Are You Applying to More Than One Specialty?

Although the majority of U.S. medical students predominantly apply to only one specialty, some apply to more than one. When it comes to emergency medicine (EM), applicants may apply to additional specialties due to several reasons: being international medical graduates as well as their inability to make a decision regarding the choice of specialty, fear from the growing competitiveness of EM, or the desire to stay in a specific geographic area. Accordingly, in this article we aim to guide medical students through the process of applying to more than one specialty, including using the Electronic Residency Application Service application, writing a personal statement, getting letters of recommendation, and an Early Match. Moreover, we elaborate on the effect of applying to more than one specialty on a student's application to a residency in EM.

What Do Program Directors Look for in an Applicant?

Program directors (PDs) are faced with an increasing number of applicants to emergency medicine (EM) and a limited number of positions. This article will provide candidates with insight to what PDs look for in an applicant. We will elaborate on the performance in the emergency medicine clerkship, interview, clinical rotations (apart from EM), board scores, Alpha Omega Alpha membership, letters of recommendation, Medical Student Performance Evaluation or dean's letter, extracurricular activities, Gold Humanism Society membership, medical school attended, research and scholarly projects, personal statement, and commitment to EM. We stress the National Resident Matching Program process and how, ultimately, selection of a residency is equally dependent on an applicant's selection process.

Awake Laryngoscopy in the Emergency Department.

BACKGROUND: Many emergency physicians gain familiarity with the laryngeal anatomy only during the brief view achieved during rapid sequence induction and intubation. Awake laryngoscopy in the emergency department (ED) is an important and clinically underutilized procedure. DISCUSSION: Providing benefit to the emergency physician through a slow, controlled, and deliberate examination of the airway, awake laryngoscopy facilitates confidence in the high-risk airway and eases the evolution to intubation, should it be required. Emergency physicians possess all the tools and skills required to effectively perform this procedure, through either the flexible endoscopic or rigid approaches. The procedure can be conducted utilizing local anesthesia with or without mild sedation, such that patients protect their airway. CONCLUSION: We discuss two clinical scenarios, indications/contraindications, patient selection, and steps to performing two approaches to awake laryngoscopy in the ED.

Management of Acute Exacerbation of Asthma and Chronic Obstructive Pulmonary Disease in the Emergency Department.

Acute asthma and chronic obstructive pulmonary disease (COPD) exacerbations are the most common respiratory diseases requiring emergent medical evaluation and treatment. Asthma and COPD are chronic, debilitating disease processes that have been differentiated traditionally by the presence or absence of reversible airflow obstruction. Asthma and COPD exacerbations impose an enormous economic burden on the US health care budget. In daily clinical practice, it is difficult to differentiate these 2 obstructive processes based on their symptoms, and on their nearly identical acute treatment strategies; major differences are important when discussing anatomic sites involved, long-term prognosis, and the nature of inflammatory markers.

Design and effectiveness of a required pre-clinical simulation-based curriculum for fundamental clinical skills and procedures.

BACKGROUND: For more than 20 years, medical literature has increasingly documented the need for students to learn, practice and demonstrate competence in basic clinical knowledge and skills. In 2001, the Louisiana State University Health Science Centers (LSUHSC) School of Medicine - New Orleans replaced its traditional Introduction in to Clinical Medicine (ICM) course with the Science and Practice of Medicine (SPM) course. The main component within the SPM course is the Clinical Skills Lab (CSL). The CSL teaches 30 plus skills to all pre-clinical medical students (Years 1 and 2). METHODS: Since 2002, an annual longitudinal evaluation questionnaire was distributed to all medical students targeting the skills taught in the CSL. Students were asked to rate their self- confidence (Dreyfus and Likert-type) and estimate the number of times each clinical skill was performed (clinically/non-clinically). Of the 30 plus skills taught, 8 were selected for further evaluation. RESULTS: An analysis was performed on the eight skills selected to determine the effectiveness of the CSL. All students that participated in the CSL reported a significant improvement in self-confidence and in number performed in the clinically/non-clinically setting when compared to students that did not experience the CSL. For example, without CSL training, the percentage of students reported at the end of their second year self-perceived expertise as "novice" ranged from 21.4% (CPR) to 84.7% (GU catheterization). Students who completed the two-years CSL, only 7.8% rated their self-perceived expertise at the end of the second year as "novice" and 18.8% for GU catheterization. CONCLUSION: The CSL design is not to replace real clinical patient experiences. It's to provide early exposure, medial knowledge, professionalism and opportunity to practice skills in a patient free environment.

Healthcare-associated pneumonia in the emergency department.

Emergency medicine clinicians frequently diagnose and treat patients with pneumonia. The recent recognition of healthcare-associated pneumonia (HCAP) mandates that emergency medicine clinicians remain current and able to distinguish this from community-acquired pneumonia. This article reviews the diagnosis and management of HCAP from the perspective of the emergency medicine clinician.

Teaching across the generation gap: a consensus from the Council of Emergency Medicine Residency Directors 2009 academic assembly.

BACKGROUND: Four distinct generations of physicians currently coexist within the emergency medicine (EM) workforce, each with its own unique life experience, perspective, attitude, and expectation of work and education. To the best of our knowledge, no investigations or consensus statements exist that specifically address the effect of intergenerational differences on undergraduate and graduate medical education in EM. OBJECTIVES: To review the existing literature on generational differences as they pertain to workforce expectations, educational philosophy, and learning styles and to create a consensus statement based on the shared insights of experienced educators in EM, with specific recommendations to improve the effectiveness of EM residency training programs. METHODS: A group of approximately one hundred EM program directors (PDs), assistant PDs, and other academic faculty attending an annual conference of emergency physician (EP) educators gathered at a breakout session and working group to examine the literature on intergenerational differences, to share insights and discuss interventions tailored to address these stylistic differences, and to formulate consensus recommendations. RESULTS: A set of specific recommendations, including effective educational techniques, was created based on literature from other professions and medical disciplines, as well as the contributions of a diverse group of EP educators. CONCLUSIONS: Recommendations included early establishment of clear expectations and consequences, emphasis on timely feedback and individualized guidance during training, explicit reinforcement of a patient-centered care model, use of peer modeling and support, and emphasis on more interactive and small-group learning techniques.

Health care-associated pneumonia: identification and initial management in the ED.

Traditionally, pneumonia is categorized by epidemiologic factors into community-acquired pneumonia (CAP), hospital-acquired pneumonia (HAP), and ventilator-associated pneumonia (VAP). Microbiologic studies have shown that the organisms which cause infections in HAP and VAP differ from CAP in epidemiology and resistance patterns. Patients with HAP or VAP are at higher risk for harboring resistant organisms. Other historical features that potentially place patients at a higher risk for being infected with resistant pathogens and organisms not commonly associated with CAP include history of recent admission to a health care facility, residence in a long-term care or nursing home facility, attendance at a dialysis clinic, history of recent intravenous antibiotic therapy, chemotherapy, and wound care. Because these "risk factors" have health care exposure as a common feature, patients presenting with pneumonia having these historical features have been more recently categorized as having health care-associated pneumonia (HCAP). This publication was prepared by the HCAP Working Group, which is comprised of nationally recognized experts in emergency medicine, infectious diseases, and pulmonary and critical care medicine. The aim of this article is to create awareness of the entity known as HCAP and to provide knowledge of its identification and initial management in the emergency department.

Rational antibiotic treatment of outpatient genitourinary infections in a changing environment.

In the outpatient setting, genitourinary infections (GUIs) remain costly to treat and are a significant cause of morbidity. Recent evidence supports more substantial roles for pathogens other than Escherichia coli, particularly gram-positive pathogens, in the pathogenesis of GUIs. Broad-spectrum agents should be considered in order to address this etiologic change appropriately. Criteria for antimicrobial selection set forth by the Council for Appropriate and Rational Antibiotic Therapy (CARAT) recommend using antibiotics that are supported by strong clinical evidence, have good susceptibility profiles, are safe, are cost-effective, and are used for the optimal duration. Evidence-based guidelines recommend considering local E coli resistance rates to trimethoprim-sulfamethoxazole and using fluoroquinolones as second-line therapy when resistance is high. Fluoroquinolones are recommended for the treatment of pyelonephritis and prostatitis. Among the fluoroquinolones, levofloxacin and gatifloxacin offer coverage for the gram-negative and gram-positive pathogens, which may make them preferable in treating urinary tract infections empirically in such patient groups. For the treatment of bacterial prostatitis, only trimethoprim and the fluoroquinolones possess both the appropriate bactericidal activity and the ability to diffuse into the prostate. Levofloxacin shows particularly good penetration into prostatic tissue. Safety issues to consider include imbalances in intestinal microflora caused by antimicrobial agents that may lead to overgrowth of vancomycin-resistant enterococci and Clostridium difficile-associated diarrhea. Once the optimal agent is identified, the optimal duration of treatment should be determined to maximize treatment success while minimizing the potential for resistance. Finally, cost considerations include the costs of treatment failure due to inappropriate therapy or nonadherence to the therapeutic regimen.

Evaluation and initial management of the patient in respiratory distress.

Evaluation of the patient in acute respiratory distress poses a complex problem to the emergency physician. Because of the heterogeneity of the population of patients presenting in acute respiratory distress, there is a paucity of evidence-based medicine recommendations. Practice habit dictates most of our diagnostic and therapeutic approach. It is of paramount importance to understand the limitations of history, physical examination, and diagnostic screening studies in evaluating and treating patients with respiratory distress. The emergency physician should become aware of the benefits of NPPV in the management of respiratory failure. Essential to the management of these patients is the ability to anticipate difficulty in airway management and the formulation of alternative airway strategies.