American Board of Emergency Medicine Report on Residency and Fellowship Training Information (2022-2023).

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 and the residents and fellows training in those programs. We present the 2023 annual report on the status of physicians training in ACGME-accredited emergency medicine training programs in the United States.

Early validity and reliability evidence for the American Board of Emergency Medicine Virtual Oral Examination.

Background: The American Board of Emergency Medicine (ABEM) in-person Oral Certification Examination (OCE) was halted abruptly in 2020 due to the COVID-19 pandemic. The OCE was reconfigured to be administered in a virtual environment starting in December 2020. Objectives: The purpose of this investigation was to determine whether there was sufficient validity and reliability evidence to support the continued use of the ABEM virtual Oral Examination (VOE) for certification decisions. Methods: This retrospective, descriptive study used multiple data sources to provide validity evidence and reliability data. Validity evidence focused on test content, response processes, internal structure (e.g., internal consistency and item response theory), and the consequences of testing. A multifaceted Rasch reliability coefficient was used to measure reliability. Study data were from two 2019 in-person OCEs and the first four VOE administrations. Results: There were 2279 physicians who took the 2019 in-person OCE examination and 2153 physicians who took the VOE during the study period. Among the OCE group, 92.0% agreed or strongly agreed that the cases on the examination were cases that an emergency physician should be expected to see; 91.1% of the VOE group agreed or strongly agreed. A similar pattern of responses given to a question about whether the cases on the examination were cases that they had seen. Additional evidence of validity was obtained by the use of the EM Model, the process for case development, the use of think-aloud protocols, and similar test performance patterns (e.g., pass rates). For reliability, the Rasch reliability coefficients for the OCE and the VOE during the study period were all >0.90. Conclusions: There was substantial validity evidence and reliability to support ongoing use of the ABEM VOE to make confident and defensible certification decisions.

Clinical Outcomes Following Implementation of a Formalized "Flashes and Floaters" Emergency Department Triage Protocol.

PURPOSE: To report outcomes of patients presenting to the emergency department (ED) with new-onset visual flashes and/or floaters following implementation of a formalized triage protocol allowing eligible patients to be discharged for prompt outpatient ophthalmic examination. DESIGN: Retrospective consecutive case series. METHODS: Patient characteristics, protocol eligibility, and clinical outcomes were recorded for adult patients triaged within a formal "flashes and floaters" protocol at a single academic ED. RESULTS: A total of 457 patients presented for 471 unique ED encounters with a chief complaint of visual flashes and/or floaters between October 2014 and May 2018. In all, 61% of patient encounters (287/471) met protocol criteria for prompt outpatient ophthalmic examination, of whom 94% (269/287) were examined within 48 hours. Final diagnoses of protocol-eligible patients were posterior vitreous detachment only (73%, 197/269), retinal break(s) (10%, 26/269), migraine (5%, 14/269), and no cause or new cause found (10%, 27/269). No protocol-eligible patients had retinal detachment or diagnoses requiring emergent diagnostic or therapeutic care (0%, 95% CI = 0%-1.1%). Final diagnoses following 175 encounters not meeting criteria for deferred examination included posterior vitreous detachment only (25%, 43/175), retinal break(s) (19%, 33/175), macula-involving retinal detachment (13%, 22/175), macula-sparing retinal detachment (11%, 19/175), retinal arterial occlusion (2%, 3/175), and stroke (0.6%, 1/175). The Cohen kappa for agreement on protocol eligibility between the ED physician and ophthalmologist was 0.85. CONCLUSIONS: A formalized ED "flashes and floaters" triage protocol may help identify patients for whom prompt outpatient ophthalmic examination may be more safely considered.

Using network analysis to model the effects of the SARS Cov2 pandemic on acute patient care within a healthcare system.

Consolidation of healthcare in the US has resulted in integrated organizations, encompassing large geographic areas, with varying services and complex patient flows. Profound changes in patient volumes and behavior have occurred during the SARS Cov2 pandemic, but understanding these across organizations is challenging. Network analysis provides a novel approach to address this. We retrospectively evaluated hospital-based encounters with an index emergency department visit in a healthcare system comprising 18 hospitals, using patient transfer as a marker of unmet clinical need. We developed quantitative models of transfers using network analysis incorporating the level of care provided (ward, progressive care, intensive care) during pre-pandemic (May 25, 2018 to March 16, 2020) and mid-pandemic (March 17, 2020 to March 8, 2021) time periods. 829,455 encounters were evaluated. The system functioned as a non-small-world, non-scale-free, dissociative network. Our models reflected transfer destination diversification and variations in volume between the two time points - results of intentional efforts during the pandemic. Known hub-spoke architecture correlated with quantitative analysis. Applying network analysis in an integrated US healthcare organization demonstrates changing patterns of care and the emergence of bottlenecks in response to the SARS Cov2 pandemic, consistent with clinical experience, providing a degree of face validity. The modelling of multiple influences can identify susceptibility to stress and opportunities to strengthen the system where patient movement is common and voluminous. The technique provides a mechanism to analyze the effects of intentional and contextual changes on system behavior.

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.

Retrospective analysis of 450 emergency department dermatology consultations: An analysis of in-person and teledermatology consultations from 2015 to 2019.

INTRODUCTION: Dermatologic complaints are a common reason for emergency department visits. METHODS: Retrospective chart review from 1 January 2015 to 31 December 2019. Patients in the Mayo Clinic Emergency Department receiving dermatology consultation were included. RESULTS: Dermatitis (24.7%, n = 113), infection (20.4%, n = 93), and drug reaction (10.3%, n = 47) accounted for the majority of diagnoses. Emergency department providers often provide no diagnosis (38%) or a differential diagnosis (22%), and dermatology consultation frequently alters diagnosis (46%) and treatment (83%). Patients receiving in-person consultations are admitted more frequently than those receiving teledermatology consultations (40% vs. 16%, p < 0.001). Primary diagnostic concordance with subsequent dermatology evaluation is high for in-person (94%) and teledermatology (88%) consultations. DISCUSSION: This is the largest study of emergency department dermatology consultations in the United States and the first to compare in-person and teledermatology emergency department consultation utilization in clinical practice. These modalities are utilized in a complementary fashion at our institution, with severe dermatologic diagnoses seen in-person. The valuable role of emergency department dermatologists is highlighted by frequent changes to diagnosis and treatment plans that result from dermatology consultation. Furthermore, our data suggest that teledermatology is an effective modality with the potential to expand access to dermatologic expertise in the emergency department setting.

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.

Impact of the SARS-CoV-2 Pandemic on Emergency Department Presentations in an Integrated Health System.

OBJECTIVE: To quantify the impact of the severe acute respiratory syndrome coronavirus 2 pandemic on emergency department volumes and patient presentations and evaluate changes in community mortality for the purpose of characterizing new patterns of emergency care use. PATIENTS AND METHODS: This is an observational cross-sectional study using electronic health records for emergency department visits in an integrated multihospital system with academic and community practices across 4 states for visits between March 17 and April 21, 2019, and February 9 and April 21, 2020. We compared numbers and proportions of common and critical chief symptoms and diagnoses, triage assessments, throughput, disposition, and selected hospital lengths of stay and out-of-hospital deaths. RESULTS: In the period of interest, emergency department visits decreased by nearly 50% (35037 to 18646). Total numbers of patients with myocardial infarctions, stroke, appendicitis, and cholecystitis diagnosed decreased. The percentage of visits for mental health symptoms increased. There was an increase in deaths, driven by out-of-hospital mortality. CONCLUSION: Fewer patients presenting with acute and time-sensitive diagnoses suggests that patients are deferring care. This may be further supported by an increase in out-of-hospital mortality. Understanding which patients are deferring care and why will allow us to develop outreach strategies and ensure that those in need of rapid assessment and treatment will do so, preventing downstream morbidity and mortality.

Patient Length of Stay Under the Two-Midnight Rule: Assessing the Accuracy of Providers' Predictions.

EXECUTIVE SUMMARY: We sought to determine emergency medicine physicians' accuracy in designating patients' disposition status as "inpatient" or "observation" at the time of hospital admission in the context of Medicare's Two-Midnight rule and to identify characteristics that may improve the providers' predictions. We conducted a 90-day observational study of emergency department (ED) admissions involving adults aged 65 years and older and assessed the accuracy of physicians' disposition decisions. Logistic regression models were fit to explore associations and predictors of disposition. A total of 2,257 patients 65 and older were admitted through the ED. The overall error rate in physician designation of observation or inpatient was 36%. Diagnoses most strongly associated with stays lasting less than two midnights included diverticulitis, syncope, and nonspecific chest pain. Diagnoses most strongly associated with stays lasting two or more midnights included orthopedic fractures, biliary tract disease, and back pain. ED physicians inaccurately predicted patient length of stay in more than one third of all patients. Under the Two-Midnight rule, these inaccurate predictions place hospitals at risk of underpayment and patients at risk of significant financial liability. Further work is needed to increase providers' awareness of the financial repercussions of their admission designations and to identify interventions that can improve prediction accuracy.

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.

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.

A Time-Driven Activity-Based Costing Analysis of Emergency Department Scribes.

OBJECTIVE: To apply time-driven activity-based costing (TDABC) methodology to determine emergency medicine physician documentation costs with and without scribes. METHODS: This was a prospective observation cohort study in a large academic emergency department. Two research assistants with experience in physician-scribe interactions and ED workflow shadowed attending physicians for a total of 64 hours in the adult emergency department. A tablet-based time recorded was used to obtain estimates for physician documentation time on both control (no scribe) and intervention (scribe) shifts. RESULTS: Control shifts yielded approximately 3 hours of documentation time per 8 hours of clinical time (2 hours during the shift, 1 hour following the shift). When paired with a scribe, attending physician documentation decreased to 1 hour and 45 minutes during a shift and 15 minutes of postshift documentation. The physician cost estimate for documentation without and with a scribe is 644 and 488 dollars, respectively. CONCLUSIONS: When one looks at the time saved by the provider, scribes appear to be a financially sound decision. TDABC methodology demonstrated that scribes afford a cost-effective solution to ED clinical documentation and serves as a tool to develop an accurate costing system, based on actual resources and processes, and allowed for understanding of resource use at a more granular level.

Time Motion Analysis: Impact of Scribes on Provider Time Management.

BACKGROUND: Scribes are unlicensed professionals trained in medical data entry. Limited data exist on the impact of scribes on provider time management in the emergency department (ED). Time-motion analysis is a tool utilized in business to capture detailed movements and durations to task completion. It offers a means to categorize how providers allocate their time during a clinical shift. OBJECTIVE: Evaluate the impact of scribes on how ED providers spend their time. METHODS: A prospective observational study was conducted to assess scribe impact on provider time utilization. Four research assistants (RAs) observed attending providers on 24 8-h control shifts (without a scribe), and 24 scribed shifts. RAs observed and categorized provider activity. Providers self-reported after-hours documentation times. Two-sample t-tests were used for normally distributed data, and Wilcoxon rank-sum tests were used for skewed data. All tests were two-sided, and p-values < 0.05 were considered statistically significant. RESULTS: Scribes decreased total documentation time both on shift (mean 55.3 vs. 36.4 min, p < 0.001) and post shift (mean 42.5 vs. 23.3 min, p = 0.038). They did not significantly decrease the amount of time spent reviewing the medical records or placing orders, nor did they have an impact on provider time spent at patients' bedside or time spent discussing patient care with team members. CONCLUSION: The presence of scribes decreased provider documentation time but did not change the amount of time spent at the bedside or communicating with other team members. Scribes may be a potential strategy to decrease the clerical burden.

Physician Age and Performance on the American Board of Emergency Medicine ConCert Examination.

OBJECTIVE: This study was undertaken to expand on results from a 2014 study on the association between physician age and performance on the American Board of Emergency Medicine (ABEM) ConCert examination. METHODS: This was a retrospective, longitudinal growth study comparing performance on the ConCert examination and physicians' ages at the time of examination. All examination attempts from 1990 to 2016 made by residency-trained physicians were eligible for inclusion. Multilevel growth models were constructed to examine the relationship between age at time of examination and performance, controlling for physician characteristics. RESULTS: The study group included 15,533 examination attempts by 12,786 physicians. The mean (±SD) age of the physicians across all examination administrations was 45.02 (±5.18) years (range = 35 to 72 years). The mean (±SD) ConCert examination score across all administrations was 85.39 (±5.71; range = 51 to 100). Among first-time ConCert examination takers, older age was associated with lower examination scores (r = -0.25, p < 0.0001). Across all examination attempts, age was negatively correlated to examination scores (r = -0.24; p < 0.0001). CONCLUSIONS: After physician characteristics were controlled for, there was an association between advancing age and declining performance on the ABEM ConCert examination. This information may be important to the individual physician to develop targeted competency assessment and professional development.

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.

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.

Gender Distribution Among American Board of Medical Specialties Boards of Directors.

Since 1995, women have comprised more than 40% of all medical school graduates. However, representation at leadership levels in medicine remains considerably lower. Gender representation among the American Board of Medical Specialties (ABMS) boards of directors (BODs) has not previously been evaluated. Our objective was to determine the relative representation of women on ABMS BODs and compare it with the in-training and in-practice gender composition of the respective specialties. The composition of the ABMS BODs was obtained from websites in March 2016 for all Member Boards. Association of American Medical Colleges and American Medical Association data were utilized to identify current and future trends in gender composition. Although represented by a common board, neurology and psychiatry were evaluated separately because of their very different practices and gender demographic characteristics. A total of 25 specialties were evaluated. Of the 25 specialties analyzed, 12 BODs have proportional gender representation compared with their constituency. Seven specialties have a larger proportion of women serving on their boards compared with physicians in practice, and 6 specialties have a greater proportion of men populating their BODs. Based on the most recent trainee data (2013), women have increasing workforce representation in almost all specialties. Although women in both training and practice are approaching equal representation, there is variability in gender ratios across specialties. Directorship within ABMS BODs has a more equitable gender distribution than other areas of leadership in medicine. Further investigation is needed to determine the reasons behind this difference and to identify opportunities to engage women in leadership in medicine.