A Conceptual Model for Navigating a Career Path in Medical School Leadership.

There is a paucity of literature providing guidance to physicians hoping to attain a position as a medical school dean. Realizing this gap, the Society for Academic Emergency Medicine (SAEM) Faculty Development Committee organized an educational session focused on offering faculty guidance for obtaining a position in medical school leadership. The session involved panelists who are nationally known leaders in medical school administration and was successfully presented at the SAEM 2018 annual meeting in Indianapolis, Indiana. Knowledge and perspective gained both during this session and through literature review was analyzed using a conceptual thinking skills framework. This process offered insights that promoted the development of a conceptual model informed by current evidence and expert insight and rooted in educational, economic, and cognitive theory. This model provides a step-by-step guide detailing a process that physicians can use to create a plan for professional development that is informed, thoughtful, and individualized to their own needs to optimize their future chances of advancing to a career in medical school leadership.

Kiosk versus in-person screening for alcohol and drug use in the emergency department: patient preferences and disclosure.

INTRODUCTION: Annually eight million emergency department (ED) visits are attributable to alcohol use. Screening ED patients for at-risk alcohol and substance use is an integral component of screening, brief intervention, and referral to treatment programs, shown to be effective at reducing substance use. The objective is to evaluate ED patients' acceptance of and willingness to disclose alcohol/substance use via a computer kiosk versus an in-person interview. METHODS: This was a cross-sectional, survey-based study. Eligible participants included those who presented to walk-in triage, were English-speaking, ≥18 years, were clinically stable and able to consent. Patients had the opportunity to access the kiosk in the ED waiting room, and were approached for an in-person survey by a research assistant (9am-5pm weekdays). Both surveys used validated assessment tools to assess drug and alcohol use. Disclosure statistics and preferences were calculated using chi-square tests and McNemar's test. RESULTS: A total of 1,207 patients were screened: 229 in person only, 824 by kiosk, and 154 by both in person and kiosk. Single-modality participants were more likely to disclose hazardous drinking (p=0.003) and high-risk drug use (OR=22.3 [12.3-42.2]; p<0.0001) via kiosk. Participants who had participated in screening via both modalities were more likely to reveal high-risk drug use on the kiosk (p=0.003). When asked about screening preferences, 73.6% reported a preference for an in-person survey, which patients rated higher on privacy and comfort. CONCLUSION: ED patients were significantly more likely to disclose at-risk alcohol and substance use to a computer kiosk than an interviewer. Paradoxically patients stated a preference for in-person screening, despite reduced disclosure to a human screener.

The Emergency Department as a prevention site: a demographic analysis of substance use among ED patients.

OBJECTIVES: To identify rates of alcohol and drug use among patients presenting to an inner-city Emergency Department (ED) and to describe demographic and health characteristics of patients with high-risk use. METHODS: A cross-sectional study of patients presenting to the ED for any complaint. Patients were administered a brief screening about past 12-months alcohol and drug use. Patients who answered "yes" to any question were approached for a longer survey, the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST). Based on ASSIST scores patients received a brief intervention, and, when appropriate, a referral for brief outpatient therapy or specialized substance abuse treatment. Patients whose score indicated high-risk or dependent use were also asked demographic and health questions. RESULTS: Over a 20-month period, 19,055 patients were pre-screened. 87.1% of patients were black, 57% were male, with average age 44.8 years. 27.6% of patients pre-screened positive for drug or alcohol use; among these patients 44.2% scored in the low-risk range on the ASSIST, 35.8% moderate risk, 10% high risk and 10% probable dependence. Among patients with high-risk or dependent use, 70% rated their current health as fair/poor, with a mean of 1.7 ED visits in the prior 30 days. 40.7% reported "extreme" stress due to their use. 34.6% reported that they had stable housing and 13.6% were fully employed. CONCLUSION: Among all patients seen in the ED for any complaint, a significant proportion is engaged in alcohol and drug use that increases their risk of health and social consequences.

When patients are impatient: the communication strategies utilized by emergency department employees to manage patients frustrated by wait times.

Studies have documented the frustrations patients experience during long wait times in emergency departments (EDs), but considerably less research has sought to understand ED staff responses to these frustrations. In-depth interviews were conducted with 18 ED social workers, patient navigators, and medical staff members at a large urban hospital regarding their experiences and interpersonal strategies for dealing with frustrated patients. Staff indicated that patients often attribute delays to neglect and do not understand why their health problem is not prioritized. They voiced several strategies for addressing wait time frustrations, including expressing empathy for patients, making patients feel occupied and wait times seem more productive, and educating patients about when health issues should be treated through primary care. All staff members recognized the need for engaging in empathic communication with frustrated patients, but social workers and patient navigators were able to dedicate more time to these types of interactions.

How community members and health professionals conceptualize medical emergencies: implications for primary care promotion.

Access to continuous care through a primary care provider is associated with improved health outcomes, but many communities rely on emergency departments (EDs) for both emergent and non-emergent health problems. This article describes one portion of a community-based participatory research project and investigates the type of education that might be needed as part of a larger intervention to encourage use of a local primary care clinic. In this article we examine how people who live in a low-income urban community and the healthcare workers who serve them conceptualize 'emergency medical condition'. We conducted forum and focus group discussions with 52 community members and individual interviews with 32 healthcare workers. Our findings indicate that while community members share a common general definition of what constitutes a medical emergency, they also desire better guidelines for how to assess health problems as requiring emergency versus primary care. Pain, uncertainty and anxiety tend to influence their choice to use EDs rather than availability of primary care. Implications for increasing primary care use are discussed.

Benefit of a Tiered-Trauma Activation System to Triage Dead-on-Arrival Patients.

INTRODUCTION: Although national guidelines have been published for the management of critically injured traumatic cardiopulmonary arrest (TCPA) patients, many hospital systems have not implemented in-hospital triage guidelines. The objective of this study was to determine if hospital resources could be preserved by implementation of an in-hospital tiered triage system for patients in TCPA with prolonged resuscitation who would likely be declared dead on arrival (DOA). METHOD: We conducted a retrospective analysis of 4,618 severely injured patients, admitted to our Level I trauma center from December 2000 to December 2008 for evaluation. All of the identified patients had sustained life-threatening penetrating and blunt injuries with pre-hospital TCPA. Patients who received cardiopulmonary resuscitation (CPR) for 10 minutes were assessed for survival rate, neurologic outcome, and charge-for-activation (COA) for our hospital trauma system. RESULTS: We evaluated 4,618 charts, which consisted of patients seen by the MSM trauma service from December 2001 through December 2008. We identified 140 patients with severe, life-threatening traumatic injuries, who sustained pre-hospital TCPA requiring prolonged CPR in the field and were brought to the emergency department (ED). Group I was comprised of 108 patients sustaining TCPA (53 blunt, 55 penetrating), who died after receiving < 45 minutes of ACLS after arrival. Group II, which consisted of 32 patients (25 blunt, 7 penetrating), had resuscitative efforts in the ED lasting > 45 minutes, but all ultimately died prior to discharge. Estimated hospital charge-for-activation for Group I was approximately $540,000, based on standard charges of $5000 per full-scale trauma system activation (TSA). CONCLUSION: Full-scale trauma system activation for patients sustaining greater than 10 minutes of prehospital TCPA in the field is futile and economically depleting.

Racial and ethnic disparities in the emergency department: a public health perspective.

This article discusses racial and ethnic disparities from a public health perspective, specifically why they threaten to impede the efforts to improve the nation's health. The authors (1) provide background information, including a review of the Institute of Medicine report on health care disparities; (2) describe the racial and ethnic compositions of the individuals in the emergency department setting from the perspective of both the patient and health care provider; (3) discuss the most prevalent disease presentations to the emergency department that are likely to have racial and ethnic disparities; and (4) give conclusions and general recommendations on how to address disparities in emergency health care.

Reasons for using the emergency department: results of the EMPATH Study.

OBJECTIVES: Emergency Medicine Patients' Access To Healthcare (EMPATH) was a cross-sectional, observational study conducted to identify the principal reasons why patients seek care in hospital emergency departments (EDs) in the United States. METHODS: Twenty-eight U.S. hospitals, stratified by geographic region and hospital characteristics, participated in this study. Demographic, clinical, and insurance data were collected for a 24-hour period at each site, using chart reviews and a structured interview administered to all consenting adult patients seeking treatment during that period. Patients' reasons for presenting to the ED were assessed by their level of agreement (on a three-point Likert scale) with 21 carefully worded statements designed to capture a range of possible reasons for seeking care in the ED. Factor analysis was used to consolidate highly correlated responses and to identify the principal factors explaining patients' reasons for coming to the ED. RESULTS: A total of 1,579 patient interviews and 2,004 chart reviews were obtained from a diverse sample that was 55.4% female, 58.3% white, 28.3% African American, 7.0% Hispanic, and 6.0% other ethnic groups. This exploratory analysis yielded five factors characterizing patients' principal reasons for seeking ED care, with medical necessity the most frequent, followed by ED preference, convenience, affordability, and limitations of insurance. CONCLUSIONS: Use of the ED is, for most people, an affirmative choice over other providers rather than a last resort; it is often a choice driven by lack of access to or dissatisfaction with other sources of care.

Disparities in emergency department health care: systems and administration.

Disparities are likely to present both in the emergency department and within the larger health care system; however, disparities must be recognized to be addressed. This article summarizes the proceedings from the AEM Consensus Conference 2003: Disparities in Emergency Health Care. The goals of the conference were to examine the presence, causes, and outcomes related to disparities of health care as they occur in emergency departments, and determine the degree to which external forces have an impact on our patients. Participants were asked to describe the means of defining, assessing, measuring, and investigating disparities that may occur in emergency care. The committee members who wrote this report were asked to examine the influence of health care systems and administration on disparities in health care, using the following series of questions to frame the discussion. 1) Are all disparities bad? 2) Are only the vulnerable served inadequately by our current health care system? 3) Are what appear to be inequities really systems incompetence? 4) We assume there should be no inequality in health care: does society also assume this? 5) What would be the systems costs of equality in health care?

Clinical operations in academic emergency medicine.

The operations of an emergency department are increasingly being recognized as vital to the provision of safe, efficient, quality care. The numerous and highly variable processes that characterize our system must be closely examined and investigated to identify those which are effective and those which are not. Original research in this field should be promoted and embraced by our society for both our patients and our profession. Effective operational processes should ultimately be seen as those which preserve and enhance the patient-physician relationship.