Comparison of performance data between emergency medicine 1-3 and 1-4 program formats.

Objective: This study compares performance data from physicians completing 3-year versus 4-year emergency medicine residency training programs. Currently, there are 2 training formats and little is known about objective performance differences. Methods: This was a retrospective cross-sectional analysis of emergency residents and physicians. Multiple analyses were conducted comparing physicians' performances, including Accreditation Council of Graduate Medical Education Milestones and American Board of Emergency Medicine In-training Examination (ITE), Qualifying Examination (QE), Oral Certification Examination (OCE), and program extensions from 3-year and 4-year residency programs. Some confounding variables were not or could not be considered, such as rationale for medical students to choose one format over another, as well as application and final match rates. Results: Milestone scores are higher for emergency medicine 3 residents in 1-3 programs (3.51) versus emergency medicine 3 residents in 1-4 programs (3.07; P < 0.001, d = 1.47) and highest for emergency medicine 4 residents (3.67). There was no significant difference in program extension rates (emergency medicine 1-3, 8.1%; emergency medicine 1-4, 9.6%; P = 0.05, ω = 0.02). ITE scores were higher for emergency medicine 1, 2, and 3 residents from 1-3 programs and emergency medicine 4 residents from 1-4 programs scored highest. Mean QE score was slightly higher for emergency 1-3 physicians (83.55 vs 83.00; P < 0.01, d = 0.10). QE pass rate was higher for emergency 1-3 physicians (93.1% vs 90.8%; P < 0.001, ω = 0.08). Mean OCE score was slightly higher for emergency 1-4 physicians (5.67 vs 5.65; P = 0.03, d = -0.07) but did not reach a priori statistical significance (α < 0.01). OCE pass rate was also slightly higher for emergency 1-4 physicians (96.9% vs 95.5%; P = 0.06, ω = -0.07) but also non-significant. Conclusions: These results suggest that although performance measures demonstrate small differences between physicians from emergency medicine 1-3 and 1-4 programs, these differences are limited in their ability to make causal claims about performance on the basis of program format alone.

Four- and three-year emergency medicine residency graduates perform similarly in their first year of practice compared to experienced physicians.

INTRODUCTION: United States emergency medicine (EM) post-graduate training programs vary in training length, either 4 or 3 years. However, it is unknown if clinical care by graduates from the two curricula differs in the early post-residency period. METHODS: We performed a retrospective observational study comparing measures of clinical care and practice patterns between new graduates from 4- and 3-year EM programs with experienced new physician hires as a reference group. We included emergency department (ED) encounters from a national EM group (2016-19) between newly hired physicians from 4- and 3- year programs and experienced new hires (>2 years' experience) during their first year of practice with the group. Primary outcomes were at the physician-shift level (patients per hour and relative value units [RVUs] per hour) and encounter-level (72-h return visits with admission/transfer and discharge length of stay [LOS]). Secondary outcomes included discharge opioid prescription rates, test ordering, computer tomography (CT) use, and admission/transfer rate. We compared outcomes using multivariable linear regression models that included patient, shift, and facility-day characteristics, and a facility fixed effect. We hypothesized that experienced new hires would be most efficient, followed by new 4-year graduates and then new 3-year graduates. RESULTS: We included 1,084,085 ED encounters by 4-year graduates (n = 39), 3-year graduates (n = 70), and experienced new hires (n = 476). There were no differences in physician-level and encounter-level primary outcomes except discharge LOS was 10.60 min (2.551, 18.554) longer for 4-year graduates compared to experienced new hires. Secondary outcomes were similar among the three groups except 4- and 3-year new graduates were less likely to prescribe opioids to discharged patients, -3.70% (-5.768, -1.624) and - 3.38% (-5.136, -1.617) compared to experienced new hires. CONCLUSIONS: In this sample, measures of clinical care and practice patterns related to efficiency, safety, and flow were largely similar between the physician groups; however, experienced new hires were more likely to prescribe opioids than new graduates. These results do not support recommending a specific length of residency training in EM.

Workplace Mistreatment, Career Choice Regret, and Burnout in Emergency Medicine Residency Training in the United States.

STUDY OBJECTIVE: The influence of workplace mistreatment on the well-being and career satisfaction of emergency medicine residents is unknown. This study examined the relationships between burnout, career choice regret, and workplace mistreatment in a national sample of emergency medicine residents. METHODS: This was a secondary analysis of a survey study on the prevalence of workplace mistreatment among emergency residents. Residents who reported emotional exhaustion or depersonalization at least once per week were considered to have burnout. Residents who reported dissatisfaction with their decision to become an emergency physician were considered to have career choice regret. Respondents also reported the type (discrimination, abuse, sexual harassment) and frequency of mistreatment over the academic year. Multivariable logistic regression, adjusting for program characteristics, was used to examine resident characteristics associated with burnout and career choice regret, with the frequency of mistreatment as a covariate. RESULTS: Of the 8,162 eligible residents, 7,680 (94.1 %) participated. About a third of respondents reported burnout (2,188 of 6,902, 31.7%), whereas a minority (224 of 6,923, 3.2%) reported career choice regret. Of the 7,087 responses on mistreatment frequency, 2,117 (29.9%) reported "a few times per year," and 1,296 (18.3%) reported "a few times per month or more." Compared with residents who never experienced mistreatment, residents who reported increasing frequencies of mistreatment were associated with having burnout-from mistreatment a few times per year (OR [odds ratio],1.6; 99% CI [confidence interval], 1.3 to 1.9) to a few times per month or more (OR, 3.3; 99% CI, 2.7 to 4.1). Compared with residents without burnout, residents who reported burnout were associated with having career choice regret (OR, 11.3; 99% CI, 7.0 to 18.1). After adjusting for burnout, there were no significant relationships between the frequency of mistreatment and career choice regret. CONCLUSIONS: Workplace mistreatment is associated with burnout, but not career choice regret, among emergency medicine residents. Efforts to address workplace mistreatment may improve emergency medicine residents' professional well-being.

Emergency Medicine Residency Does Not Reduce a Racial Minority-Based Test Performance Gap.

BACKGROUND: Health care inequity is corrected more readily when safe, high-quality care is provided by physicians who reflect the gender, race, and ethnicity of patient communities. It is important to train and evaluate racially diverse physicians involved in residency training. OBJECTIVE: This study sought to determine any test-taking differences for black Emergency Medicine (EM) residents and whether any such differences would narrow as residency progressed. METHODS: This was an observational, cross-sectional study that reviewed performance (scaled scores) on the American Board of Emergency Medicine (ABEM) In-Training Examination (ITE) for 2018, 2019, and 2020. The study included EM residents in 3-year programs who took the ITE. A linear regression model was used for the variables of race, which included black physicians and white physicians (reference group), and level of training (EM resident year 1 [EM1] as the reference group). RESULTS: There were 9591 residents included; 539 were black and 9052 were white. Mean scaled scores were higher as a function of training level. Regression showed a scaled score intercept of 73.51. The ITE score increased for all groups as a function of training level (EM2 ß = +5.45, p < 0.0001; EM3 ß = +8.09, p < 0.0001). The regression coefficient for black residents was -5.87 (p < 0.0001). There was relative improvement by training level compared with improvement in the reference group, but this difference was not materially or statistically significant. CONCLUSION: In this study of the ABEM ITE, a test-taking performance gap identified early in residency for black physicians persisted into late residency.

American Board of Emergency Medicine Report on Residency and Fellowship Training Information (2021-2022).

The American Board of Emergency Medicine gathers extensive background information on the Accreditation Council of Graduate Medical Education-accredited emergency medicine residency and fellowship programs, as well as the residents and fellows training in those programs. We present the 2022 annual report on the status of physicians training in Accreditation Council of Graduate Medical Education-accredited emergency medicine training programs in the United States.

The Emergency Medicine Milestones 2.0: Setting the stage for 2025 and beyond.

INTRODUCTION: Beginning in 1999, residents in emergency medicine have been expected to demonstrate competence in the six Accreditation Council on Graduate Medical Education (ACGME) Core Competencies. Expectations were further refined and clarified through the introduction of the Milestones in 2013. Emerging research and data from milestone reporting has illustrated the need for modification of the original milestones. Against this backdrop, the ACGME convened a committee to review and revise the original milestones. METHODS: The working group was convened in December 2018 and consisted of representatives from the American Board of Emergency Medicine, American Osteopathic Association, Council of Residency Directors in Emergency Medicine, Association of American Medical Colleges, ACGME-Emergency Medicine Review Committee, three community members, a resident member, and a public member. This group also included members from both academic and community emergency medicine programs. The group was overseen by the ACGME vice president for milestones development and met in person one time followed by four virtual sessions to revise and draft the Emergency Medicine Milestones and Supplemental Guide as part of the ACGME Milestones 2.0 Project. RESULTS: Using data from milestones reporting, needs assessment data, stakeholder interviews, and community commentary, the working group engaged in revisions and updates for the Emergency Medicine Milestones and created a supplemental guide to aid programs in the design of programmatic assessment for the milestones. CONCLUSION: The Emergency Medicine Milestones 2.0 provide updated specialty-specific, competency-based behavioral anchors to guide the assessment of residents, the design of curricula, and the advancement of emergency medicine training programs.

Prevalence of Discrimination, Abuse, and Harassment in Emergency Medicine Residency Training in the US.

Importance: The prevalence of workplace mistreatment and its association with the well-being of emergency medicine (EM) residents is unclear. More information about the sources of mistreatment might encourage residency leadership to develop and implement more effective strategies to improve professional well-being not only during residency but also throughout the physician's career. Objective: To examine the prevalence, types, and sources of perceived workplace mistreatment during training among EM residents in the US and the association between mistreatment and suicidal ideation. Design, Setting, and Participants: In this survey study conducted from February 25 to 29, 2020, all residents enrolled in EM residencies accredited by the Accreditation Council for Graduate Medical Education (ACGME) who participated in the 2020 American Board of Emergency Medicine computer-based In-training Examination were invited to participate. A multiple-choice, 35-item survey was administered after the examination asking residents to self-report the frequency, sources, and types of mistreatment experienced during residency training and whether they had suicidal thoughts. Main Outcomes and Measures: The types and frequency of workplace mistreatment and the sources of the mistreatment were identified, and rates of self-reported suicidality were obtained. Multivariable logistic regression models were used to examine resident and program characteristics associated with suicidal thoughts. Results: Of 8162 eligible EM residents, 7680 (94.1%) responded to at least 1 question on the survey; 6503 (79.7%) completed the survey in its entirety. A total of 243 ACGME-accredited residency programs participated, and 1 did not. The study cohort included 4768 male residents (62.1%), 2698 female residents (35.1%), 4919 non-Hispanic White residents (64.0%), 2620 residents from other racial/ethnic groups (Alaska Native, American Indian, Asian or Pacific Islander, African American, Mexican American, Native Hawaiian, Puerto Rican, other Hispanic, or mixed or other race) (34.1%), 483 residents who identified as lesbian, gay, bisexual, transgender, queer, or other (LGBTQ+) (6.3%), and 5951 residents who were married or in a relationship (77.5%). Of the total participants, 3463 (45.1%) reported exposure to some type of workplace mistreatment (eg, discrimination, abuse, or harassment) during the most recent academic year. A frequent source of mistreatment was identified as patients and/or patients' families; 1234 respondents (58.7%) reported gender discrimination, 867 (67.5%) racial discrimination, 282 (85.2%) physical abuse, and 723 (69.1%) sexual harassment from patients and/or family members. Suicidal thoughts occurring during the past year were reported by 178 residents (2.5%), with similar prevalence by gender (108 men [2.4%]; 59 women [2.4%]) and race/ethnicity (113 non-Hispanic White residents [2.4%]; 65 residents from other racial/ethnic groups [2.7%]). Conclusions and Relevance: In this survey study, EM residents reported that workplace mistreatment occurred frequently. The findings suggest common sources of mistreatment for which educational interventions may be developed to help ensure resident wellness and career satisfaction.

Emergency Medicine Resident Burnout and Examination Performance.

OBJECTIVES: Burnout afflicts emergency physicians (EPs) to a significant degree. The impact of burnout spans from decreased clinical efficiency to increased medical errors to heightened risk of physician suicide. This large-scale study captures responses from emergency medicine (EM) residents regarding two burnout items and examines the correlation between in-training examination (ITE) scores and burnout risk as well as that between residency year and burnout risk. METHODS: This was a prospective, mixed-methods, cross-sectional cohort study. All residents in U.S. categorical EM residents who took the 2019 ITE were included. At the end of the ITE, residents were invited to complete a voluntary survey that included two items from the Maslach Burnout Inventory (MBI) that have been found to be strongly indicative of burnout: one about self-perception of being burned out and one about feelings of callousness. Responses were on a 7-level Likert scale (1-7), ranging from very low frequency (1) to very high frequency (7). Measurements included the number of residents in each year-level of training (EM1-EM4), the MBI item ratings, and the ABEM ITE score. Performance, as measured by the scaled, equated score, was compared to the MBI item responses. A corrected Spearman's correlation coefficient (ρ) was used to compare continuous data (score) against a discrete ordinal variable (MBI Likert response). RESULTS: There were 2,501 EM1 residents, 2,389 EM2 residents, 2,206 EM3 residents, and 616 EM4 residents in the study group. There were 7,206 (93.4%) physicians who completed the first MBI question about burnout; 7,172 (93%) completed the second MBI question about callousness. There was no statistically significant association between the burnout item response and ITE performance (ρ = -0.03; p = 0.015). There was a positive, statistically significant association between the callousness item response and higher ITE performance (ρ = 0.07; p < 0.001). There was a statistically significant association between the response to the burnout item and training level (ρ = 0.07; p <0.001). There was also a statistically significant association between the response to the callousness item and training level (ρ = 0.15; p < 0.001). The overall prevalence of burnout risk in various training levels were EM1, 28.2%; EM2, 39%; EM3, 41.1%; and EM4, 43.3%. CONCLUSIONS: Our study found no significant correlation between ITE score and burnout risk. There was a weakly positive correlation between ITE scores and callousness. Based on our study results, ITE scores may not be useful in prognosticating burnout risk for EM residents and, interestingly, higher ITE scores correlated to stronger feelings of callousness. Our study indicates that EM residents at higher levels of training reported stronger self-perceptions of burnout and callousness. Further investigation into why residents at higher levels of training may experience greater burnout risk is warranted.

American Board of Emergency Medicine Report on Residency and Fellowship Training Information (2019-2020).

The American Board of Emergency Medicine gathers extensive background information on Accreditation Council for Graduate Medical Education (ACGME)-accredited emergency medicine residency and fellowship programs, as well as the residents and fellows training in those programs. We present the 2020 annual report on the status of physicians training in ACGME-accredited emergency medicine training programs in the United States.

Costs and Benefits of Initial Certification for Emergency Medicine Residency Graduates.

BACKGROUND: Graduates of emergency medicine residency programs can seek certification from the American Board of Emergency Medicine (ABEM), yet the costs and perceived value by residents is not clear. OBJECTIVE: This report sought to better define the value of board certification by asking physicians taking the ABEM Oral Certification Examination (OCE) to describe its costs (eg, time, money) and perceived benefits. METHODS: A descriptive, cross-sectional, voluntary, anonymous survey was administered to physicians taking the 2018 spring and fall ABEM OCEs. Response frequencies were used to report response rates. RESULTS: There were 2016 physicians who participated in the 2018 OCEs, of whom 1565 (78%) completed a survey. With respect to preparation, 38% (599 of 1565 responses) spent more than 30 hours preparing for the examination. Regarding the expense of preparing for the examination, 21% (328) spent nothing, 50% (776) spent less than $1,000, and 2% (38) spent more than $3,000. Most physicians (80%, 1254) reported a learning benefit to preparing for and taking the OCE. There were 49% (765) of respondents who reported that preparing for the examination reinforced their knowledge of emergency medicine; 20% (311) reported no learning benefit. Most physicians (92%, 1442) reported that ABEM certification provided a career benefit, the most common of which was more career opportunities (69%, 1076). CONCLUSIONS: Initial certification requires a considerable investment of time and money. Physicians seeking initial ABEM certification found both learning and professional benefits, with the most frequently reported being reinforcement of medical knowledge and more career opportunities.

A National Study of Longitudinal Consistency in ACGME Milestone Ratings by Clinical Competency Committees: Exploring an Aspect of Validity in the Assessment of Residents' Competence.

PURPOSE: To investigate whether clinical competency committees (CCCs) were consistent in applying milestone ratings for first-year residents over time or whether ratings increased or decreased. METHOD: Beginning in December 2013, the Accreditation Council for Graduate Medical Education (ACGME) initiated a phased-in requirement for reporting milestones; emergency medicine (EM), diagnostic radiology (DR), and urology (UR) were among the earliest reporting specialties. The authors analyzed CCC milestone ratings of first-year residents from 2013 to 2016 from all ACGME-accredited EM, DR, and UR programs for which they had data. The number of first-year residents in these programs ranged from 2,838 to 2,928 over this time period. The program-level average milestone rating for each subcompetency was regressed onto the time of observation using a random coefficient multilevel regression model. RESULTS: National average program-level milestone ratings of first-year residents decreased significantly over the observed time period for 32 of the 56 subcompetencies examined. None of the other subcompetencies showed a significant change. National average in-training examination scores for each of the specialties remained essentially unchanged over the time period, suggesting that differences between the cohorts were not likely an explanatory factor. CONCLUSIONS: The findings indicate that CCCs tend to become more stringent or maintain consistency in their ratings of beginning residents over time. One explanation for these results is that CCCs may become increasingly comfortable in assigning lower ratings when appropriate. This finding is consistent with an increase in confidence with the milestone rating process and the quality of feedback it provides.

American Board of Emergency Medicine Report on Residency and Fellowship Training Information (2018-2019).

The American Board of Emergency Medicine (ABEM) gathers extensive background information on emergency medicine-sponsored residency and fellowship programs, residents and fellows training in those programs, and all fellows for whom ABEM issues subspecialty certifications. We present the 2019 annual report on the status of US emergency medicine training programs.

Clinical Informatics Competencies in the Emergency Medicine Specialist Training Standards of Five International Jurisdictions.

BACKGROUND: The field of clinical informatics (CI), and specifically the electronic health record, has been identified as a key facilitator to achieve a sustainable evidence-based health care system for the future. International graduate medical education (GME) programs have been challenged to ensure that their trainees are provided with appropriate skills to deliver effective and efficient health care in an evolving environment. OBJECTIVES: This study explored how international emergency medicine (EM) specialist training standards address competencies and training in relevant areas of CI. METHODS: A list of categories of CI competencies relative to EM was developed following a thematic review of published references documenting CI curriculum and competencies. Publicly available documents outlining core content, curriculum, and competencies from international organizations responsible for specialty GME and/or credentialing in EM for Australasia, Canada, Europe, the United Kingdom, and the United States were identified. These EM training standards were reviewed to identify inclusion of topics related to the relevant categories of CI competencies. RESULTS: A total of 23 EM curriculum documents were included in the review. Curricula content related to critical appraisal/evidence-based medicine, leadership, quality improvement, and privacy/security were included in all EM curricula. The CI topics related to fundamental computer skills, computerized provider order entry, and patient-centered informatics were only included in the EM curricula documents for the United States and were absent for the other jurisdictions. CONCLUSION: There is variation in the CI-related content of the international EM specialty training standards reviewed. Given the increasing importance of CI in the future delivery of health care, organizations responsible for training and credentialing specialist emergency physicians must ensure that their training standards incorporate relevant CI content, thus ensuring that their trainees gain competence in essential aspects of CI.

American Board of Emergency Medicine Report on Residency and Fellowship Training Information (2017-2018).

The American Board of Emergency Medicine (ABEM) gathers extensive background information on emergency medicine-sponsored residency and fellowship programs, as well as the residents and fellows training in those programs. We present the 2018 annual report on the status of US emergency medicine training programs.

Straight Line Scoring by Clinical Competency Committees Using Emergency Medicine Milestones.

BACKGROUND: In 2013, milestone ratings became a reporting requirement for emergency medicine (EM) residency programs. Programs rate each resident in the fall and spring on 23 milestone subcompetencies. OBJECTIVE: This study examined the incidence of straight line scoring (SLS) for EM Milestone ratings, defined as a resident being assessed the same score across the milestone subcompetencies. METHODS: This descriptive analysis measured the frequencies of SLS for all Accreditation Council for Graduate Medical Education (ACGME)-accredited EM programs during the 2015-2016 academic year. Outcomes were the frequency of SLS in the fall and spring milestone assessments, changes in the number of SLS reports, and reporting trends. Chi-square analysis compared nominal variables. RESULTS: There were 6257 residents in the fall and 6588 in the spring. Milestone scores were reported for 6173 EM residents in the fall (99% of 6257) and spring (94% of 6588). In the fall, 93% (5753 residents) did not receive SLS ratings and 420 (7%) did, with no significant difference compared with the spring (5776 [94%] versus 397 [6%]). Subgroup analysis showed higher SLS results for residents' first ratings (183 of 2136 versus 237 of 4220, P < .0001) and for their final ratings (200 of 2019 versus 197 of 4354, P < .0001). Twenty percent of programs submitted 10% or more SLS ratings, and a small percentage submitted more than 50% of ratings as SLS. CONCLUSIONS: Most programs did not submit SLS ratings. Because of the statistical improbability of SLS, any SLS ratings reduce the validity assertions of the milestone assessments.

American Board of Emergency Medicine Report on Residency and Fellowship Training Information (2016-2017).

The American Board of Emergency Medicine (ABEM) gathers extensive background information on emergency medicine residency programs and the residents training in those programs. We present the 2017 annual report on the status of US emergency medicine training programs.