LGBTQ+ individuals are not explicitly represented in emergency medicine simulation curricula.

Background: Medical educational societies have emphasized the inclusion of marginalized populations, including the lesbian, gay, bisexual, transgender and queer (LGBTQ+) population, in educational curricula. Lack of inclusion can contribute to health inequality and mistreatment due to unconscious bias. Little didactic time is spent on the care of LGBTQ+ individuals in emergency medicine (EM) curricula. Simulation based medical education can be a helpful pedagogy in teaching cross-cultural care and communication skills. In this study, we sought to determine the representation of the LGBTQ+ population in EM simulation curricula. We also sought to determine if representations of the LGBTQ+ population depicted stigmatized behavior. Methods: We reviewed 971 scenarios from six simulation case banks for LGBTQ+ representation. Frequency distributions were determined for major demographic variables. Chi-Squared or Fisher's Exact Test, depending on the cell counts, were used to determine if relationships existed between LGBTQ+ representation and bank type, author type, and stigmatized behavior. Results: Of the 971 scenarios reviewed, eight (0.82%) scenarios explicitly represented LGBTQ+ patients, 319 (32.85%) represented heterosexual patients, and the remaining 644 (66.32%) did not specify these patient characteristics. All cases representing LGBTQ+ patients were found in institutional case banks. Three of the eight cases depicted stigmatized behavior. Conclusions: LGBTQ+ individuals are not typically explicitly represented in EM simulation curricula. LGBTQ+ individuals should be more explicitly represented to reduce stigma, allow EM trainees to practice using gender affirming language, address health conditions affecting the LGBTQ+ population, and address possible bias when treating LGBTQ+ patients.

Is boarding compromising our residents' education? A national survey of emergency medicine program directors.

Background: Boarding patients in the emergency department (ED) potentially affects resident education. Program director (PD) perceptions of the impact of boarding on their trainees have not been previously described. Methods: We surveyed a cross-sectional convenience sample of emergency medicine PDs using a mixed-methods approach to explore their perceptions of how boarding has affected their residents' training. Descriptive data were reported as percentages and differences were calculated using Pearson's chi-square test, with p < 0.05 considered significant. A framework model was used to qualitatively analyze free-text responses. Results: A total of 170 responses were collected, for a response rate of 63%. Most respondents felt that boarding had at least some effect on resident education with 29%, 35%, 18%, and 12% noting "a little," "a moderate amount," "a lot," and "a great deal," respectively, and 5% noting "no effect at all." Respondents perceived a negative impact of boarding on resident education and training, with 80% reporting a "somewhat" or "extremely negative" effect, 18% feeling neutral, and 2% noting a "somewhat positive" effect. Most noted a "somewhat" or "extremely negative" effect on resident education in managing ED throughput (70%) and high patient volumes (66%). Fifty-four percent noted a "somewhat" or "extremely negative" impact on being involved in the initial workup of undifferentiated patients. Thirty-two percent saw a "somewhat" or "extremely positive" effect on learning the management of critically ill patients. Qualitative analysis of challenges, mitigation strategies, and resident feedback emphasized the lack of exposure to managing departmental patient flow, impact on bedside teaching, and need for flexibility in resident staffing. Conclusions: Most PDs agree that boarding negatively affects resident education and identify several strategies to mitigate the impact. These findings can help inform future interventions to optimize resident learning in the complex educational landscape of high ED boarding.

Trends in nursing feedback for emergency medicine residents: A mixed-methods survey analysis of national practices.

Background: Feedback is critical for physician development. Multisource feedback is especially important in a team-based specialty such as emergency medicine (EM) and is required by the Accreditation Council for Graduate Medical Education. Nursing assessments provide a unique perspective, but little is known about the current national patterns of their collection and use in EM. Methods: We surveyed EM program directors using a mixed-methods approach to explore the use of nursing assessment of EM residents. Descriptive data were reported as absolute numbers and percentages. An adjunct analysis of free-text responses was done using the framework method. Results: The response rate for our survey was 63% (190 responses), of which 84% currently collect nursing feedback. Respondents from 94% of programs agreed that nursing feedback is useful in assessing professionalism and respondents from 92% of programs agreed that nursing feedback is useful in assessing communication and interpersonal skills, while 44% agreed that it is useful in informing resident medical knowledge. Forty-two percent reported that nursing feedback did not directly influence residents' progression through their training, while 2% indicated that such feedback played a significant role in leading to dismissal or probation. The majority of programs (64%) that do not collect feedback from nurses have done so in the past and hope to do so in the future. Qualitative analysis revealed themes of logistic challenges with data collection, concern regarding quality of feedback, and retributive or gender-disparate feedback. Conclusions: Nursing assessments of EM residents were collected by most responding programs and majority of those who do not collect them presently wish to do so in the future. They were considered particularly useful in the assessment of interpersonal skills, communication, and professionalism. However, lack of uniform methods for collecting assessment that meaningfully informs resident development and progression represents a challenge and direction for future inquiry.

The impact of interviewer characteristics on residency candidate scores in Emergency Medicine: a brief report.

Background: At the conclusion of residency candidate interview days, faculty interviewers commonly meet as a group to reach conclusions about candidate evaluations based on shared information. These conclusions ultimately translate into rank list position for The Residency Match. The primary objective is to determine if the post-interview discussion influences the final scores assigned by each interviewer, and to investigate whether interviewer characteristics are significantly associated with the likelihood of changing their score. Based on Foucault's 'theory of discourse' and Bourdieu's 'social capital theory,' we hypothesized that interviewer characteristics, and the discourse itself, would contribute to score changes after a post-interview discussion regarding emergency medicine residency candidates. Methods: We conducted a cross-sectional observational study of candidate scores for all candidates to a four-year emergency medicine residency program affiliated with Yale University School of Medicine during a single application cycle. The magnitude and direction of score changes, if any, after group discussion were plotted and grouped by interviewer academic rank. We created a logistic regression model to determine the odds that candidate scores changed from pre- and post-discussion ratings related to specific interviewer factors. Results: A total of 24 interviewers and 211 candidates created 471 unique interviewer-candidate scoring interactions, with 216 (45.8%) changing post-discussion. All interviewers ranked junior to professor were significantly more likely to change their score compared to professors. Interviewers who were women had significantly lower odds of changing their individual scores following group discussion (p=0.020; OR 0.49, 95% CI 0.26-0.89). Conclusions: Interviewers with lower academic rank had higher odds of changing their post-discussion scores of residency candidates compared to professors. Future work is needed to further characterize the influencing factors and could help create more equitable decision processes during the residency candidate ranking process.

Differences in faculty feedback for high, expected, and below-expected clinically performing emergency medicine residents.

Objectives: A lifelong pursuit such as medicine is frequently paired with a framework of "deliberate practice" for improvement. It is unclear whether the quality of feedback varies across different learner levels. Our study aims to assess whether a difference exists in the quality of feedback delivered to high-, expected-, and below-expected performer emergency medicine (EM) residents based on their attending-identified performance level. Methods: We conducted a retrospective review of written EM resident feedback collected between November 2018 and March 2021. Clinical performance level was subjectively determined by attending faculty in their feedback. Feedback was coded on a scale from 0-5 based on the presence (1) or absence (0) of the items modified from the Ende's SMART criteria: Specific (S), Measurable (M), Achievable (A), Relevant (R), and Time-bound (T). The primary outcome was any total modified SMART criteria score difference concerning performance level using logistic regression with Generalized Estimating Equations (GEE). Secondary outcomes were differences for individual criteria. Results: We analyzed 1284 evaluations (311 high performers, 930 expected performers, and 43 below-expected performers) of 94 unique residents from 66 different evaluators. Mean total modified SMART scores were significantly higher in high and below-expected performers than those designated as expected performers by faculty evaluators. Achievable and Relevant written feedback was provided to high performers in a significantly larger proportion than expected and below-expected performers. Only 278 out of 1284 evaluations met criteria for Specific. Conclusions: Mean total modified SMART feedback scores were significantly greater in high performers and below-expected performers when compared to expected performers. Achievable and Relevant feedback was provided in greater proportions to high performer residents compared to expected and below-expected performers. These findings are a challenge to academic faculty to engage in quality feedback delivery for residents at all performance levels.

Implementation of a Diversity Committee to Improve Structural Inclusion in an Emergency Medicine Residency.

Introduction: To describe structural changes that can be made in an emergency medicine residency program to increase diversity and foster an inclusive environment. Methods: We established a diversity committee to introduce several simultaneous structural changes focusing on resident recruitment, education and engagement. Some of these changes include establishment of a scholarship to recruit visiting students from diverse backgrounds and a second look weekend for minority applicants. Others focused on ensuring residency didactics, were inclusive and addressed topics pertaining to diversity in emergency medicine. Results: We increased the number of minority residents underrepresented in medicine matching in our program from zero to between 2 and 4 annually. We increased the percentage of women matching in our program from 33% to 47%. We worked with residency leadership to increase the number of didactics focusing on diversity and inclusion. Conclusions: Implementation of a Diversity Committee in emergency medicine training programs can be an important tool to improve diversity on a structural level.

Meeting expectations: An exploration of academic emergency medicine faculty experiences and preferences in the virtual meeting environment by age, gender and parental status.

Background: During the COVID-19 pandemic, virtual meetings became the norm in academic emergency medicine (EM) departments. This study explores the experiences of academic EM faculty within this environment. Methods: In 2021, authors surveyed a cross-sectional convenience sample of EM faculty using a mixed-methods approach to explore perceptions of the virtual meeting environment. Authors reported data on a five-point Likert scale, summarized as percentages, and calculated differences using Pearson's chi-squared test, where p < 0.05 was significant. Free text responses were analyzed qualitatively. Results: Two-hundred-fifty-nine responses were collected, (female [55.6%], ≤40 years old, [39.8%]) of which 33.2% had children ≤7 years old. Most respondents felt the total number of virtual meetings had increased and were more likely to happen outside of regular business hours compared to in-person meetings. Most faculty preferred meetings during regular hours and liked the virtual format overall. Younger faculty respondents were more polarized in their preferences of timing of meetings and reported more pressure to accept meetings outside of regular hours. Female respondents with young children were more likely to dislike meetings outside regular hours and to have declined them. Women faculty, younger faculty, and women faculty with young children were significantly more likely to agree that women had been "more impacted by the new virtual work environment." Qualitative themes highlighting the flexibility provided by the virtual work environment and decreased commuting time, though many felt communication was limited in virtual meetings. Conclusions: Academic EM faculty mostly preferred keeping meetings during regular business hours and in a virtual format. Experiences varied by age but not by gender overall. Women with young children reported greater challenges than women without. Men did not differ by parental status. The virtual format provided increased flexibility but limited communication and engagement. Academic EM departments may use this data to inform future meeting practices.

Resident Perceptions of a Publicly Disclosed Daily Productivity Dashboard.

INTRODUCTION: Following resident requests, we created a public metrics dashboard to inform residents of their daily productivity. Our goal was to iteratively improve the dashboard based on resident feedback and to measure the impact of reviewing aggregate data on self-perceived productivity. METHODS: A 10-question anonymous survey was completed by our postgraduate year 1-3 residents. Residents answered questions on the dashboard and rated their own productivity before and after reviewing aggregate peer-comparison data. Using the Wilcoxon signed-rank test we calculated summary statistics for survey questions and compared distributions of pre- and post-test, self-rated productivity scores. RESULTS: All 43 eligible residents completed the survey (response rate 100%). Thirteen (30%) residents "rarely" or "never" reviewed the dashboard. No respondents felt the dashboard measured their productivity or quality of care "extremely accurately" or "very accurately." Seven (16%) residents felt "very" or "extremely pressured" to change their practice patterns based on the metrics provided, and 28 (65%) would have preferred private over public feedback. Fifteen residents (35%) changed their self-perceived rank after viewing peer-comparison data, although not significantly in a particular direction (z = 0.71, P = 0.48). CONCLUSION: Residents did not view the presented metrics as reflective of their productivity or quality of care. Viewing the dashboard did not lead to statistically significant changes in resident self-perception of productivity. This finding highlights the need for expanding the resident conversation and education on metrics, given their frequent inclusion in attending physician workforce payment and incentive models.

Socially distanced, virtually connected: Faculty and resident perceptions of virtual didactics.

BACKGROUND: During the COVID-19 pandemic, emergency medicine (EM) residency programs have transitioned from traditional in-person to virtual synchronous didactics to comply with social distancing guidelines. This study explores the perceptions of EM residents and faculty regarding this new virtual format. METHODS: This was a multicenter, cross-sectional study at five EM residencies using a mixed-methods approach to investigate resident and faculty perceptions of virtual didactics. Institutions selected reflect different program lengths and geographic locations. Quantitative data measured on a Likert scale were summarized as percentages. Differences were calculated using Welch's t-test and chi-square, where p < 0.05 was significant. Open-ended responses were analyzed qualitatively. RESULTS: Our response rate was 64% (n = 141) for residents and 48% (n = 108) for faculty. Fifty-one percent of faculty and 54% of residents felt that they were more likely to attend virtually than in person. Among residents, 77% felt that they were more likely to attend virtual conferences during vacation or elective rotations. Perceived retention of information from virtual sessions was perceived to be the same or better for 69% of residents and 58% of faculty. Residents felt that they paid more attention in the virtual format (29% vs. 26%, p = 0.037). Both groups missed the social interactions of in-person conference (86% of faculty, 75% of residents). Respondents from both groups felt that < 20% of total didactic time should remain virtual once social distancing recommendations are lifted. Qualitative analysis revealed recommendations from residents and faculty to optimize lecture style and interactivity. Decreased commute time and ability to multitask at home increased wellness for both groups. CONCLUSIONS: While benefits of virtual didactics were acknowledged, residents and faculty missed the social interaction of in-person conference and preferred < 20% of future didactics to be virtual. Further research should assess the difference in knowledge acquisition and retention between conference models.

Successful Implementation of a Resident Liaison to Medical Students in Emergency Medicine Rotations.

BACKGROUND: As the role of the resident-as-teacher grows, some residents are inspired to develop themselves early as leaders in education while in training. We describe the successful implementation of a resident liaison (RL) to medical students in emergency medicine (EM) as a way to develop resident leaders in medical education. METHODS: This position was implemented to develop interested residents as leaders in medical education and to provide medical students access to an EM physician who is closer to their training level and may be more approachable than the clerkship director. RLs are mentored by the clerkship director and are involved in curricular programming and education research. RESULTS: This innovation has strengthened our student EM rotations and has provided residents with a unique opportunity to explore a career in medical education. Residents have made tangible contributions to our educational programming in this role and have pursued careers in medical education. The program has been recognized as a "best practice" by students and the school of medicine. CONCLUSIONS: The RL initiative has conferred significant benefits to residents and medical students. Implementation of a RL program may benefit EM rotations outside of our institution and perhaps outside of the EM specialty.

Implementation of a Physician Assistant Emergency Medicine Residency Within a Physician Residency.

Physician assistants (PA) are an important part of emergency department healthcare delivery and are increasingly seeking specialty-specific postgraduate training. Our goal was to pilot the implementation of a PA postgraduate program within an existing physician residency program and produce emergency medicine-PA (EM-PA) graduates of comparable skill to their physician counterparts who have received the equivalent length of EM residency training to date (evaluated at the end of first year of EM training).The curriculum was based on the Society for Emergency Medicine Physician Assistants (SEMPA) recommendations with a special focus on side-by-side training with EM resident physicians. In reviewing the program, the authors examined faculty evaluations, as well as procedure and ultrasound experience that the trainees received. We found comparable evaluations between first-year EM-PA and physician trainee cohorts. This program serves as a pilot study to demonstrate the feasibility of collocating clinical and didactic programming for physicians and EM-PAs during their postgraduate training. This brief innovation report outlines the logistics of the clinical and didactic curriculum and provides a summary of outcomes evaluated.

Emergency Medicine Residents Consistently Rate Themselves Higher than Attending Assessments on ACGME Milestones.

INTRODUCTION: In 2012 the Accreditation Council for Graduate Medical Education (ACGME) introduced the Next Accreditation System (NAS), which implemented milestones to assess the competency of residents and fellows. While attending evaluation and feedback is crucial for resident development, perhaps equally important is a resident's self-assessment. If a resident does not accurately self-assess, clinical and professional progress may be compromised. The objective of our study was to compare emergency medicine (EM) resident milestone evaluation by EM faculty with the same resident's self-assessment. METHODS: This is an observational, cross-sectional study that was performed at an academic, four-year EM residency program. Twenty-five randomly chosen residents completed milestone self-assessment using eight ACGME sub-competencies deemed by residency leadership as representative of core EM principles. These residents were also evaluated by 20 faculty members. The milestone levels were evaluated on a nine-point scale. We calculated the average difference between resident self-ratings and faculty ratings, and used sample t-tests to determine statistical significance of the difference in scores. RESULTS: Eighteen residents evaluated themselves. Each resident was assessed by an average of 16 attendings (min=10, max=20). Residents gave themselves statistically significant higher milestone ratings than attendings did for each sub-competency examined (p<0.0001). CONCLUSION: Residents over-estimated their abilities in every sub-competency assessed. This underscores the importance of feedback and assessment transparency. More attention needs to be paid to methods by which residency leadership can make residents' self-perception of their clinical ability more congruent with that of their teachers and evaluators. The major limitation of our study is small sample size of both residents and attendings.

A prospective study of loss of consciousness in epilepsy using virtual reality driving simulation and other video games.

Patients with epilepsy are at risk of traffic accidents when they have seizures while driving. However, driving is an essential part of normal daily life in many communities, and depriving patients of driving privileges can have profound consequences for their economic and social well-being. In the current study, we collected ictal performance data from a driving simulator and two other video games in patients undergoing continuous video/EEG monitoring. We captured 22 seizures in 13 patients and found that driving impairment during seizures differed in terms of both magnitude and character, depending on the seizure type. Our study documents the feasibility of a prospective study of driving and other behaviors during seizures through the use of computer-based tasks. This methodology may be applied to further describe differential driving impairment in specific types of seizures and to gain data on anatomical networks disrupted in seizures that impair consciousness and driving safety.

Dual-source computed tomography angiography image quality in patients with fast heart rates.

BACKGROUND: Dual-source computed tomography (DSCT) provides diagnostic quality images of the coronary arteries over a wide range of heart rates (HRs). Current dose reduction techniques, including electrocardiographic (ECG) dose modulation and prospective triggering, are optimized for use in patients with relatively slow (<70 beats/min) HRs by limiting radiation dose to the ideal phases of image acquisition. OBJECTIVE: We evaluated coronary vessel image quality (IQ) at different reconstruction phases in patients with fast HRs (>80 beats/min) to assess potential feasibility of prospective triggering techniques on DSCT. METHODS: Patients (n=101) underwent 64-slice DSCT with retrospective ECG-gating without beta-blocker premedication. Image reconstructions were performed at 10% R-R wave phase intervals (0%-90%). Patients were grouped by mean HR: group A, <60 beats/min (n=22); group B, 60-80 beats/min (n=57); group C, >80 beats/min (n=22). Coronary artery IQ was assessed by 2 readers in consensus on a 5-point scale. RESULTS: Optimal IQ occurred at 70% phase for all arteries in groups A and B. In group C, optimal IQ occurred at 30% and 40% phases. The 70% phase achieved diagnostic IQ in 97% of group A and 86% of group B. A widened reconstruction window (30%-50%) was necessary for diagnostic IQ in a similar high proportion (84%) of group C. CONCLUSION: Optimal IQ occurs during late-systolic phases for patients with fast HRs (>80 beats/min). Late-systolic phase prospective triggering is potentially feasible in these patients; however, given the widened reconstruction windows required, a higher radiation dose may be required compared with patients with slower HRs (<80 beats/min).

Myocardial bridging: evaluation using single- and dual-source multidetector cardiac computed tomographic angiography.

OBJECTIVE: To evaluate the prevalence and characteristics of myocardial bridging in patients who underwent single- or dual-source multidetector cardiac computed tomographic angiography (MDCTA). METHODS: Retrospective review of the imaging characteristics of 57 myocardial bridges in 53 patients who underwent cardiac MDCTA examinations was performed. RESULTS: The prevalence of myocardial bridges was 10.4%, most of which were located in the mid-left anterior descending coronary artery. The average myocardial bridge length was 23.4 mm, and the average tunneled artery depth was 2.6 mm. CONCLUSIONS: Myocardial bridges are commonly found in patients who undergo cardiac multidetector computed tomographic angiograms on both single- and dual-source computed tomographic scanners and are most frequently located in the mid-left anterior descending coronary artery. Increasing utilization of cardiac MDCTA for noninvasive evaluation of coronary artery disease permits recognition, characterization, and functional assessment of this entity in a single examination.

Nitric oxide and superoxide in rat mesangial cells: modulation by C-reactive protein.

BACKGROUND: C-reactive protein (CRP) has been linked to cardiovascular and renal disease. We evaluated the effects of CRP on the production of nitric oxide (NO) and superoxide by rat mesangial cells (RMC) and the impact on cell function. METHODS AND RESULTS: RMC were incubated with cytokines (IFN-gamma, IL-1beta, and LPS) and CRP (10-100 microg/ml) for 24-72 h. Exposure to CRP resulted in a time- and dose-dependent reduction in NO accumulation (p<0.05). Although inducible nitric oxide synthase (iNOS) protein expression was unaltered after 48 h, CRP stimulated expression of HSP90. Steady state abundance of iNOS mRNA increased nearly threefold after a 24-h exposure to CRP. Incubation with 100 microg/ml CRP for 60-120 min resulted in a 272% increase in superoxide production that was prevented by diphenyleneiodium chloride but not L-NAME (p<0.0001). CONCLUSION: CRP enhances superoxide release in RMC, which in turn inactivates NO and reduces net production. The functional relevance of these CRP-induced changes is supported by increased expression of HSP90 in RMC exposed to the mediator. These findings suggest that systemic inflammation, which contributes to the pathogenesis of atherosclerosis, may play a role in the progression of kidney disease.