Relationship between individual and country-level socio-economic background, USMLE step scores, and demographics of international medical graduates and residency match results.

PURPOSE: Twenty five percent of practicing physicians in the US are International Medical Graduates (IMGs) - physicians who completed their medical school training outside of the United States and Canada. There are multiple studies demonstrating higher socio-economic background is associated with medical school matriculation in the US. However, despite a substantial prevalence of IMGs in the American healthcare system, studies of the association between demographics, socio-economic background, and securing a residency position in the match are lacking. METHODS: We created a survey with questions on residency match-related data and information on personal socio-economic background. An invitation to participate in the study was sent to all IMGs that applied to the included residency programs after the conclusion of the 2022 residency match. We used multivariable logistic regression to compare survey responses to the odds of securing a residency match. RESULTS: The total number of survey respondents was 744 (response rate 15.1%). We found that younger age, higher United States Medical License Examination (USMLE) scores, higher-income country of origin (including the United States), fewer match attempts, applying to fewer specialties, having parents with college degree or higher, and coming from higher-than-average or lower-than-average family income were independently associated with increased odds of matching. Gender, personal income, and visa status did not demonstrate significant associations with residency match. CONCLUSIONS: Residency match is a significant expense for IMGs, especially for those from lower-income countries. International applicants from higher socio-economic backgrounds might have advantages in securing medical residency positions in the United States when controlling for other variables.

Defining the clinical and procedural opportunities available to residents during rural rotations.

Introduction: Many emergency medicine (EM) residency programs include clinical rotations in rural emergency departments ("rural rotations") as part of their curriculum. These rotations are designed to expose residents to clinical scenarios that are less frequently encountered in tertiary centers. The objective of this study was to determine the rate at which residents were exposed to certain clinical and procedural experiences (CPEs) while on rural rotations compared to their usual academic training hospital. Methods: We conducted a retrospective chart review of all patient encounters involving EM residents at a large academic hospital in Rochester, Minnesota, compared with two rural hospitals in Austin, Minnesota, and Albert Lea, Minnesota, from July 1, 2019, to June 30, 2020. The frequency of each CPE was calculated and expressed as the number of CPEs encountered per 100 clinical hours worked. These values were compared between the rural and academic sites. Results: A total of 33,417 patient encounters over a total of 41,700 resident clinical hours were analyzed between the three study sites. The two settings (rural vs. academic) had significant differences in baseline patient demographics including age, acuity, and admission rates. Several CPEs were found to occur at a higher frequency in the rural hospitals versus the academic hospital: ambulance necessity documentation (9.3/100 h rural vs. 0.07/100 h academic, p ≤ 0.0001), laceration repair (3.39/100 h rural vs. 2.0/100 h academic, p = 0.0004), and splint/cast application (1.53/100 h rural vs. 0.07/100 h academic, p ≤ 0.0001). Conclusions: Rural EM rotations provide residents exposure to a variety of valuable educational experiences. These rotations may provide residents with superior exposures to some clinical experiences compared to academic hospitals, particularly out-of-ED transfers and orthopedic procedures. Residency programs without a current rural rotation should consider creating this as an option for their trainees.

A review of medical malpractice cases involving trainees in the emergency department.

Background: This study characterizes medical malpractice lawsuits involving trainees providing care in the emergency department (ED), affording insight into the types of patients involved, clinical scenarios, and legal outcomes of these cases. Methods: Cases were identified using the legal database, Westlaw. Per chart review methods, relevant information was abstracted by 2 trained reviewers onto a standardized data abstraction form, with a senior author arbitrating disagreements. Results: We identified 60 cases reported between 1982 and 2017 in which a trainee was named in a lawsuit related to patient care provided in the ED. The most common alleged errors included diagnostic (n = 37, 61%), treatment (n = 13, 21%), and procedural errors (n = 19, 16%). In 21 cases (35%), it was alleged that no attending physician was directly involved in the care at any time. The attending was noted to have seen the patient in person at any point in only 11 total cases (18%). Of the 50 cases with known outcomes, 15 (30%) decided in favor of the patient, 21 (42%) were resolved in the physician's favor, and 14 (28%) were settled. Conclusion: This study underscores that trainees are vulnerable to malpractice cases and that lack of direct supervision is a prominent theme in these cases. This information suggests areas for further work and may help training programs, trainees, and supervising physicians design their practice patterns in ways that mitigate these risks in the future.

The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies.

Mental and behavioral health (MBH) emergencies in children and youth continue to increasingly affect not only the emergency department (ED), but the entire spectrum of emergency medical services for children, from prehospital services to the community. Inadequate community and institutional infrastructure to care for children and youth with MBH conditions makes the ED an essential part of the health care safety net for these patients. As a result, an increasing number of children and youth are referred to the ED for evaluation of a broad spectrum of MBH emergencies, from depression and suicidality to disruptive and aggressive behavior. However, challenges in providing optimal care to these patients include lack of personnel, capacity, and infrastructure, challenges with timely access to a mental health professional, the nature of a busy ED environment, and paucity of outpatient post-ED discharge resources. These factors contribute to prolonged ED stays and boarding, which negatively affects patient care and ED operations. Strategies to improve care for MBH emergencies, including systems level coordination of care, is therefore essential. The goal of this policy statement and its companion technical report is to highlight strategies, resources, and recommendations for improving emergency care delivery for pediatric MBH.

Comparison of clinical note quality between an automated digital intake tool and the standard note in the emergency department.

BACKGROUND: Medical encounters require an efficient and focused history of present illness (HPI) to create differential diagnoses and guide diagnostic testing and treatment. Our aim was to compare the HPI of notes created by an automated digital intake tool versus standard medical notes created by clinicians. METHODS: Prospective trial in a quaternary academic Emergency Department (ED). Notes were compared using the 5-point Physician Documentation Quality Instrument (PDQI-9) scale and the Centers for Medicare & Medicaid Services (CMS) level of complexity index. Reviewers were board certified emergency medicine physicians blinded to note origin. Reviewers received training and calibration prior to note assessments. A difference of 1 point was considered clinically significant. Analysis included McNemar's (binary), Wilcoxon-rank (Likert), and agreement with Cohen's Kappa. RESULTS: A total of 148 ED medical encounters were charted by both digital note and standard clinical note. The ability to capture patient information was assessed through comparison of note content across paired charts (digital-standard note on the same patient), as well as scores given by the reviewers. Reviewer agreement was kappa 0.56 (CI 0.49-0.64), indicating moderate level of agreement between reviewers scoring the same patient chart. Considering all 18 questions across PDQI-9 and CMS scales, the average agreement between standard clinical note and digital note was 54.3% (IQR 44.4-66.7%). There was a moderate level of agreement between content of standard and digital notes (kappa 0.54, 95%CI 0.49-0.60). The quality of the digital note was within the 1 point clinically significant difference for all of the attributes, except for conciseness. Digital notes had a higher frequency of CMS severity elements identified. CONCLUSION: Digitally generated clinical notes had moderate agreement compared to standard clinical notes and within the one point clinically significant difference except for the conciseness attribute. Digital notes more reliably documented billing components of severity. The use of automated notes should be further explored to evaluate its utility in facilitating documentation of patient encounters.

Integrating self-assessment into feedback for emergency medicine residents.

BACKGROUND: In 2013 the Accreditation Council for Graduate Medical Education (ACGME) introduced "Milestones" designed to nationally standardize the assessment of resident physicians. Previous studies compare resident self-assessment on milestones to faculty assessment, with varying degrees of agreement, but integration of self-assessment into the formative feedback process has not yet been directly studied. This study uses a conceptual framework of self-determination theory, integrated with concepts from adult learning theory, to compare the perception of the feedback quality given in semiannual reviews before and after the incorporation of resident self-assessment into the feedback process. METHODS: This was an interventional study conducted in a single emergency medicine residency program at a major academic hospital over 1 calendar year. Residents first engaged in a semiannual review without self-assessment. At subsequent semiannual reviews, residents completed a Milestone-based self-assessment that was provided to the faculty member assigned to conduct their semiannual review. Residents and faculty completed surveys rating perception of feedback quality. Two-sided Wilcoxon signed-rank tests were used in comparison analysis. RESULTS: One resident did not self-assess prior to the semiannual review and was excluded leaving 25 paired surveys for analysis. Residents found feedback after the self-assessment more actionable (p = 0.013), insightful (p = 0.010), and better overall (p = 0.025). Similarly, faculty felt the feedback they provided was more actionable (p < 0.001), more insightful (p < 0.001), and better communicated (p < 0.001); led to improved resident understanding of milestones (p < 0.001); and were overall more satisfied (p < 0.001). Free-text comments explore pre- and postintervention perceptions of feedback. CONCLUSIONS: Integration of self-assessment into semiannual reviews improves perception of feedback given to residents as perceived by both residents and faculty. Although limited by sample size, the results are promising for a simple, evidence-based intervention to improve feedback during an existing mandated feedback opportunity.

High-Sensitivity Troponin T Testing for Pediatric Patients in the Emergency Department.

Debate exists on the usefulness of high-sensitivity cardiac troponin (hs-cTn) testing in pediatric patients due to the perceived low incidence of myocardial injury and lack of data concerning its efficacy. We evaluated the contribution of an increased hs-cTnT above the 99th percentile upper-reference limit (URL) to clinical diagnoses made in pediatric patients presenting to the emergency department (ED). Retrospective cohort study including patients aged 0-18 years presenting to the ED from 2018 to 2020 where hs-cTnT was measured. Sex-specific 99th percentile URLs of 15 and 10 ng/L for males and females, respectively, were used, with concentrations above these thresholds considered indicative of myocardial injury. Overall, 356 patients were identified in whom hs-cTnT concentrations were measured during ED clinical evaluation. Hs-cTnT was increased above the 99th percentile on presentation in 36 patients (10.1%). Twelve patients (3.4%) had a clinical cardiac diagnosis made. Hs-cTnT was increased in 6 of these (50.0%). Serial hs-cTnT from 106 patients with an initial hs-cTnT < 99th percentile was subsequently elevated in 5 (4.6%); none of whom had a final clinical cardiac diagnosis. Hs-cTnT has high specificity, but low sensitivity when used as a screening tool for myocardial injury when the gold standard is mostly clinical assessment. In present practice, however, they do not appear to track well with clinical diagnoses. Further studies are needed to more clearly define the role of hs-cTnT in this patient population.

Use of antitussive medications in acute cough in young children.

Acute cough, a common complaint in young children, is often the result of a viral upper respiratory infection. Cough and cold remedies generate billions of dollars in annual sales in the United States, despite a lack of evidence of their efficacy and multiple warnings by the US Food and Drug Administration. The current article begins with the best available evidence for common over-the-counter (OTC) and prescription antitussive remedies in children. The article concludes with a discussion of the pros and cons for the use of antitussives in children with cough. In general, OTC antitussive medications should not be routinely used in children under 2 years of age. In certain cases, antitussives with minimal adverse profile and some evidence of benefit may be recommended after informed counseling.

Descriptive Analysis of Components of Emergency Medicine Residency Program Websites.

INTRODUCTION: Most emergency medicine (EM) applicants use the internet as a source of information when evaluating residency programs. Previous studies have analyzed the components of residency program websites; however, there is a paucity of information regarding EM program websites. The purpose of our study was to analyze information on EM residency program websites. METHODS: In April-May 2020, we evaluated 249 United States EM residency program websites for presence or absence of 38 items relevant to EM applicants. Descriptive statistics were performed, including means and standard deviations. RESULTS: Of the 249 EM websites evaluated, the websites contained a mean of 20 of 38 items (53%). Only 16 programs (6%) contained at least three-quarters of the items of interest, and no programs contained all 38 items. The general categories with the least amount of items were social media use (9%), research (46%), and lifestyle (49%), compared to the other general categories such as application process (58%), resident information (63%), general program information (67%), and facility information (69%). The items provided by programs most often included program description (98%), blocks and rotations (91%), and faculty listing (88%). The items provided least often included housing/neighborhood information (17%) and social media links (19%). CONCLUSION: Our comprehensive review of EM residency websites in the US revealed the absence of many variables on most programs' websites. Use of this information to enhance accessibility of desired information stands to benefit both applicants and programs in the increasingly competitive specialty of EM.

Intranasal ketamine for acute pain management in children: A systematic review and meta-analysis.

STUDY OBJECTIVE: To assess the efficacy and safety of intranasal analgesic-dose ketamine as compared to intranasal fentanyl for pediatric acute pain. METHODS: A systematic review and meta-analysis was performed following the PRISMA guidelines. We searched PubMed, Embase, and Scopus databases for randomized controlled trials from inception to December 2019. We conducted meta-analysis with random-effects models to evaluate pain reduction, rescue analgesia, adverse events and sedation between intranasal ketamine and intranasal fentanyl. Random-effects models were used to estimate weighted mean differences (WMD) and pooled relative risks (RR). RESULTS: A total of 546 studies were screened and 4 trials were included. In the meta-analysis of 4 studies including 276 patients, ketamine had similar reductions in pain scores from baseline to all post-intervention times (10 to 15 min: WMD -1.42, 95% CI -9.95 to 7.10; 30 min: WMD 0.40, 95% CI -6.29 to 7.10; 60 min: WMD -0.64, 95% CI -6.76 to 5.47). Ketamine was associated with similar rates of rescue analgesia (RR 0.74, 95% CI 0.44 to 1.25). Ketamine had a higher risk of non-serious adverse events (RR 2.00, 95% CI 1.43 to 2.79), and no patients receiving ketamine had a serious adverse event. There was one serious adverse event (hypotension) with fentanyl that self-resolved. No patients receiving either IN fentanyl or ketamine had significant sedation. CONCLUSION: Intranasal analgesic-dose ketamine may be considered as an alternative to opioids for acute pain management in children. Its accepted use will depend on the tolerability of non-serious adverse events and the desire to avoid opioids.

Optimizing the workforce: a proposal to improve regionalization of care and emergency preparedness by broader integration of pediatric emergency physicians certified by the American Board of Pediatrics.

BACKGROUND: Emergency care in the United States faces notable challenges with regard to children. In some jurisdictions, available resources are not sufficient to meet local needs. Physicians with specialty training in pediatric emergency care are largely concentrated in children's medical centers within larger urban areas. Rural emergency facilities, which are more likely to face ongoing staffing shortages in all specialties, are particularly deficient in pediatric emergency medicine (PEM) physicians. This paper addresses challenges in distribution of pediatric emergency care specialists into suburban and rural health care facilities, and proposes potential local and regional solutions to improve pediatric emergency care capabilities as well as to enhance disaster response in children. OBJECTIVES: The American College of Emergency Physicians (ACEP) committee on PEM generated the objective to study and explore methods and strategies to address current challenges and shortcomings in the distribution of pediatric emergency physicians and to develop recommendations to improve access to emergency pediatric expertise in all care settings. A sub-committee was formed to generate a written report followed by full committee input. The content was reviewed by the ACEP Board of Directors. DISCUSSION: Pediatric emergency physicians are certified either by the American Board of Emergency Medicine or the American Board of Pediatrics (ABP) depending on whether their training occurred through the emergency medicine or a pediatric residency program. ABP-certified PEM that account for the majority of PEM physicians, remain largely concentrated in urban tertiary pediatric care centers, primarily children's hospitals. By contrast to the resources, the majority of pediatric patients receive emergency care in emergency departments (EDs) outside this setting. The goal of our recommendations is to help regionalize PEM expertise, allowing sharing of such resources with facilities that have traditionally not had access to PEM expertise. Financial or low number of pediatric cases likely contributed to lack of PEM resources in suburban and rural EDs, although a significant factor for lack of access to ABP-certified PEM physicians may be local privilege and practice restrictions. Expanding the scope of practice for ABP-certified PEM physicians beyond traditionally assigned arbitrary age limits to include selective adult patients has the potential to alleviate credentialing barriers and offset the financial and volume concerns while enhancing preparedness efforts, resource utilization, and access to specialized pediatric emergency care. CONCLUSION: Recognition that the training of ABP-certified PEM physicians allows for these individuals to safely care for selective adult patients with common disease patterns that extend beyond traditionally assigned arbitrary pediatric age limits has the potential to improve resource dissemination and utilization, allowing for greater access to pediatric emergency physicians in currently underserved settings.

What is the effect of a decision aid in potentially vulnerable parents? Insights from the head CT choice randomized trial.

OBJECTIVE: To test the hypotheses that use of the Head CT Choice decision aid would be similarly effective in all parent/patient dyads but parents with high (vs low) numeracy experience a greater increase in knowledge while those with low (vs high) health literacy experience a greater increase in trust. METHODS: This was a secondary analysis of a cluster randomized trial conducted at seven sites. One hundred seventy-two clinicians caring for 971 children at intermediate risk for clinically important traumatic brain injuries were randomized to shared decision making facilitated by the DA (n = 493) or to usual care (n = 478). We assessed for subgroup effects based on patient and parent characteristics, including socioeconomic status (health literacy, numeracy and income). We tested for interactions using regression models with indicators for arm assignment and study site. RESULTS: The decision aid did not increase knowledge more in parents with high numeracy (P for interaction [Pint ] = 0.14) or physician trust more in parents with low health literacy (Pint  = 0.34). The decision aid decreased decisional conflict more in non-white parents (decisional conflict scale, -8.14, 95% CI: -12.33 to -3.95; Pint  = 0.05) and increased physician trust more in socioeconomically disadvantaged parents (trust in physician scale, OR: 8.59, 95% CI: 2.35-14.83; Pint  = 0.04). CONCLUSIONS: Use of the Head CT Choice decision aid resulted in less decisional conflict in non-white parents and greater physician trust in socioeconomically disadvantaged parents. Decision aids may be particularly effective in potentially vulnerable parents.

Sertraline-Induced Rhabdomyolysis, Trismus, and Cardiac Arrest in a Child.

Selective serotonin reuptake inhibitors are a commonly used and often effective class of medications in the treatment of mood disorders such as anxiety and depression. Sertraline (1S,4S-N-methyl-4-[3,4-dichlorophenyl]-1,2,3,4-tetrahydro-1-naphthylamine [Zoloft; Pfizer, New York City, NY]) is a frequently used selective serotonin reuptake inhibitor that has shown efficacy in children, adolescents, and adults. We report the case of a 13-year-old boy with sertraline-induced rhabdomyolysis and renal failure, trismus, and cardiopulmonary arrest. Pharmacogenetic testing later revealed our patient had serotonin transporter polymorphisms and enzymatic alterations that put him at risk for increased levels of sertraline and greater likelihood for untoward side effects.

Pediatric Minor Head Injury 2.0: Moving from Injury Exclusion to Risk Stratification.

Visits for pediatric minor blunt head trauma continue to increase. Variability exists in clinician evaluation and management of this generally low-risk population. Clinical decision rules identify very low-risk children who can forgo neuroimaging. Observation before imaging decreases neuroimaging rates. Outcome data can be used to risk stratify children into more discrete categories. Decision aids improves knowledge and accuracy of risk perception and facilitates identification of caregiver preferences, allowing for shared decision making. For children in whom imaging is performed and is normal or shows isolated linear skull fractures, deterioration and neurosurgical intervention are rare and hospital admission can be avoided.

Effect of the Head Computed Tomography Choice Decision Aid in Parents of Children With Minor Head Trauma: A Cluster Randomized Trial.

Importance: The Pediatric Emergency Care Applied Research Network prediction rules for minor head trauma identify children at very low, intermediate, and high risk of clinically important traumatic brain injuries (ciTBIs) and recommend no computed tomography (CT) for those at very low risk. However, the prediction rules provide little guidance in the choice of home observation or CT in children at intermediate risk for ciTBI. Objective: To compare a decision aid with usual care in parents of children at intermediate risk for ciTBI. Design, Settings, and Participants: This cluster randomized trial was conducted in 7 geographically diverse US emergency departments (EDs) from April 1, 2014, to September 30, 2016. Eligible participants were emergency clinicians, children ages 2 to 18 years with minor head trauma at intermediate risk for ciTBI, and their parents. Interventions: Clinicians were randomly assigned (1:1 ratio) to shared decision-making facilitated by the Head CT Choice decision aid or to usual care. Main Outcomes and Measures: The primary outcome, selected by parent stakeholders, was knowledge of their child's risk for ciTBI and the available diagnostic options. Secondary outcomes included decisional conflict, parental involvement in decision-making, the ED CT rate, 7-day health care utilization, and missed ciTBI. Results: A total of 172 clinicians caring for 971 children (493 decision aid; 478 usual care) with minor head trauma at intermediate risk for ciTBI were enrolled. The patient mean (SD) age was 6.7 (7.1) years, 575 (59%) were male, and 253 (26%) were of nonwhite race. Parents in the decision aid arm compared with the usual care arm had greater knowledge (mean [SD] questions correct: 6.2 [2.0] vs 5.3 [2.0]; mean difference, 0.9; 95% CI, 0.6-1.3), had less decisional conflict (mean [SD] decisional conflict score, 14.8 [15.5] vs 19.2 [16.6]; mean difference, -4.4; 95% CI, -7.3 to -2.4), and were more involved in CT decision-making (observing patient involvement [OPTION] scores: mean [SD], 25.0 [8.5] vs 13.3 [6.5]; mean difference, 11.7; 95% CI, 9.6-13.9). Although the ED CT rate did not significantly differ (decision aid, 22% vs usual care, 24%; odds ratio, 0.81; 95% CI, 0.51-1.27), the mean number of imaging tests was lower in the decision aid arm 7 days after injury. No child had a missed ciTBI. Conclusions and Relevance: Use of a decision aid in parents of children at intermediate risk of ciTBI increased parent knowledge, decreased decisional conflict, and increased involvement in decision-making. The intervention did not significantly reduce the ED CT rate but safely decreased health care utilization 7 days after injury. Trial Registration: ClinicalTrials.gov Identifier: NCT02063087.

Pediatric Sepsis Secondary to an Occult Dental Abscess: A Case Report.

BACKGROUND: In general, hematogenous spread of bacteria in children is uncommon. Bacteremia, however, is a known complication of dental procedures and severe caries, but is infrequently associated with primary, asymptomatic, non-procedural-related, dentoalveolar infection. CASE REPORT: The patient is a 7-year-old previously healthy boy who presented to the Emergency Department (ED) with "fever, mottling, and shaking chills." In the ED, he appeared systemically ill with fever, mottling, delayed capillary refill, and rigors. Physical examination by three different physicians failed to reveal any focus of infection. Laboratory evaluation, including blood cultures, was obtained. The patient later developed unilateral facial swelling and pain, and a dentoalveolar abscess was found. He was started on antibiotics, underwent pulpectomy and eventually, extraction, prior to improvement in symptoms. Blood cultures grew two separate anaerobic bacteria (Veillonella and Lactobacillus). This is, to our knowledge, one of the first reported cases of pediatric sepsis with two different anaerobic organisms secondary to occult dentoalveolar abscess in a pediatric patient. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: It is imperative for emergency physicians to recognize the possibility of pediatric sepsis in the setting of acute maxillary or mandibular pain, as well as in patients for whom no clear focus of infection can be found. This is particularly important for those who appear ill at presentation or meet systemic inflammatory response syndrome criteria and would benefit from further laboratory evaluation, including blood cultures, and possibly antibiotic therapy.