What You Didn't Learn in Residency: A Collective Curriculum for New Academic EM Faculty and Fellows.

Audience and Type of Curriculum: This curriculum is designed for emergency medicine fellows and first-year junior faculty. The curriculum covers core topics related to academic and professional success for an early career faculty member. Length of Curriculum: The curriculum is designed as quarterly sessions over the course of one academic year. Introduction: An increasing number of emergency medicine graduates are pursuing fellowship after completion of residency.1 Fellowship can be challenging as newly minted graduates begin to explore their academic niche, refine their clinical practice, and define their personal and professional spheres. We propose a structured curriculum to help guide fellows and new faculty to mitigate these challenges. Educational Goals: The aim of this curriculum is to develop relevant skills to promote academic success for fellows and first-year faculty at the start of their academic career and which could be completed during a one-year training timeline. We included topics relevant to all fellow and new faculty's expected personal and professional journey during this first year, including time management, academic productivity, resilience/wellness, and developing a national reputation. Educational Methods: The educational strategies used in this curriculum consist primarily of lecture seminars. There is one short individual activity associated with the lectures and one small group discussion. Research Methods: The course was assessed with pre- and post-test surveys following each lecture. Surveys assessed participants' reaction, learning, and behavior for each session. Evaluations were completed based on a 5-point Likert scale (1=strongly disagree, 5=strongly agree). Results: Fifteen participants attended the seminar series encompassing fellows and first-year faculty/post-fellows from ten different fellowship subspecialities. Average pre-assessment scores were low for many of the self-reported skills and confidence throughout the seminar series. Overall, participants reported increased confidence on the post-test for each of the seminar topics. In addition, participants reported that they learned new skills and planned to use the new ideas presented. All participants reported they would recommend these seminars to someone else on their same career path. Discussion: Overall, participants reported increased confidence, new skills, and plans to use the ideas presented in the seminar series. The content appears applicable to this learner set since all reported they would recommend the series to others on their career path. In conclusion, we believe our seminar series will build skills for fellows and first-year faculty which will promote academic success. Topics: Academic success, professional development, early career development.

Documentation from trained medical students has a low rate of relative downcoding for emergency medicine encounters.

Background: Since 2018, the Centers for Medicare & Medicaid Services (CMS) guidelines have allowed teaching physicians to bill for evaluation and management services based on medical student documentation. Limited previous data suggest that medical student documentation suffers from a high rate of downcoding relative to faculty documentation. We sought to compare the coding outcomes of documentation performed by medical students, and not edited by faculty, with documentation edited and submitted by faculty. Methods: A total of 104 randomly selected notes from real patient encounters written by senior medical students were compared to the revised notes submitted by faculty. The note pairs were then split and reviewed by blinded professional coders and assigned level of service (LoS) codes 1-5 (corresponding to E&M CPT codes 99281-99285). Results: We found that the LoS agreement between student and faculty note versions was 63%, with 23% of all student notes receiving lower LoS compared to faculty notes (downcoded). This was found to be similar to baseline variability in professional coder LoS designations. Conclusions: Notes from medical students who have completed a focused documentation curriculum have less LoS downcoding than in previous reports.

Changing Medical Education When Change Is Hard: Implementing an Interdepartmental Entrustable Professional Activity.

BACKGROUND: Entrustable professional activities (EPAs) are a new tool for assessing learners that represents a significant movement in graduate medical education (GME) toward competency-based assessment and serves as a bridge between milestones and clinical practice. Whenever a major change is implemented to any system, resistance to change is expected. Many change management models have been proposed to overcome this resistance; a newer model is outlined in the book Switch. The objective was to describe the change management principles used to institute an EPA. METHODS: The model introduced in Switch was used as a framework for implementing a trauma resuscitation EPA in a joint effort between the departments of surgery and emergency medicine (EM) at the University of Wisconsin Hospitals and Clinics. The Department of Emergency Medicine used the principles of change management, completing 295 faculty evaluations of trauma resuscitations compared to the Department of Surgery, whose faculty completed 50 evaluations between the study period of July 2018 through October 2019. A survey completed winter 2019 of EM faculty was used to determine the most important principles toward successful implementation. RESULTS: Twenty-seven of 35 (78% response rate) of EM faculty identified key concepts from Switch as being instrumental in the successful implementation. Internal discussion of the implementation approach used by the Department of Surgery identified several limitations that would have been overcome by using these same change management principles. CONCLUSION: We conclude that the principles of change management provide a useful framework for successfully implementing EPAs into GME.

Natural language processing and entrustable professional activity text feedback in surgery: A machine learning model of resident autonomy.

BACKGROUND: Entrustable Professional Activities (EPAs) contain narrative 'entrustment roadmaps' designed to describe specific behaviors associated with different entrustment levels. However, these roadmaps were created using expert committee consensus, with little data available for guidance. Analysis of actual EPA assessment narrative comments using natural language processing may enhance our understanding of resident entrustment in actual practice. METHODS: All text comments associated with EPA microassessments at a single institution were combined. EPA-entrustment level pairs (e.g. Gallbladder Disease-Level 1) were identified as documents. Latent Dirichlet Allocation (LDA), a common machine learning algorithm, was used to identify latent topics in the documents associated with a single EPA. These topics were then reviewed for interpretability by human raters. RESULTS: Over 18 months, 1015 faculty EPA microassessments were collected from 64 faculty for 80 residents. LDA analysis identified topics that mapped 1:1 to EPA entrustment levels (Gammas >0.99). These LDA topics appeared to trend coherently with entrustment levels (words demonstrating high entrustment were consistently found in high entrustment topics, word demonstrating low entrustment were found in low entrustment topics). CONCLUSIONS: LDA is capable of identifying topics relevant to progressive surgical entrustment and autonomy in EPA comments. These topics provide insight into key behaviors that drive different level of resident autonomy and may allow for data-driven revision of EPA entrustment maps.

Entrustable Professional Activities in General Surgery: Trends in Resident Self-Assessment.

OBJECTIVE: Effective self-assessment is a cornerstone of lifelong professional development; however, evidence suggests physicians have a limited ability to self-assess. Novel strategies to improve the accuracy of learner self-assessment are needed. Our institution's surgical entrustable professional activity (EPA) implementation strategy incorporates resident self-assessment to address this issue. This study evaluates the accuracy of resident self-assessment versus faculty assessment across 5 EPAs in general surgery. DESIGN, SETTING, PARTICIPANTS: Within a single academic general surgery residency program, assessment data for 5 surgery EPAs was prospectively collected using a mobile application. Matched assessments (resident and faculty assessments for the same clinical encounter) were identified and the remainder excluded. Assessment scores were compared using Welch's t test. Agreement was analyzed using Cohen's kappa with squared weights. RESULTS: One thousand eight hundred and fifty-seven EPA assessments were collected in 17 months following implementation. One thousand one hundred and fifty-five (62.2%) were matched pairs. Residents under-rated their own performance relative to faculty assessments (2.36 vs 2.65, p < 0.01). This pattern held true for all subsets except for Postgraduate Year (PGY)2 residents and Inguinal Hernia EPAs. There was at least moderate agreement between matched resident and faculty EPA assessment scores (κ = 0.57). This was consistent for all EPAs except Trauma evaluations, which were completed by faculty from 2 different departments. Surgery resident self-assessments more strongly agreed with Surgery faculty assessments than Emergency Medicine faculty assessments (κ = 0.58 vs 0.36). CONCLUSIONS: Resident EPA self-assessments are equivalent or slightly lower than faculty assessments across a wide breadth of clinical scenarios. Resident and faculty matched assessments demonstrate moderate agreement.

Use of graded responsibility and common entrustment considerations among United States emergency medicine residency programs.

PURPOSE: The Accreditation Council for Graduate Medical Education (ACGME) requires all residency programs to provide increasing autonomy as residents progress through training, known as graded responsibility. However, there is little guidance on how to implement graded responsibility in practice and a paucity of literature on how it is currently implemented in emergency medicine (EM). We sought to determine how emergency medicine (EM) residency programs apply graded responsibility across a variety of activities and to identify which considerations are important in affording additional responsibilities to trainees. METHODS: We conducted a cross-sectional study of EM residency programs using a 23-question survey that was distributed by email to 162 ACGME-accredited EM program directors. Seven different domains of practice were queried. RESULTS: We received 91 responses (56.2% response rate) to the survey. Among all domains of practice except for managing critically ill medical patients, the use of graded responsibility exceeded 50% of surveyed programs. When graded responsibility was applied, post-graduate year (PGY) level was ranked an "extremely important" or "very important" consideration between 80.9% and 100.0% of the time. CONCLUSION: The majority of EM residency programs are implementing graded responsibility within most domains of practice. When decisions are made surrounding graded responsibility, programs still rely heavily on the time-based model of PGY level to determine advancement.

Implementation of Entrustable Professional Activities into a General Surgery Residency.

OBJECTIVE: Concerns over resident ability to practice effectively after graduation have led to the competency-based medical education movement. Entrustable professional activities (EPAs) may facilitate competency-based medical education in surgery, but implementation is challenging. This manuscript describes 1 strategy used to implement EPAs into an academic general surgery residency. DESIGN, SETTING, PARTICIPANTS: A mobile application was developed incorporating 5 EPAs developed by the American Board of Surgery; residents and faculty from the Departments of Surgery, Emergency Medicine, and Hospital Medicine at a single tertiary care center were trained in its use. Entrustment levels and free text feedback were collected. Self-assessment was paired with supervisor assessment, and faculty assessments were used to inform clinical competency committee entrustment decisions. Feedback was regularly solicited from app users and results distributed on a monthly basis. RESULTS: One thousand seven hundred and twenty microassessments were collected over the first 16 months of implementation; 898 (47.8%) were performed by faculty with 569 (66.0%) matched pairs. Engagement was skewed with small numbers of high performers in both resident and faculty groups. Continued development of resident and faculty was required to sustain engagement with the program. Nonsurgical specialties contributed significantly to resident assessments (496, 28.8%). CONCLUSIONS: EPAs are being successfully integrated into the assessment framework at our institution. EPA implementation in surgery residency is a long-term process that requires investment, but may address limitations in the current assessment framework.

Misunderstanding the Match: Do Students Create Rank Lists Based on True Preferences?

INTRODUCTION: The "stable marriage" algorithm underlying the National Residency Match Program (NRMP) has been shown to create optimal outcomes when students submit true preference lists. Previous research has shown students may allow external information to affect their rank lists. The objective of this study was to determine whether medical students consistently make rank lists that reflect their true preferences. METHODS: A voluntary online survey was sent to third-year students at a single midwestern medical school. Students were given hypothetical scenarios that either should or should not affect their true residency preferences and rated the importance of six factors to their final rank list. The survey was edited by a group of education scholars and revised based on feedback from a pilot with current postgraduate year 1 residents. RESULTS: Of 175 students surveyed, 140 (80%) responded; 63% (88/140) reported that their "perceived competitiveness" would influence their rank list at least a "moderate amount. Of 135 students, 31 (23%) moved a program lower on their list if they learned they were ranked "low" by that program, while 6% (8/135) of respondents moved a program higher if they learned they were ranked "at the top of the list." Participants responded similarly (κ = 0.71) when presented with scenarios asking what they would do vs what a classmate should do. CONCLUSION: Students' hypothetical rank lists did not consistently match their true residency preferences. These results may stem from a misunderstanding of the Match algorithm. Medical schools should consider augmenting explicit education related to the NRMP Match algorithm to ensure optimal outcomes for students.

Assessing Residency Applicants' Communication and Professionalism: Standardized Video Interview Scores Compared to Faculty Gestalt.

INTRODUCTION: The Association of American Medical Colleges has introduced the Standardized Video Interview (SVI) to assess the communication and professionalism skills of residency applicants to allow a more holistic view of applicants beyond academic performance. Initial data suggests scores are not correlated with academic performance and provide a new measure of applicant attributes. It is not currently known how the SVI compares to existing metrics for assessing communication and professionalism during the interview process. METHODS: Applicants to the University of Wisconsin Emergency Medicine Residency program were invited and interviewed without use of the SVI scores or videos. All faculty interviewers were blinded to applicants' SVI information and asked to rate each applicant on their communication and professionalism on a scale from 1-25 (faculty gestalt score), analogous to the 6-30 scoring used by the SVI. We transformed SVI scores to our 1-25 system (transformed SVI score) for ease of comparison and compared them to faculty gestalt scores as well as applicants' overall score for all components of their interview day (interview score). RESULTS: We collected data for 125 residency candidates. Each applicant received a faculty gestalt score from up to four faculty interviewers. There was no significant correlation of SVI scores with faculty gestalt scores (Spearman's rank correlation coefficient [rs] (123)=0.09, p=0.30) and no correlation with the overall interview score (rs(123)=0.01, p=0.93). Faculty gestalt scores were correlated positively with interview scores (rs(123)=0.65, p<0.01). CONCLUSION: SVI scores show no significant correlation with faculty gestalt scores of communication and professionalism. This could relate to bias introduced by knowledge of an applicant's academic performance, different types of questions being asked by faculty interviewers, or lack of uniform criteria by which faculty assess these competencies. Further research is needed to determine whether SVI scores or faculty gestalt correlate with performance during residency.

A Graduated Responsibility Supervising Resident Experience Using Mastery Learning Principles.

This article was migrated. The article was marked as recommended. Introduction: Supervising other residents and independently running an emergency department (ED) is different from anything residents are asked to do in their early years of residency. There is often little training for this new responsibility. We created a new supervising experience that allows residents to progressively master skills associated with independently running an ED. Methods: We created an experience where PGY-3 residents supervised at our community site, removing the difficulties associated with an academic site such as junior residents and multiple consultants but requiring them to perform all other duties expected of the attending. Residents were scheduled in blocks of 4 shifts to allow them to iteratively improve their performance. Mastery was defined as 23 of 24 points across two shift evaluations, with 3 points available across 4 domains of Organization, Leadership/Communication, Flow and Patient Care. Residents who achieved this standard were allowed to progress to a more advanced supervising experience. Results: Eighty three percent of PGY-3 residents (10/12) achieved the mastery standard by the end of the year. Residents scored highest in Leadership/Communication (2.67 out of 3). They scored lowest on Flow (2.41 out of 3). Ninety percent of residents felt that the experience prepared them for being an attending. Discussion: A mastery learning-based supervising experience successfully allows residents to progressively acquire skills associated with running a busy ED. We plan to continue to evaluate the effectiveness of this intervention by examining the number of residents meeting the mastery standard as well as feedback from residents and faculty.

Maggots, Mucous and Monkey Meat: Does Disgust Sensitivity Affect Case Mix Seen During Residency?

INTRODUCTION: Emergency physicians encounter scenarios daily that many would consider "disgusting," including exposure to blood, pus, and stool. Physicians in procedural specialties such as surgery and emergency medicine (EM) have lower disgust sensitivity overall, but the role this plays in clinical practice is unclear. The objective of this study was to determine whether emergency physicians with higher disgust sensitivity see fewer "disgusting" cases during training. METHODS: All EM residents at a midsize urban EM program were eligible to complete the Disgust Scale Revised (DS-R). We preidentified cases as "disgust elicitors" based on diagnoses likely to induce disgust due to physician exposure to bodily fluids, anogenital anatomy, or gross deformity. The "disgust elicitor" case percent was determined by "disgust elicitor" cases seen as the primary resident divided by the number of cases seen thus far in residency. We calculated Pearson's r, t-tests and descriptive statistics on resident and population DS-R scores and "disgust elicitor" cases per month. RESULTS: Mean DS-R for EM residents (n = 40) was 1.20 (standard deviation [SD] 1.24), significantly less than the population mean of 1.67 (SD 0.61, p<0.05). There was no correlation (r = -0.04) between "disgust elicitor" case (n = 2191) percent and DS-R scores. There was no significant difference between DS-R scores for junior residents (31.1, 95% confidence interval [CI], 26.8-35.4) and for senior residents (29.0, 95%CI, 23.4-34.6). CONCLUSION: Higher disgust sensitivity does not appear to be correlated with a lower percentage of "disgust elicitor" cases seen during EM residency.

Post-interview Thank-you Communications Influence Both Applicant and Residency Program Rank Lists in Emergency Medicine.

INTRODUCTION: The National Residency Matching Program (NRMP) allows post-interview contact between residency applicants and residency programs. Thank-you communications represent one of the most common forms, but data on their value to applicants and program directors (PD) are limited. The objective of this study was to assess the effect of thank-you communications on applicant- and residency-program rank lists. METHODS: Two anonymous, voluntary surveys were sent after the 2018 NRMP Match, one to applicants who were offered an interview at a single academic site in the 2017-2018 Match cycle, and one to EM PDs nationwide. The surveys were designed in conjunction with a nationally-recognized survey center and piloted and revised based on feedback from residents and faculty. RESULTS: Of 196 residency applicants, 97 (49.5%) responded to the survey. Of these, 73/95 (76.8%) reported sending thank-you communications. Twenty-two of 73 (30%) stated that they sent thank-you communications to improve their spot on a program's rank list; and 16 of 73 (21.9%) reported that they changed their rank list based upon the responses they received to their thank-you communications. Of 163 PDs, 99 (60.7%) responded to the survey. Of those PDs surveyed, 22.6% reported that an applicant could be moved up their program's rank list and 10.8% reported that an applicant could move down a program's rank list based on their thank-you communications (or lack thereof). CONCLUSION: The majority of applicants to EM are sending thank-you communications. A significant minority of applicants and PDs changed their rank list due to post-interview thank-you communications.

The Development of Best Practice Recommendations to Support the Hiring, Recruitment, and Advancement of Women Physicians in Emergency Medicine.

BACKGROUND: Women in medicine continue to experience disparities in earnings, promotion, and leadership roles. There are few guidelines in place defining organization-level factors that promote a supportive workplace environment beneficial to women in emergency medicine (EM). We assembled a working group with the goal of developing specific and feasible recommendations to support women's professional development in both community and academic EM settings. METHODS: We formed a working group from the leadership of two EM women's organizations, the Academy of Women in Academic Emergency Medicine (AWAEM) and the American Association of Women Emergency Physicians (AAWEP). Through a literature search and discussion, working group members identified four domains where organizational policies and practices supportive of women were needed: 1) global approaches to supporting the recruitment, retention, and advancement of women in EM; 2) recruitment, hiring, and compensation of women emergency physicians; 3) supporting development and advancement of women in EM; and 4) physician health and wellness (in the context of pregnancy, childbirth, and maternity leave). Within each of these domains, the working group created an initial set of specific recommendations. The working group then recruited a stakeholder group of EM physician leaders across the country, selecting for diversity in practice setting, geographic location, age, race, and gender. Stakeholders were asked to score and provide feedback on each of the recommendations. Specific recommendations were retained by the working group if they achieved high rates of approval from the stakeholder group for importance and perceived feasibility. Those with >80% agreement on importance and >50% agreement on feasibility were retained. Finally, recommendations were posted in an open online forum (blog) and invited public commentary. RESULTS: An initial set of 29 potential recommendations was created by the working group. After stakeholder voting and feedback, 16 final recommendations were retained. Recommendations were refined through qualitative comments from stakeholders and blog respondents. CONCLUSIONS: Using a consensus building process that included male and female stakeholders from both academic and community EM settings, we developed recommendations for organizations to implement to create a workplace environment supportive of women in EM that were perceived as acceptable and feasible. This process may serve as a model for other medical specialties to establish clear, discrete organization-level practices aimed at supporting women physicians.

Cherry Picking Patients: Examining the Interval Between Patient Rooming and Resident Self-assignment.

OBJECTIVE: We aimed to evaluate the association between patient chief complaint and the time interval between patient rooming and resident physician self-assignment ("pickup time"). We hypothesized that significant variation in pickup time would exist based on chief complaint, thereby uncovering resident preferences in patient presentations. METHODS: A retrospective medical record review was performed on consecutive patients at a single, academic, university-based emergency department with over 50,000 visits per year. All patients who presented from August 1, 2012, to July 31, 2013, and were initially seen by a resident were included in the analysis. Patients were excluded if not seen primarily by a resident or if registered with a chief complaint associated with trauma team activation. Data were abstracted from the electronic health record (EHR). The outcome measured was "pickup time," defined as the time interval between room assignment and resident self-assignment. We examined all complaints with >100 visits, with the remaining complaints included in the model in an "other" category. A proportional hazards model was created to control for the following prespecified demographic and clinical factors: age, race, sex, arrival mode, admission vital signs, Emergency Severity Index code, waiting room time before rooming, and waiting room census at time of rooming. RESULTS: Of the 30,382 patients eligible for the study, the median time to pickup was 6 minutes (interquartile range = 2-15 minutes). After controlling for the above factors, we found systematic and significant variation in the pickup time by chief complaint, with the longest times for patients with complaints of abdominal problems, numbness/tingling, and vaginal bleeding and shortest times for patients with ankle injury, allergic reaction, and wrist injury. CONCLUSIONS: A consistent variation in resident pickup time exists for common chief complaints. We suspect that this reflects residents preferentially choosing patients with simpler workups and less perceived diagnostic ambiguity. This work introduces pickup time as a metric that may be useful in the future to uncover and address potential physician bias. Further work is necessary to establish whether practice patterns in this study are carried beyond residency and persist among attendings in the community and how these patterns are shaped by the information presented via the EHR.

Simulation Training to Maintain Neonatal Resuscitation and Pediatric Sedation Skills for Emergency Medicine Faculty.

BACKGROUND: Neonatal resuscitations and significant adverse cardiorespiratory events during pediatric sedations are infrequent. Thus, it is challenging to maintain the skills necessary to manage patients experiencing these events. As the pediatric emergency medicine specialty expands, exposure of general emergency medicine physicians to these potentially critical patients may become even more limited. As such, effective training strategies need to be developed. Simulation provides the opportunity to experience a rare event in a safe learning environment, and has shown efficacy in skill acquisition for medical students and residents. Less is known regarding its use for faculty-level learners. OBJECTIVES: To assess the acceptability, efficacy, and feasibility of a simulation-based educational intervention for emergency medicine faculty on their knowledge, comfort, and perceived competence in neonatal resuscitation and pediatric sedation skills. METHODS: Eighteen academic emergency medicine faculty participated in a 4-hour educational intervention with high-fidelity simulation sessions focused on neonatal resuscitation (precipitous delivery of a depressed newborn) and adverse events associated with pediatric sedation (laryngospasm and hypoventilation). Faculty also practiced umbilical vein catheterization, video laryngoscopy skills, and reviewed supplies stocked in our pediatric resuscitation cart. A pre- and postintervention evaluation was completed consisting of knowledge and attitude questions. Paired t test analysis was used to detect statistically significant change (P ≤ 0.05). RESULTS: Results were obtained from 17 faculty members. Simulation training was well accepted pre- and postintervention, and simulation was effective with statistically significant improvement in both knowledge and attitude. This type of event was feasible with 83% of emergency medicine faculty participating. CONCLUSION: Emergency medicine faculty have limited opportunities to manage neonatal resuscitations and adverse events in pediatric sedations. Simulation training appears to be an effective educational modality to help maintain these important skills.

Focus on abnormal air: diagnostic ultrasonography for the acute abdomen.

Emergency ultrasonography is a frequently used imaging tool in the bedside diagnosis of the acute abdomen. Classic indications include imaging for acute abdominal aneurysm, acute cholecystitis, hydronephrosis, and free intra-abdominal fluid in patients with trauma or suspected vascular or ectopic pregnancy rupture. Point-of-care sonographic imaging often emphasizes the diagnostic utility of fluid and edema, both as a significant finding and as a desirable adjunct for improved imaging. Conversely, the finding of sonographic intra-abdominal air is commonly 'tolerated' as a necessary evil that can foil image acquisition. This is in stark contrast to the accepted diagnostic utility of air in other imaging modalities for the acute abdomen, such as computed tomography and conventional radiography. Countering the bias against air as a deterrent for diagnostic ultrasound's accuracy are several published studies suggesting that abnormal air patterns can be used with high precision to diagnose pneumoperitoneum. These studies advocate that sonographic findings of abnormal air can be straightforward and can become crucial for increasing the diagnostic yield of bedside ultrasound of the acute abdomen. They suggest that practitioners should familiarize themselves with the findings and techniques to gain the experience required to make the diagnosis with confidence. This article will discuss four groups of abnormal air patterns found in the abdomen and the retroperitoneum and the respective scanning techniques, with a focus on the use of ultrasound for diagnosing pneumoperitoneum and a suggested scanning approach in the emergency setting.