Test ordering guidelines can alter ordering patterns in an academic emergency department.

To determine the impact of an educational program designed to modify test ordering behavior in an academic Emergency Department (ED), an observational, before-and-after study was conducted at a university tertiary referral center and Emergency Medicine (EM) residency site. Test ordering standards were developed by EM faculty, RNs, and NPs based upon group consensus and published data. The standards were given to all ED staff beginning February 1996, and included in the evidence-based medicine orientation and educational program for all residents and medical students prior to beginning their rotation. No restrictions were placed on actual test ordering. The number of laboratory tests (total and individual) ordered per 100 patients decreased significantly after the educational program began for: total testing, CBC, and liver function test (LFT). In addition, declines during individual months for these tests were statistically significant. Prothrombin time and blood culture testing showed no significant decreases in test ordering frequency. Chemistry test ordering frequency showed statistically significant increases. Overall, approximately $50,000 was saved by decreasing test ordering. Test ordering behavior can be modified and maintained by an educational program and may have significant economic effects.

University and community hospital medical student emergency medicine clerkship experiences.

OBJECTIVE: To determine whether there is a significant difference between educational opportunities for fourth-year medical students rotating at a university hospital (UH) compared with several community hospitals (CHs) during a mandatory emergency medicine (EM) clerkship. METHODS: A self-reported clinical tool was completed in real time by each student rotating for 2 weeks at the UH and 2 weeks at 1 of 4 CHs (3 affiliated and 1 unaffiliated). Students are required to document the number of patients seen and the number of procedures performed on each of 20 six-hour shifts. They rated the EM attending clinical teaching by site using a 5-point scale at the end of the clerkship. RESULTS: Most (95%) of the 87 students in the 7 clerkship blocks of the 1996-97 academic year rotated at the UH and a CH. Most (71%) students rated both the UH and the CH for the quality of teaching by attendings. There was a significant difference in the mean number of patients evaluated/shift (2.2 +/- 0.10 vs 2.8 +/- 0.10, UH vs CH; p < 0.001) and the mean number of procedures performed/shift (0.36 +/- 0.04 vs 0.56 +/- 0.05, UH vs CH; p < 0.001). Attending clinical teaching scores were significantly higher (p = 0.03) at the CHs. CONCLUSIONS: The educational opportunities for students in an EM clerkship to evaluate patients and perform procedures were significantly greater at the community hospitals. Inclusion of community hospital settings in a medical student EM clerkship may optimize the clinical experience.

Sexual assault.

All patients should be screened for a history of sexual abuse and victimization. Survivors of acute sexual assault have physical, psychological, and legal needs. The goal is to minimize additional trauma while simultaneously ensuring quality care and maximizing efforts to collect evidence. A pertinent history, physical examination, and treatment plan should be completed. Chain of custody needs to be maintained. The patient should be discharged with family or friends with appropriate follow-up.

Personal exposure of faculty and medical students to family violence.

OBJECTIVE: To determine the prevalence of exposure to personal family violence among medical students and full-time faculty at a major medical center. DESIGN: Self-reported, double-mailing, anonymous survey conducted in September 1995. PARTICIPANTS: Of 406 medical students and 917 full-time faculty surveyed, 787 (59%) responded, including 217 students and 559 faculty members who identified academic status and 292 women and 482 men who identified gender. MAIN OUTCOME MEASURE: Self-reported personal experience with partner abuse, child abuse, physical abuse, and sexual abuse. RESULTS: Response rates were higher for women (69%) than men (54%) (P<.001) and were higher for faculty (61%) than students (53%) (P=.01). Of the 787 respondents, 99 (12.6%; 95% confidence interval [CI], 10.9%-15.6%) reported physical abuse, sexual abuse, or both by a partner during their adult life, 118 (15.0%; 95% CI, 12.8%-17.8%) reported physical abuse, sexual abuse, or both as a child, and 188 (23.9%; 95% CI, 22.0-28.1%) reported physical abuse, sexual abuse, or both in their lifetime. Based on positive responses, a minimum of 17% of the female medical students and faculty and 3% of the male medical students and faculty have experienced physical abuse or sexual abuse by a partner in their adult life. CONCLUSIONS: Family violence is a pervasive problem that crosses into the personal experience of medical professionals. The conservative estimate of partner abuse for female medical students and faculty appears comparable with the general population national estimates. The acknowledgment by physicians that family violence is a potential risk for everyone, physicians and patients alike, is a step toward enhancing the identification of abuse and initiating interventions on behalf of survivors of family violence.

Hidden trauma: the mostly missed diagnosis of domestic violence.

Domestic violence is an epidemic that rages throughout our society. Despite its overwhelming incidence and prevalence, this abuse goes unrecognized and unaddressed in the majority of health care settings. Nonetheless, battered women expect health care providers to initiate discussions about abuse. Improved awareness through education at all levels and protocols will help interrupt the cycle of intergenerational learned violence. Without intervention, domestic violence is perpetuated and escalates.