Perceptions of gender equity in emergency medicine in Canada.

INTRODUCTION: Women-identifying emergency physicians face gender-based discrimination throughout their careers. The purpose of this study was to explore emergency physician's perceptions and experiences of gender equity in emergency medicine. METHODS: We conducted a secondary analysis of data from a previously conducted survey of Canadian emergency physicians on barriers to gender equity in emergency medicine. Survey responses were analyzed using logistic regression to determine the impact that gender, practice setting, years since graduation, race, equity-seeking status, and parental status had on agreement about gender equity in emergency medicine and five of the problem statements. RESULTS: A total of 710 participants completed the survey. Most identified as women (58.8%), white (77.4%), graduated between 2010 and 2019 (40%), had CCFP (Emergency Medicine) designation (47.9%), an urban practice (84.4%), were parents (62.4%) and did not identify as equity-seeking (79.9%). Women-identifying physicians were less likely to perceive gender equity in emergency medicine, OR 0.52, CI [0.38, 0.73]. Women-identifying physicians were more likely to agree with statements about microaggressions, OR 4.39, CI [2.66, 7.23]; barriers to leadership, OR 3.51, CI [2.25, 5.50]; gender wage gap, OR 13.46, CI [8.27, 21.91]; lack of support for parental leave, OR 2.85, CI [1.82, 4.44]; and education on allyship, OR 2.23 CI [1.44, 3.45] than men-identifying physicians. CONCLUSION: In this study, women-identifying physicians were less likely to perceive that there was gender equity in emergency medicine than men-identifying physicians. Women-identifying physicians agreed that there are greater barriers for career advancement including fewer opportunities for leadership, a gender wage gap, a lack of parental leave policies to support a return to work and a lack of education for men to become allies. Men-identifying physicians were less aware of these inequities. Health systems must work to improve gender equity in emergency medicine and this will require education and allyship from men-identifying physicians.

RéSUMé: INTRODUCTION: Les femmes médecins urgentistes sont confrontées à une discrimination fondée sur le sexe tout au long de leur carrière. L'objectif de cette étude était d'explorer les perceptions et les expériences des médecins urgentistes en matière d'équité entre les sexes en médecine d'urgence. MéTHODES: Nous avons procédé à une analyse secondaire des données d'une enquête menée précédemment auprès des médecins urgentistes canadiens sur les obstacles à l'équité entre les sexes en médecine d'urgence. Les réponses au sondage ont été analysées à l'aide d'une régression logistique pour déterminer l'incidence que le sexe, le milieu de pratique, les années écoulées depuis l'obtention du diplôme, la race, le statut de demandeur d'équité et le statut parental avaient sur l'accord sur l'équité entre les sexes en médecine d'urgence et cinq des énoncés de problème. RéSULTATS: Au total, 710 participants ont répondu à l'enquête. La plupart d'entre eux sont des femmes (58.8 %), de race blanche (77.4 %), ont obtenu leur diplôme entre 2010 et 2019 (40 %), ont le titre de CCMF (médecine d'urgence) (47.9 %), exercent en milieu urbain (84.4 %), sont parents (62.4 %) et ne se déclarent pas en quête d'équité (79.9 %). Les médecins s'identifiant à des femmes étaient moins susceptibles de percevoir l'équité entre les sexes en médecine d'urgence, OR 0.52, IC [0.38,0.73]. Les médecins s'identifiant comme femmes étaient plus susceptibles d'être d'accord avec les déclarations sur les microagressions, OR 4.39, IC [2.66, 7.23] ; obstacles au leadership, OR 3.51, IC [2.25, 5.50] ; écart salarial entre les hommes et les femmes, OR 13.46, IC [8.27, 21.91] ; le manque de soutien pour le congé parental, OR 2.85, IC [1.82, 4.44]; et l'éducation sur l'alliance, OR 2.23 IC [1.44, 3.45] que les médecins s'identifiant comme hommes. CONCLUSION: Dans cette étude, les médecins s'identifiant à des femmes étaient moins susceptibles de percevoir qu'il y avait une équité entre les sexes en médecine d'urgence que les médecins s'identifiant à des hommes. Les femmes médecins s'accordent à dire qu'il existe davantage d'obstacles à l'avancement professionnel, notamment moins d'opportunités de leadership, un écart salarial entre les hommes et les femmes, un manque de politiques de congé parental pour favoriser le retour au travail et un manque d'éducation des hommes pour qu'ils deviennent des alliés. Les médecins s'identifiant à des hommes étaient moins conscients de ces inégalités. Les systèmes de santé doivent s'efforcer d'améliorer l'équité entre les sexes dans la médecine d'urgence, ce qui nécessitera une formation et un allié de la part des médecins qui s'identifient aux hommes.

Using Natural Language Processing to Evaluate the Quality of Supervisor Narrative Comments in Competency-Based Medical Education.

PURPOSE: Learner development and promotion rely heavily on narrative assessment comments, but narrative assessment quality is rarely evaluated in medical education. Educators have developed tools such as the Quality of Assessment for Learning (QuAL) tool to evaluate the quality of narrative assessment comments; however, scoring the comments generated in medical education assessment programs is time intensive. The authors developed a natural language processing (NLP) model for applying the QuAL score to narrative supervisor comments. METHOD: Samples of 2,500 Entrustable Professional Activities assessments were randomly extracted and deidentified from the McMaster (1,250 comments) and Saskatchewan (1,250 comments) emergency medicine (EM) residency training programs during the 2019-2020 academic year. Comments were rated using the QuAL score by 25 EM faculty members and 25 EM residents. The results were used to develop and test an NLP model to predict the overall QuAL score and QuAL subscores. RESULTS: All 50 raters completed the rating exercise. Approximately 50% of the comments had perfect agreement on the QuAL score, with the remaining resolved by the study authors. Creating a meaningful suggestion for improvement was the key differentiator between high- and moderate-quality feedback. The overall QuAL model predicted the exact human-rated score or 1 point above or below it in 87% of instances. Overall model performance was excellent, especially regarding the subtasks on suggestions for improvement and the link between resident performance and improvement suggestions, which achieved 85% and 82% balanced accuracies, respectively. CONCLUSIONS: This model could save considerable time for programs that want to rate the quality of supervisor comments, with the potential to automatically score a large volume of comments. This model could be used to provide faculty with real-time feedback or as a tool to quantify and track the quality of assessment comments at faculty, rotation, program, or institution levels.

GridlockED as an Intervention for Nurses (GAAIN) Study.

BACKGROUND: GridlockED (The Game Crafter, LLC) is a serious game that was developed to teach challenges that face nursing and medical professionals in the emergency department (ED). However, few studies have explored nurses' perceptions of the utility, fidelity, acceptability, and applicability of the serious game modality. This study examined how ED nurses view GridlockED as a continuing education platform. METHOD: This single-center observational study explored how nurses engage with and respond to Grid-lockED. The convenience sample included participants recruited from a local continuing nursing education day. Participants completed a presurvey, engaged in a full game play session with the GridlockED game for approximately 45 minutes, and immediately completed a post-game play survey. RESULTS: Of the 48 participants (11 male, 37 female; 44 of 48 were RNs), most (91%) agreed that the workflow reflected in the game was equivalent to the flow in a typical ED. Almost all (96%) found the cases in the game reflective of real ED patients, and most (92%) found the game a useful educational tool to prepare new nurses to transition into the ED environment. CONCLUSION: The GridlockED game shows potential as a serious game to support nursing education, particularly for new ED nurse orientation and transition to ED practice. [J Contin Educ Nurs. 2024;55(5):231-238.].

Was Virtual Care as Safe as In-Person Care? Analyzing Patient Outcomes at Seven and Thirty Days in Ontario during the COVID-19 Pandemic.

In 2020, almost overnight, the paradigm for healthcare interactions changed in Ontario. To limit person-to-person transmission of COVID-19, the norm of in-person interactions shifted to virtual care. While this shift was part of broader public health measures and an acknowledgment of patient and societal concerns, it also represented a change in care modalities that had the potential to affect the quality of care provided, as well as short- and long-term patient outcomes. While public policy decisions were being made to moderate the use of virtual care at the end of the declared pandemic, a thorough analysis of short-term patient outcomes was needed to quantify the impact of virtual care on the population of Ontario.

Prevalence and characterization of food insecurity in a Canadian paediatric emergency department.

Objectives: Food insecurity (FI) is associated with a number of adverse child health outcomes and increased emergency department (ED) use. The COVID-19 pandemic exacerbated the financial hardship faced by many families. We sought to determine the prevalence of FI among children with ED visits, compare this to pre-pandemic rates, and describe associated risk factors. Methods: From September to December 2021, families presenting to a Canadian paediatric ED were asked to complete a survey screening for FI along with health and demographic information. Results were compared to data collected in 2012. Multivariable logistic regression was used to measure associations with FI. Results: In 2021, 26% (n = 173/665) of families identified as food insecure compared to 22.7% in 2012 (n = 146/644) a difference of 3.3% (95% CI [-1.4%, 8.1%]). In multivariable analysis, greater number of children in the home (OR 1.19, 95% CI [1.01, 1.41]), financial strain from medical expenses (OR 5.31, 95% CI [3.45, 8.18]), and a lack of primary care access (OR 1.27, 95% CI [1.08, 1.51]) were independent predictors of FI. Less than half of families with FI reported use of food charity, most commonly food banks, while one-quarter received help from family or friends. Families experiencing FI expressed a preference for support through free or low-cost meals and financial assistance with medical expenses. Conclusion: More than one in four families attending a paediatric ED screened positive for FI. Future research is needed to examine the effect of support interventions for families assessed in medical care facilities including financial support for those with chronic medical conditions.

From Innovation to Intrapreneurship: Fostering academic success via the GridlockED project and innovation fund.

Background: Funding for educational innovations is increasingly scarce in academic medicine. While there is some funding for medical education research, this is often for discovery or application work, and there are few avenues for those with a heavy innovation focus to fund early work. Objective of the Innovation: The objective was to develop an intrapreneurial unit focused on medical education projects and scholarship. Development Process and Implementation: The GridlockED and TriagED games are educational or serious games that seek to teach health care learners about emergency medicine processes. Both games were cocreated with learners and brought to market in the past 3 years. All of the proceeds from the sales of these games have been accrued over time to create a new innovation fund. This fund seeks to support trainees and early career educators in their medical education projects. Outcomes: Sales for GridlockED began in March 2018 and the TriagED began in November 2019. In the first year, sales for GridlockED yielded a total of $9,534. After 18 months of sales, the fund has accrued a total of $14,530. The fund has helped finance the development of new games. Additionally, the fund awarded two internal $500 Kickstarter grants to assist with evaluating and improving two local education projects. The GridlockED and TriagED games have also spurred multiple academic opportunities for junior educators interested in this domain: five workshops, eight conference abstracts, two peer-reviewed papers, and two research protocols are being developed. Conclusions: The GridlockED and TriagED games represent a new academically oriented, intrapreneurial approach to medical education work.

Factors influencing HINTS exam usage by Canadian Emergency Medicine Physicians.

OBJECTIVES: The HINTS examination (head impulse, nystagmus, test of skew) is a bedside physical examination technique that can distinguish between vertigo due to stroke, and more benign peripheral vestibulopathies. Uptake of this examination is low among Emergency Medicine (EM) physicians; therefore, we surveyed Canadian EM physicians to determine when the HINTS exam is employed, and what factors account for its low uptake. METHODS: We designed and tested a 26-question online survey, and disseminated it via email to EM physicians registered with the Canadian Association of Emergency Physicians (CAEP), with 3 and 5-week reminder emails to increase completion. This anonymous survey had no incentives for participation, and was completed by 185 EM physicians, with post-graduate medical training in either Emergency Medicine or Family Medicine. The primary outcomes were the frequencies of various responses to survey questions, with secondary outcomes being the associations between participant characteristics and given responses. RESULTS: 88 respondents (47.8%) consistently use the HINTS examination in the work-up of vertigo, and 117 (63.7%) employ it in scenarios where its clinical utility is limited. The latter is more common among physicians working in non-academic settings, without 5-year EM residency training, and with greater years of practice (p < 0.01). The most frequent explanations for non-use were a lack of need for the HINTS examination, the lack of validation of the exam among EM physicians, and concerns surrounding the head-impulse test. CONCLUSIONS: Though HINTS exam usage is common, there is a need for education on when to apply it, and how to do so, particularly as concerns the head-impulse test. Our attached rubric may assist with this, but quality-improvement initiatives are warranted. Low uptake is partly due to the lack of validation of this examination among EM physicians, so effort should be made to conduct well-designed HINTS trials exclusively involving EM physicians.

RéSUMé: OBJECTIFS: L'examen HINTS (head impulse, nystagmus, test of skew) est une technique d'examen physique au chevet du patient qui permet de distinguer les vertiges dus à un accident vasculaire cérébral des vestibulopathies périphériques plus bénignes. Cet examen est peu pratiqué par les médecins en médecine d'urgence (MU). Nous avons donc mené une enquête auprès des médecins d'urgence canadiens afin de déterminer quand l'examen HINTS est utilisé et quels sont les facteurs qui expliquent sa faible utilisation. MéTHODES: Nous avons conçu et testé une enquête en ligne de 26 questions, et l'avons diffusée par courriel aux médecins urgentistes inscrits à l'Association canadienne des médecins d'urgence (ACMU), avec des courriels de rappel de trois et cinq semaines pour augmenter le taux de réponse. Cette enquête anonyme, qui ne comportait aucune incitation à la participation, a été remplie par 185 médecins de médecine d'urgence ayant suivi une formation médicale postuniversitaire en médecine d'urgence ou en médecine familiale. Les résultats primaires étaient les fréquences des diverses réponses aux questions de l'enquête, les résultats secondaires étant les associations entre les caractéristiques des participants et les réponses données. RéSULTATS: 88 répondants (47,8 %) utilisent systématiquement l'examen HINTS dans l'évaluation des vertiges, et 117 (63,7 %) l'emploient dans des scénarios où son utilité clinique est limitée. Cette dernière est plus fréquente chez les médecins travaillant dans des établissements non universitaires, n'ayant pas suivi une formation de 5 ans en résidence en médecine d'urgence et ayant un plus grand nombre d'années de pratique (p < 0,01). Les explications les plus fréquentes de la non-utilisation étaient le manque de nécessité de l'examen HINTS, le manque de validation de l'examen parmi les médecins de médecine d'urgence et les préoccupations concernant le test d'impulsion de la tête. CONCLUSIONS: Bien que l'utilisation de l'examen HINTS soit courante, il existe un besoin d'éducation sur le moment où il faut l'appliquer et sur la manière de le faire, en particulier en ce qui concerne le test d'impulsion de la tête. Notre rubrique ci-jointe peut vous aider à cet égard, mais des initiatives d'amélioration de la qualité sont justifiées. Le faible taux d'utilisation est en partie dû au manque de validation de cet examen parmi les médecins de la médecine d'urgence. Il faut donc s'efforcer de mener des essais HINTS bien conçus impliquant exclusivement des médecins de la médecine d'urgence.

Priority strategies to improve gender equity in Canadian emergency medicine: proceedings from the CAEP 2021 Academic Symposium on leadership.

OBJECTIVES: Gender inequities are deeply rooted in our society and have significant negative consequences. Female physicians experience numerous gender-related inequities (e.g., microaggressions, harassment, violence). These inequities have far-reaching consequences on health, well-being and career longevity and may result in the devaluing of various strengths that female emergency physicians bring to the table. This, in turn, has an impact on patient healthcare experience and outcomes. During the 2021 Canadian Association of Emergency Physicians (CAEP) Academic Symposium, a national collaborative sought to understand gender inequities in emergency medicine in Canada. METHODS: We used a multistep stakeholder-engagement-based approach (harnessing both quantitative and qualitative methods) to identify and prioritize problems with gender equity in emergency medicine in Canada. Based on expert consultation and literature review, we developed recommendations to effect change for the higher priority problems. We then conducted a nationwide consultation with the Canadian emergency medicine community via online engagement and the CAEP Academic Symposium to ensure that these priority problems and solutions were appropriate for the Canadian context. CONCLUSION: Via the above process, 15 recommendations were developed to address five unique problem areas. There is a dearth of research in this important area and we hope this preliminary work will serve as a starting point to fuel further research. To facilitate these scholarly endeavors, we have appended additional documents identifying other key problems with gender equity in emergency medicine in Canada as well as proposed next steps for future research.

RéSUMé: OBJECTIFS: Les inégalités entre les sexes sont profondément ancrées dans notre société et ont des conséquences négatives importantes. Les femmes médecins subissent de nombreuses inégalités liées au genre (par exemple, microagressions, harcèlement, violence). Ces inégalités ont des conséquences considérables sur la santé, le bien-être et la longévité de la carrière et peuvent entraîner la dévalorisation des différents atouts que les femmes médecins urgentistes apportent à la table. Ceci, à son tour, a un impact sur l'expérience et les résultats des soins de santé des patients. Au cours du Symposium académique 2021 de l'Association canadienne des médecins d'urgence (ACMU), une collaboration nationale a cherché à comprendre les inégalités entre les sexes en médecine d'urgence au Canada. MéTHODES: Nous avons utilisé une approche en plusieurs étapes basée sur l'engagement des parties prenantes (en utilisant des méthodes quantitatives et qualitatives) pour identifier et classer par ordre de priorité les problèmes d'équité entre les sexes en médecine d'urgence au Canada. À partir d'une consultation d'experts et d'une revue de la littérature, nous avons élaboré des recommandations visant à apporter des changements aux problèmes les plus prioritaires. Nous avons ensuite mené une consultation nationale auprès de la communauté canadienne de médecine d'urgence par le biais d'un engagement en ligne et du symposium universitaire de l'ACMU afin de nous assurer que ces problèmes prioritaires et ces solutions étaient adaptés au contexte canadien. CONCLUSION: Grâce au processus ci-dessus, 15 recommandations ont été élaborées pour traiter 5 domaines problématiques uniques. Il existe un manque de recherche dans ce domaine important et nous espérons que ce travail préliminaire servira de point de départ pour alimenter d'autres recherches. Pour faciliter ces efforts de recherche, nous avons annexé d'autres documents identifiant d'autres problèmes clés en matière d'équité entre les sexes en médecine d'urgence au Canada, ainsi que des propositions d'étapes pour de futures recherches.

Seeing potential opportunities for teaching (SPOT): Evaluating a bundle of interventions to augment entrustable professional activity acquisition.

INTRODUCTION: Within the Canadian competency-based medical education system, entrustable professional activities (EPAs) are used to assess residents on performed clinical duties. This study aimed to determine whether implementing a bundle of two interventions (a case-based discussion intervention and a rotation-based nudging system) could increase the number of EPA assessments that could occur for our trainees. METHODS: The authors designed an intervention bundle with two components: 1) a case-based workshop where trainees discussed which EPAs could be assessed with multiple cases and 2) a nudging system wherein each trainee was reminded of EPAs that would be useful to them on each rotation in their first year. We conducted a retrospective program evaluation to compare the intervention cohort (2019) to two historical cohorts using similar EPAs (2017, 2018). RESULTS: Data from 22 trainees (seven in 2017, eight in 2018, and seven in 2019) were analyzed. There was a marked increase in the total number of EPA assessments acquired in the 2019 cohort (average per resident = 285.7, 95% confidence interval [CI] = 256.1 to 312.3, range = 195-350) compared to the two other years (2018 [average = 132.4, 95% CI = 107.5 to 157.02, range = 107-167] and 2017 [70.1, 95% CI 45.3 to 91.0, range = 49-95]), yielding an effect size of Cohen's d = 4.02 for our intervention bundle. CONCLUSIONS: Within the limitations of a small sample size, there was a strong effect of introducing two interventions (a case-based orientation and a nudging system) upon EPA assessments with PGY-1 residents. These strategies may be useful to others seeking to improve EPA assessment numbers in other specialties and clinical environments.

Parental Leave Policies in Canadian Residency Education.

BACKGROUND: In recent decades, the gender makeup of Canadian medical residents has approached parity. As residency training years coincide closely with childbearing years and paid parental leave is associated with numerous benefits for both parents and children, it is important for there to be clarity about parental leave benefits. OBJECTIVES: We aimed to conduct a comprehensive review of maternity and parental leave policies in all residency education programs in Canada, to highlight gaps that might be improved or areas in which Canadian programs excel. METHODS: We searched websites of the 8 provincial housestaff organizations (PHOs) for information regarding pregnancy workload accommodations, maternity leave, and parental leave policies in each province in effect as of January 2020. We summarized the policies and analyzed their readability using the Flesch Reading Ease. RESULTS: All Canadian PHOs provide specific accommodations around maternity and parental leave for medical residents. All organizations offer at least 35 weeks of total leave, while only 3 PHOs offer extended leave of about 63 weeks, in line with federal regulations. All but 2 PHOs offer supplemental income to their residents, although not for the full duration of offered leave. All PHOs offer workplace accommodations for pregnant residents in their second and/or third trimester. CONCLUSIONS: Although all provinces had some form of leave, significant variability was found in the accommodations, duration of leave, and financial benefits provided to medical residents on maternity and parental leave across Canada. There is a lack of clarity in policy documents, which may be a barrier to optimal uptake.

Faculty-lead Opinions on Workplace-based Methods for Graduated Managerial Teaching (FLOW MGMT): A National Cross-sectional Survey of Canadian Emergency Medicine Lead Educators.

OBJECTIVES: Patient volumes are increasing in emergency departments (ED), causing issues with long wait times and overcrowding. One strategy to cope with this phenomenon is to focus on improving patient flow through the ED. Building on earlier work that identified how staff physicians manage flow and what techniques they employ to teach managerial skills to residents, we aimed to determine when it was most appropriate to implement these teaching strategies in a resident's training. METHODS: We employed a Canada-wide cross-sectional survey of experienced emergency medicine (EM) teaching faculty to determine when they felt our previously identified teaching strategies would be appropriate to implement. The survey was piloted with local educational experts. RESULTS: A total of 21 EM (38% female, 62% male) educators from 11 programs responded to the survey. The respondents provided an average of 42.5 endorsements per participant for specific teaching techniques across the stages of training. The core of discipline (35.9%) and transition to practice (39.7%) were the stages of training that received the most endorsement. The top two teaching techniques included the observational teaching technique "attitudinal role modeling (i.e. a strong work ethic)" and the conversational teaching technique "teacher provides clinical pearls, tips, pointers." The participants showed fairly high agreement, with the advanced in situ techniques showing fairly high reliability as measured by intraclass correlation coefficients ranging from 0.88 to 0.90. CONCLUSIONS: Our results show a trend toward faculty utilizing more didactic and observational teaching techniques early in residency and then progressing toward more experiential techniques in the senior stages of training. This is consistent with a graduated increase in responsibility as residents demonstrate competency and progress through their training. The results of this study will help inform faculty development around teaching managerial skills in the area of competency-based medical education.

Just the Facts: how to teach emergency department flow management.

Even before starting your evening shift you know it's going to be busy. Ambulances are lined up in front of the hospital, and the charge nurse already seems stressed out. The senior Emergency Medicine (EM) resident is standing in the physician office, ready to start her shift as well. You have worked with her a few times during this rotation. She is competent, you trust in her management plans for all her individual patients. Together you both review the patient tracker: a variety of patient presentations ready to be seen, plus an additional 20 patients in the waiting room. Negotiating the learning objective for the shift, the resident indicates that she would like to work on more efficiently managing patient flow and the administration of the emergency department (ED). But…isn't that a skill you just learn from experience? You wonder what evidence-informed strategies might exist for training her for this next step.

Creating GridlockED: A Serious Game for Teaching About Multipatient Environments.

PROBLEM: As patient volumes increase, it is becoming increasingly important to find novel ways to teach junior medical learners about the intricacies of managing multiple patients simultaneously and about working in a resource-limited environment. APPROACH: Serious games (i.e., games not intended purely for fun) are a teaching modality that have been gaining momentum as teaching tools in medical education. From May 2016 to August 2017, the authors designed and tested a serious game, called GridlockED, to provide a focused educational experience for medical trainees to learn about multipatient care and patient flow. The game allows as many as six people to play it at once. Gameplay relies on the players working collaboratively (as simulated members of a medical team) to triage, treat, and disposition "patients" in a manner that simulates true emergency department operations. After researching serious games, the authors developed the game through an iterative design process. Next, the game underwent preliminary peer review by experienced gamers and practicing clinicians, whose feedback the authors used to adjust the game. Attending physicians, nurses, and residents have tested GridlockED for usability, fidelity, acceptability, and applicability. OUTCOMES: On the basis of initial testing, clinicians suggest that this game will be useful and has fidelity for teaching patient-flow concepts. NEXT STEPS: Further play testing will be needed to fully examine learning opportunities for various populations of trainees and for various media. GridlockED may also serve as a model for developing other games to teach about processes in other environments or specialties.

Exploring Policy Change in the Emergency Department: A Qualitative Approach to Understanding Local Policy Creation and the Barriers to Implementing Change.

Introduction With thousands of new medical trials released every year, health care policymakers must work diligently to incorporate new evidence into clinical practice. Although there are some broad conceptual frameworks for knowledge translation in the emergency department (ED), there are few user-centered studies that illustrate how local policymakers develop and disseminate new policies. Objectives Our study sought to evaluate the process by which new departmental policies are formed in ED, how new evidence was integrated into this process, and to explore barriers to implementation. Methods Semi-structured interviews were conducted with local administrators from nine major hospitals in Ontario, Canada. Interviews were transcribed and qualitative data was analyzed using constructivist grounded theory. Results Five broad steps in the policy creation process were identified: 1) Problem identification and motivation for change; 2) building a policy team; 3) policy construction; 4) implementation and monitoring of new departmental policies; 5) actively addressing barriers to the ED policymaking process. Common sub-themes in each of these categories were highlighted. Four main themes also emerged regarding barriers experienced in policymaking: Education and knowledge transfer; lack of a change culture; resource limitations; and cumbersome bureaucratic structures. Conclusion Our study identified common facilitators and barriers that policymakers face in their ability to create health policy in the ED. While local context influences the policymaking process, a standardized framework would ensure a more systematic approach for policymakers and allow scientists to better understand how evidence is integrated at the local level.

Resident Development via Progress Testing and Test-Marking: An Innovation and Program Evaluation.

INTRODUCTION: Since 2008, the McMaster University Royal College Emergency Medicine residency training program has run practice Short Answer Question (SAQ) examinations to help residents test their knowledge and gain practice in answering exam-style questions. However, marking this type of SAQ exam is time-consuming. METHODS: To help address this problem, we require that senior residents help mark at least one exam per year alongside faculty members. Examinees' identities are kept anonymous by assigning a random number to each resident, which is only decoded after marking. Aggregation of marks is done by faculty only. The senior residents and faculty members all share sequential marking of each question. Each question is reviewed, and exemplar "best practice" answers are discussed. As novel/unusual answers appear, instantaneous fact-checking (via textbooks, or the internet) and discussions occur allowing for real-time modification to the answer keys as needed. RESULTS: A total of 22 out of 37 residents (post graduate year 1 to post graduate year 5 (PGY1 to PGY5)) participated in a recent program evaluation focus group. This evaluation showed that residents feel quite positive about this process. With the anonymization process, residents do not object to their colleagues seeing and marking their answers. Senior residents have found this process informative and have felt that this process helps them gain insight into better "examsmanship." CONCLUSIONS: Involving residents in marking short-answer exams is acceptable and perceived as useful experience for improving exam-taking skills. More studies of similar innovations would be required to determine to what extent this may be the case.