.S. medical schools. Our objective was to investigate the association of individual level risk factors, track of academic appointment, and use of institutional leave policies with departure in junior faculty of a research-intensive school of medicine. METHODS: Participants included 901 faculty newly hired as assistant professors from July 1, 1999, through December 30, 2007, at the Perelman School of Medicine at the University of Pennsylvania. The faculty affairs database was used to determine demographics, hiring date, track of appointment, track changes, time to departure, and use of work-life policies for an extension of the probationary period for mandatory review, reduction in duties, and leave of absence. RESULTS: Over one quarter (26.7%) of faculty departed during follow-up. Faculty appointed on the clinician educator or research tracks were at increased risk of departure compared to the tenure track (hazard ratio [HR] 1.87, confidence interval, [CI] 1.28-2.71; HR 4.50, CI 2.91-6.96; respectively). Women appointed on the clinician educator track were at increased risk of departure compared to men (HR 1.46, CI 1.04-2.05). Faculty who took an extension of the probationary period were at decreased risk of departure (HR 0.36, CI 0.25-0.52). CONCLUSIONS: At this institution, junior faculty on the tenure track were least likely to depart before their mandatory review compared to faculty on the clinician educator or research tracks. Female assistant professors on the clinician educator track are of significant risk for departure. Taking advantage of the work-life policy for an extension of the probationary period protects against attrition.

Analgesia for older adults with abdominal or back pain in emergency department.

OBJECTIVE: To determine the association between age and analgesia for emergency department (ED) patients with abdominal or back pain. METHODS: Using a fully electronic medical record, we performed a retrospective cohort study of adults presenting with abdominal or back pain to two urban EDs. To assess differences in analgesia administration and time to analgesia between age groups, we used chi-square and Kruskal-Wallis test respectively. To adjust for potential confounders, we used a generalized linear model with log link and Gaussian error. RESULTS: Of 24,752 subjects (mean age 42 years, 65% female, 69% black, mean triage pain score 7.5), the majority (76%) had abdominal pain and 61% received analgesia. The ≥80 years group (n=722; 3%), compared to the 65-79 years group (n=2,080; 8%) and to the <65 years group (n=21,950; 89%), was more often female (71 vs. 61 vs. 65%), black (72 vs. 65 vs. 69%), and had a lower mean pain score (6.6 vs. 7.1 vs. 7.6). Both older groups were less likely to receive any analgesia (48 vs. 59 vs. 62%, p<0.0001) and the oldest group less likely to receive opiates (35 vs. 47 vs. 44%, p<0.0001). Of those who received analgesia, both older groups waited longer for their medication (123 vs. 113 vs. 94 minutes; p<0.0001). After controlling for potential confounders, patients ≥80 years were 17% less likely than the <65 years group to receive analgesia (95% CI 14-20%). CONCLUSION: Older adults who present to the ED for abdominal or back pain are less likely to receive analgesia and wait significantly longer for pain medication compared to younger adults.

Racial disparity in analgesic treatment for ED patients with abdominal or back pain.

OBJECTIVE: Research on how race affects access to analgesia in the emergency department (ED) has yielded conflicting results. We assessed whether patient race affects analgesia administration for patients presenting with back or abdominal pain. METHODS: This is a retrospective cohort study of adults who presented to 2 urban EDs with back or abdominal pain for a 4-year period. To assess differences in analgesia administration and time to analgesia between races, Fisher exact and Wilcoxon rank sum test were used, respectively. Relative risk regression was used to adjust for potential confounders. RESULTS: Of 20,125 patients included (mean age, 42 years; 64% female; 75% black; mean pain score, 7.5), 6218 (31%) had back pain and 13,907 (69%) abdominal pain. Overall, 12,109 patients (60%) received any analgesia and 8475 (42%) received opiates. Comparing nonwhite (77 %) to white patients (23%), nonwhites were more likely to report severe pain (pain score, 9-10) (42% vs 36%; P < .0001) yet less likely to receive any analgesia (59% vs 66%; P < .0001) and less likely to receive an opiate (39% vs 51%; P < .0001). After controlling for age, sex, presenting complaint, triage class, admission, and severe pain, white patients were still 10% more likely to receive opiates (relative risk, 1.10; 95% confidence interval, 1.06-1.13). Of patients who received analgesia, nonwhites waited longer for opiate analgesia (median time, 98 vs 90 minutes; P = .004). CONCLUSIONS: After controlling for potential confounders, nonwhite patients who presented to the ED for abdominal or back pain were less likely than whites to receive analgesia and waited longer for their opiate medication.

The effect of emergency department crowding on analgesia in patients with back pain in two hospitals.

OBJECTIVES: The authors assessed the association between measures of emergency department (ED) crowding and treatment with analgesia and delays to analgesia in ED patients with back pain. METHODS: This was a retrospective cohort study of nonpregnant patients who presented to two EDs (an academic ED and a community ED in the same health system) from July 1, 2003, to February 28, 2007, with a chief complaint of "back pain." Each patient had four validated crowding measures assigned at triage. Main outcomes were the use of analgesia and delays in time to receiving analgesia. Delays were defined as greater than 1 hour to receive any analgesia from the triage time and from the room placement time. The Cochrane-Armitage test for trend, the Cuzick test for trend, and relative risk (RR) regression were used to test the effects of crowding on outcomes. RESULTS: A total of 5,616 patients with back pain presented to the two EDs over the study period (mean+/-SD age=44+/-17 years, 57% female, 62% black or African American). Of those, 4,425 (79%) received any analgesia while in the ED. A total of 3,589 (81%) experienced a delay greater than 1 hour from triage to analgesia, and 2,985 (67%) experienced a delay more than 1 hour from room placement to analgesia. When hospitals were analyzed separately, a higher proportion of patients experienced delays at the academic site compared with the community site for triage to analgesia (87% vs. 74%) and room to analgesia (71% vs. 63%; both p<0.001). All ED crowding measures were associated with a higher likelihood for delays in both outcomes. At the academic site, patients were more likely to receive analgesia at the highest waiting room numbers. There were no other differences in ED crowding and likelihood of receiving medications in the ED at the two sites. These associations persisted in the adjusted analysis after controlling for potential confounders of analgesia administration. CONCLUSIONS: As ED crowding increases, there is a higher likelihood of delays in administration of pain medication in patients with back pain. Analgesia administration was not related to three measures of ED crowding; however, patients were actually more likely to receive analgesics when the waiting room was at peak levels in the academic ED.

Gender characteristics among academic ophthalmology leadership, faculty, and residents: results from a cross-sectional survey.

PURPOSE: To determine if there is any association in ophthalmology between the gender of the chairperson and residency program director and the gender of faculty and residents. METHODS: An anonymous electronic survey was sent to 121 ophthalmology residency program directors. Demographic information pertaining to size, location, academic or community affiliation, and gender distribution of the faculty, residents, residency program directors and chairs was obtained. RESULTS: The response rate was 45.45% with 55 residency program directors responding to the survey. Academic programs comprised 53 (96%) of the programs studied. Male department chairs led all 53 (96%) programs. In terms of the residency program director gender, 37 (67%) were male, whereas 18 (34%) were female. Female faculty and residents comprised 313 (28%) and 270 (45%), respectively. Compared to departments with male chairs, departments with a female chair had a higher crude proportion of female faculty (35% vs. 28%; P = 0.300) and female residents (50% vs. 45%; P = 0.660), although there was no statistical difference. Departments with either a male or female residency program director had similar number of female faculty (28% vs. 28%; P = 0.991) and residents (44% vs. 46%; P = 0.689). CONCLUSIONS: We found no significant association between the gender of the residency program director and chairperson with the proportion of female faculty and residents. Given a higher ratio of female residents relative to female faculty, it is probable that graduating female residents are choosing not to pursue academic medicine, shrinking the potential pool of female candidates for positions of departmental leadership.

Recommendations from the Society for Academic Emergency Medicine (SAEM) Taskforce on women in academic emergency medicine.

The Society for Academic Emergency Medicine (SAEM) convened a taskforce to study issues pertaining to women in academic emergency medicine (EM). The charge to the Taskforce was to "Create a document for the SAEM Board of Directors that defines and describes the unique recruitment, retention, and advancement needs for women in academic emergency medicine." To this end, the Taskforce and authors reviewed the literature to highlight key data points in understanding this issue and made recommendations for individuals at four levels of leadership and accountability: leadership of national EM organizations, medical school deans, department chairs, and individual women faculty members. The broad range of individuals targeted for recommendations reflects the interdependent and shared responsibility required to address changes in the culture of academic EM. The following method was used to determine the recommendations: 1) Taskforce members discussed career barriers and potential solutions that could improve the recruitment, retention, and advancement of women in academic EM; 2) the authors reviewed recommendations in the literature by national consensus groups and experts in the field to validate the recommendations of Taskforce members and the authors; and 3) final recommendations were sent to all Taskforce members to obtain and incorporate additional comments and ensure a consensus. This article contains those recommendations and cites the relevant literature addressing this topic.

Extrinsic risk factors for pressure ulcers early in the hospital stay: a nested case-control study.

BACKGROUND: Little is known about the impact of extrinsic factors on pressure ulcer risk. The objective of this study was to determine whether risk of pressure ulcers early in the hospital stay is associated with extrinsic factors such as longer emergency department (ED) stays, night or weekend admission, potentially immobilizing procedures and medications, and admission to an intensive care unit (ICU). METHODS: A nested case-control study was performed in two teaching hospitals in Philadelphia, Pennsylvania. Participants were medical patients age > or =65 years admitted through the ED. Cases (n = 195) had > or =1 possibly or definitely hospital-acquired pressure ulcers. Three controls per case were sampled randomly from among noncases at the same hospital in the same month (n = 597). Pressure ulcer status was determined by a research nurse on the third day of hospitalization. Pressure ulcers were classified as preexisting, possibly hospital-acquired, or definitely hospital-acquired. Information on extrinsic factors was obtained by chart review. RESULTS: The odds of pressure ulcers were twice as high for those with an ICU stay as for those without (adjusted odds ratio [aOR] 2.0, 95% confidence interval [CI], 1.2-3.5). The aOR was 0.6 (95% CI, 0.3-0.9) for use of any potentially immobilizing medications during the early inpatient period. CONCLUSIONS: Many of the procedures experienced by patients in the ED and early in the inpatient stay do not confer excess pressure ulcer risk. Having an ICU stay is associated with a doubling of risk. This finding emphasizes the importance of developing and evaluating interventions to prevent pressure ulcers among patients in the ICU.

Strategies for dealing with emergency department overcrowding: a one-year study on how bedside registration affects patient throughput times.

The objective of this study was to determine if the implementation of bedside registration would affect patient throughput times in an urban, academic emergency department. This was a before-and-after interventional study. An 8-month period before initiating bedside registration in November 2001 was compared to three subsequent 4-month intervals. Four times of day and three triage classifications were examined. Data were analyzed using a three-way analysis of covariance. There were 58,225 patient encounters analyzed. There was a significant difference in time from triage to room after bedside registration began (p < 0.0001). When examined by triage class, there were no differences in triage-to-room for emergent patients, a significant decrease for urgent patients initially and a significant decrease for non-urgent patients. Bedside registration by time of day initially reduced all four time-of-day periods but over the year they returned to pre-bedside registration levels, except for the morning period. Bedside registration decreased triage-to-room times for non-urgent patients and urgent patients initially, but this was not sustained at the end of 1 year. It had no effect on emergent patients who are routinely taken into the patient care area immediately. The sustainable effects of bedside registration were during the morning time when emergency department beds were available.

Pressure ulcers among elderly patients early in the hospital stay.

BACKGROUND: Pressure ulcers among elderly hospital patients diminish quality of life and increase the cost of hospital care. Evidence suggests that pressure ulcers can arise after only a few hours of immobility. The goals of this study were to estimate the incidence of hospital-acquired pressure ulcers in the first 2 days of the hospital stay and to identify patient characteristics associated with higher incidence. METHODS: A prospective cohort study was performed between 1998 and 2001. A total of 3233 patients 65 years old or older admitted through the Emergency Department to the inpatient Medical Service at two study hospitals were examined by a research nurse on the third day of hospitalization. Pressure ulcers were ascertained using standard criteria and were classified as either preexisting, possibly hospital-acquired, or definitely hospital-acquired. RESULTS: There were 201 patients with one or more possibly or definitely hospital-acquired pressure ulcers for a cumulative incidence of 6.2% (95% confidence interval, 5.4%-7.1%). Most of the pressure ulcers were stage 2, and the majority were in the sacral area or on the heels. In multivariable analysis, pressure ulcer incidence was significantly associated with increasing age, male gender, dry skin, urinary and fecal incontinence, difficulty turning in bed, nursing home residence prior to admission, recent hospitalization, and poor nutritional status. CONCLUSIONS: A small but significant proportion of elderly emergently admitted hospital patients acquire pressure ulcers soon after their admission. New models of care may be required to ensure that preventive interventions are provided very early in the elderly person's hospital stay.

Radiology services in emergency medicine residency programs: a national survey.

OBJECTIVES: To determine who reads plain film radiographs, how quickly radiologists' interpretations are available, how many initial readings require correction, and how satisfied emergency physicians (EPs) are with radiology in emergency departments (EDs) with emergency medicine (EM) residency programs. METHODS: A questionnaire was sent to the chairs of all U.S. EM residencies, asking about EM radiology services. RESULTS: Of 120 sites surveyed, 97 (81%) responded. Respondents reported that, on weekday days, EM attendings or residents performed the radiograph interpretation used for clinical decision making at 66% of sites; on nights and weekends, EPs performed the clinically relevant readings at 79% of sites. Twenty-one percent of sites reported that no radiologist reviewed images before patients left the ED on nights and weekends. Only 39% of sites reported that all images were read within four hours on weekday days, and only 19% of sites reported readings within this time frame on nights and weekends. Median misinterpretation rates were reported as 1% on weekday days and 1.5% at other times. Overall, EPs were satisfied with their interactions with radiology at 63% of EDs. CONCLUSIONS: This study summarizes the perceptions of EPs regarding radiology services; the findings must be interpreted with caution, given the lack of external validation. Nevertheless, EPs report that many EM residency programs depend on EPs' interpretations of radiographs. Emergency physicians report that attending radiologists rarely read images on nights and weekends and that images are misread more frequently at these times. Although EPs were satisfied with many aspects of radiology, EPs expressed the most dissatisfaction with turnaround times and misreads.