Geographic Location and Corporate Ownership of Hospitals in Relation to Unfilled Positions in the 2023 Emergency Medicine Match.

Introduction: In the 2023 National Resident Matching Program (NRMP) match, there were 554 unfilled emergency medicine (EM) positions before the Supplemental Offer and Acceptance Program (SOAP). We sought to describe features of EM programs that participated in the match and the association between select program characteristics and unfilled positions. Methods: The primary outcome measures included the proportion of positions filled in relation to state and population density, hospital ownership type, and physician employment model. Secondary outcome measures included comparing program-specific attributes between filled and unfilled programs, including original accreditation type, year of original accreditation, the total number of approved training positions, length of training, urban-rural designation, hospital size by number of beds, resident-to-bed ratio, and the percentage of disproportionate share patients seen. Results: The NRMP Match had 276 unique participating EM programs with 554 unfilled positions. Six states offered 52% of the total NRMP positions available. Five states were associated with two-thirds of the unfilled positions. Public hospitals had a statistically significant higher match rate (88%) when compared to non-profit and for-profit hospitals, which had match rates of 80% and 75%, respectively (P < 0.001). Programs with faculty employed by a health system had the highest match rate of 87%, followed by clinician partnerships at 79% and private equity groups at 68% (P < 0.001 overall and between all subgroups). Conclusion: The 2023 match in EM saw increased rates in the number of residency positions and programs that did not fill before the SOAP. Public hospitals had higher match rates than for-profit or non-profit hospitals. Residency programs that employed academic faculty through the hospital or health system were associated with higher match rates.

Assessment of Clinical Reasoning in Undergraduate Medical Education: A Pragmatic Approach to Programmatic Assessment.

PURPOSE: Clinical reasoning, a complex construct integral to the practice of medicine, has been challenging to define, teach, and assess. Programmatic assessment purports to overcome validity limitations of judgments made from individual assessments through proportionality and triangulation processes. This study explored a pragmatic approach to the programmatic assessment of clinical reasoning. METHOD: The study analyzed data from 2 student cohorts from the University of Utah School of Medicine (UUSOM) (n = 113 in cohort 1 and 119 in cohort 2) and 1 cohort from the University of Colorado School of Medicine (CUSOM) using assessment data that spanned from 2017 to 2021 (n = 199). The study methods included the following: (1) asking faculty judges to categorize student clinical reasoning skills, (2) selecting institution-specific assessment data conceptually aligned with clinical reasoning, (3) calculating correlations between assessment data and faculty judgments, and (4) developing regression models between assessment data and faculty judgments. RESULTS: Faculty judgments of student clinical reasoning skills were converted to a continuous variable of clinical reasoning struggles, with mean (SD) ratings of 2.93 (0.27) for the 232 UUSOM students and 2.96 (0.17) for the 199 CUSOM students. A total of 67 and 32 discrete assessment variables were included from the UUSOM and CUSOM, respectively. Pearson r correlations were moderate to strong between many individual and composite assessment variables and faculty judgments. Regression models demonstrated an overall adjusted R2 (standard error of the estimate) of 0.50 (0.19) for UUSOM cohort 1, 0.28 (0.15) for UUSOM cohort 2, and 0.30 (0.14) for CUSOM. CONCLUSIONS: This study represents an early pragmatic exploration of regression analysis as a potential tool for operationalizing the proportionality and triangulation principles of programmatic assessment. The study found that programmatic assessment may be a useful framework for longitudinal assessment of complicated constructs, such as clinical reasoning.

Implementation of dedicated social worker coaching for emergency medicine residents - Lessons learned.

Emergency medicine training is associated with high levels of stress and burnout, which were exacerbated by the COVID-19 pandemic. The pandemic further exposed a mismatch between trainees' mental health needs and timely support services; therefore, the objective of our innovation was to create an opportunity for residents to access a social worker who could provide consistent coaching. The residency leadership team partnered with our graduate medical education (GME) office to identify a clinical social worker and professionally-trained coach to lead sessions. The project was budgeted at an initial cost of $15,000 over 1 year. Residents participated in 49 group and 73 individual sessions. Post implementation in 2021, we compared this intervention to all other wellness initiatives. Resident response rate was 80.88% (n = 55/68) and median interquartile range (IQR) score of the initiative was 2 (1 = detrimental and 4 = beneficial) versus 3.79 (3.69-3.88) the median IQR of all wellness initiatives. A notable number, 22%, rated the program as detrimental, which could be related to summary comments regarding ability to attend sessions, lack of session structure, loss of personal/educational time, and capacity of the social worker to relate with them. Summary comments also revealed the innovation was useful, with individual sessions preferred to group sessions. Application of a social worker coaching program in an emergency medicine residency program appears to be a feasible novel intervention. Lessons learned after implementation include the importance of recruiting someone with emergency department/GME experience, orienting them to culture before implementation and framing coaching as an integrated residency resource.

Art in medicine: in the classroom, exam room, and Reading room.

In this article, the authors discuss the development and current curriculum of the Art in Medicine course at the University of Colorado School of Medicine (CUSOM), developed in collaboration with the Centre for Bioethics and Humanities, and the Denver Art Museum. Examples of art museum-based techniques implemented with medical students are discussed with objectives, methods, and pedagogy highlighted. Translational skillsets for medical professionals, including empathy, tolerance of ambiguity, perspective taking, bias, and communication are emphasised through practice in engagement in visual arts with facilitation by medical faculty and art museum educators. Following the discussion of classroom based activities, two of the co-authors, physician-educators from the CUSOM Departments of Medicine and Radiology, discuss the direct applications and importance of these skillsets in the context of the exam room and the reading room respectively.

Physician reentry-A timely topic for emergency medicine.

As physician workforce shortages persist, physician reentry is an important and timely issue for the specialty of emergency medicine. Physician reentry is defined as a return to clinical practice following an extended period of clinical inactivity not resulting from discipline or impairment. This review provides a general overview of the physician reentry published literature with a focus on the specialty of emergency medicine. Transition into a non-clinical position, personal health, family issues, and career dissatisfaction all contribute to physicians leaving the workforce voluntarily. Previously, the majority of reentry physicians did not pursue additional training prior to returning to the workforce; however, regulatory agencies are now increasingly requiring additional training, standardized testing, and fitness to practice evaluations prior to restarting clinical work. The burden of proof is on the reentry physician to meet the appropriate requirements for licensure, certification, and credentialing prior to returning to clinical work.

Impact of a Dedicated Teaching Attending Experience on a Required Emergency Medicine Clerkship.

INTRODUCTION: One published strategy for improving educational experiences for medical students in the emergency department (ED) while maintaining patient care has been the implementation of dedicated teaching attending shifts. To leverage the advantages of the ED as an exceptional clinical educational environment and to address the challenges posed by the rapid pace and high volume of the ED, our institution developed a clerkship curriculum that incorporates a dedicated clinical educator role - the teaching attending - to deliver quality bedside teaching experiences for students in a required third-year clerkship. The purpose of this educational innovation was to determine whether a dedicated teaching attending experience on a third-year required emergency medicine (EM) clerkship would improve student-reported clinical teaching evaluations and student-reported satisfaction with the overall quality of the EM clerkship. METHODS: Using a five-point Likert-type scale (1 - poor to 5 - excellent), student-reported evaluation ratings and the numbers of graduating students matching into EM were trended for 10 years retrospectively from the inception of the clerkship for the graduating class of 2009 through and including the graduating class of 2019. We used multinomial logistic regression to evaluate whether the presence of a teaching attending during the EM clerkship improved student-reported evaluation ratings for the EM clerkship. We used sample proportion tests to assess the differences between top-box (4 or 5 rating) proportions between years when the teaching attending experience was present and when it was not. RESULTS: For clinical teaching quality, when the teaching attending is present the estimated odds of receiving a rating of 5 is 77.2 times greater (p <0.001) than when the teaching attending is not present and a rating of 4 is 27.5 times greater (p =0.0017). For overall clerkship quality, when the teaching attending is present, the estimated odds of receiving a rating of 5 is 13 times greater (p <0.001) and a rating of 4 is 5.2 times greater (p=0.0086) than when the teaching attending is not present. CONCLUSION: The use of a dedicated teaching attending shift is a successful educational innovation for improving student self-reported evaluation items in a third-year required EM clerkship.

Taking Advantage of the Teachable Moment: A Review of Learner-Centered Clinical Teaching Models.

When working in a chaotic Emergency Department (ED) with competing priorities, clinical teaching may be sacrificed for the sake of patient flow and throughput. An organized, efficient approach to clinical teaching helps focus teaching on what the learner needs at that moment, incorporates regular feedback, keeps the department on track, and prevents over-teaching. Effective clinical teaching in a busy environment is an important skill for senior residents and faculty to develop. This review will provide a critique and comparison of seven structured teaching models to better prepare readers to seize the teachable moment.

Creating a Cadre of Fellowship-Trained Medical Educators, Part II: A Formal Needs Assessment to Structure Postgraduate Fellowships in Medical Education Scholarship and Leadership.

PURPOSE: Education leaders at the 2012 Academic Emergency Medicine Consensus Conference on education research proposed that dedicated postgraduate education scholarship fellowships (ESFs) might provide an effective model for developing future faculty as scholars. A formal needs assessment was performed to understand the training gap and inform the development of ESFs. METHOD: A mixed-methods needs assessment was conducted of four emergency medicine national stakeholder groups in 2013: department chairs; faculty education/research leaders; existing education fellowship directors; and current education fellows/graduates. Descriptive statistics were reported for quantitative data. Qualitative data from semistructured interviews and free-text responses were analyzed using a thematic approach. RESULTS: Participants were 11/15 (73%) education fellowship directors, 13/20 (65%) fellows/graduates, 106/239 (44%) faculty education/research leaders, and a convenience sample of 26 department chairs. Department chairs expected new education faculty to design didactics (85%) and teach clinically (96%). Faculty education/research leaders thought new faculty were inadequately prepared for job tasks (83.7%) and that ESFs would improve the overall quality of education research (91.1%). Fellowship directors noted that ESFs provide skills, mentorship, and protected time for graduates to become productive academicians. Current fellows/graduates reported pursing an ESF to develop skills in teaching and research methodology. CONCLUSIONS: Stakeholder groups uniformly perceived a need for training in education theory, clinical teaching, and education research. These findings support dedicated, deliberate training in these areas. Establishment of a structure for scholarly pursuits prior to assuming a full-time position will effectively prepare new faculty. These findings may inform the development, implementation, and curricula of ESFs.

Creating a Cadre of Fellowship-Trained Medical Educators: A Qualitative Study of Faculty Development Program Leaders' Perspectives and Advice.

PURPOSE: Well-trained educators fill essential roles across the medical education continuum. Some medical schools offer programs for existing faculty to enhance teaching and scholarship. No standard postgraduate training model exists for residency graduates to attain competency as faculty members before their first academic appointment. The objective of this study is to inform the development of postgraduate medical education fellowships by exploring perceptions of educational leaders who direct well-established faculty development programs. METHOD: The authors undertook a qualitative study, using purposeful sampling to recruit participants and a constant comparative approach to identify themes. They conducted semistructured telephone interviews with directors of faculty development fellowships using an interpretivist/constructivist paradigm (November 2013). Questions addressed curricular and fiscal structure, perceived benefits and challenges, and advice for starting a postgraduate fellowship. RESULTS: Directors reported institutional and participant benefits, notably the creation of a community of educators and pool of potential leaders. Curricular offerings focused on learning theory, teaching, assessment, leadership, and scholarship. Funding and protected time were challenges. Advice for new program directors included evaluating best practices, defining locally relevant goals; garnering sufficient, stable financial support; and rallying leaders' endorsement. CONCLUSIONS: Medical education fellowships cultivate leaders and communities of trained educators but require participants to balance faculty responsibilities with professional development. Advice of current directors can inform the development of postgraduate programs modeled after accredited clinical specialty fellowships. Programs with the support of strategic partners, financial stability, and well-defined goals may allow new faculty to begin their careers with existing competency in medical education skills.

Ethical considerations in education research in emergency medicine.

The 2012 Academic Emergency Medicine consensus conference on education research in emergency medicine (EM) addressed various issues, including that of ethics in medical education research for EM. Education research in EM is essential to patient care and safety, and with recent advances in simulation and the advent of the Milestones project, it will become even more vital. Education research in EM is guided by the same principles that guide the ethical conduct of all human subjects' research: respect for persons, beneficence, and justice. Regulatory provisions and widely accepted ethical standards provide a framework for research in EM education; however, special considerations exist for education research. To ensure patient and trainee safety and to maintain the integrity of new knowledge, ethical considerations should remain at the forefront of EM education research. For EM education researchers, recognition of the vulnerability of residents, medical students, and others as research subjects is paramount. This article fills an important gap by outlining the principles guiding education research in EM, exploring the ethical challenges and approaches to education research, and offering a framework and future directions for the ethical conduct of education research in EM.

Strategies for coping with stress in emergency medicine: Early education is vital.

INTRODUCTION: Physician burnout has received considerable attention in the literature and impacts a large number of emergency medicine physicians, but there is no standardized curriculum for wellness in resident education. A culture change is needed to educate about wellness, adopt a preventative and proactive approach, and focus on resiliency. DISCUSSION: We describe a novel approach to wellness education by focusing on resiliency rather than the unintended endpoint of physician burnout. One barrier to adoption of wellness education has been establishing legitimacy among emergency medicine (EM) residents and educators. We discuss a change in the language of wellness education and provide several specific topics to facilitate the incorporation of these topics in resident education. CONCLUSION: Wellness education and a culture of training that promotes well-being will benefit EM residents. Demonstrating the impact of several factors that positively affect emergency physicians may help to facilitate alert residents to the importance of practicing activities that will result in wellness. A change in culture and focus on resiliency is needed to adequately address and optimize physician self-care.

Defining a core curriculum for education scholarship fellowships in emergency medicine.

A trained cadre of medical education scholars with a focus on methodologically sound research techniques is needed to ensure development of innovations that can be translated to educational practice, rigorous evaluation of instructional strategies, and progress toward improving patient care outcomes. Most established educational programs are aimed at existing faculty members and focus primarily on the development of teaching and leadership skills. At the 2012 Academic Emergency Medicine (AEM) consensus conference, "Education Research in Emergency Medicine: Opportunities, Challenges, and Strategies for Success," a breakout session was convened to develop training recommendations for postgraduate fellowship programs in medical education scholarship that would enable residency graduates to join academic faculties armed with the skills needed to perform research in medical education. Additionally, these graduates would enjoy the benefits of established mentorships. A group of 23 medical education experts collaborated to address the following objectives: 1) construct a formal needs assessment for fellowship training in medical education scholarship in emergency medicine (EM), 2) compare and contrast current education scholarship programs in both EM and non-EM specialties, and 3) develop a set of core curriculum guidelines for specialized fellowship training in medical education scholarship in EM. Fellowship-trained faculty need to be proficient in learner instruction and assessment, organizational leadership, curriculum development, educational methodology, and conducting generalizable hypothesis-driven research to improve patient care.

A suggested core content for education scholarship fellowships in emergency medicine.

A working group at the 2012 Academic Emergency Medicine consensus conference on education research in emergency medicine (EM) convened to develop a curriculum for dedicated postgraduate fellowships in EM education scholarship. This fellowship is intended to create future education scholars, equipped with the skills to thrive in academic careers. This proceedings article reports on the consensus of a breakout session subgroup tasked with defining a common core content for education scholarship fellowships. The authors propose that the core content of an EM education scholarship fellowship can be categorized in four distinct areas: career development, theories of learning and teaching methods, education research methods, and educational program administration. This core content can be incorporated into curricula for education scholarship fellowships in EM or other fields and can also be adapted for use in general medical education fellowships.

The "guitar pick" sign: a novel sign of retrobulbar hemorrhage.

Retrobulbar hemorrhage is a rare complication of blunt ocular trauma. Without prompt intervention, permanent reduction in visual acuity can develop in as little as 90 minutes. We report a novel bedside ultrasound finding of conical deformation of the posterior ocular globe: the "guitar pick" sign. In our elderly patient, the ocular globe shape normalized post-lateral canthotomy and inferior cantholysis. Identifying this sonographic finding may add to the clinical examination when deciding whether to perform decompression.

Effects of physician experience on costs and outcomes on an academic general medicine service: results of a trial of hospitalists.

BACKGROUND: Hospitalists may decrease costs and improve outcomes in hospitalized patients, but existing evidence is limited and has not identified mechanisms for such effects. OBJECTIVE: To study the costs and outcomes for patients on an academic general medicine service assigned to teams led by hospitalists and nonhospitalists. DESIGN: Cohort study. SETTING: Academic general medicine service. PATIENTS: 6511 patients admitted to the hospital from July 1997 through June 1999. INTERVENTION: All patients admitted every fourth day were assigned to 1 of 2 hospitalists caring for inpatients 6 months each year or 1 of 58 nonhospitalists caring for inpatients 1 to 2 months each year. MEASUREMENTS: Length of stay; inpatient costs; and 30-, 60-, and 365-day mortality. RESULTS: Patients assigned to hospitalists (24.8%) and nonhospitalists (75.2%) did not differ in age, race, sex, diagnosis mix, or Charlson index score. In year 1, average adjusted length of stay was 0.29 day shorter for patients cared for by hospitalists than by nonhospitalists (95% CI, -0.66 to 0.06 day; P = 0.06); in year 2, average adjusted length of stay was 0.49 day shorter for patients cared for by hospitalists (CI, -0.79 to -0.15 day; P = 0.01). Average adjusted costs were not significantly reduced for hospitalists compared with nonhospitalists in year 1 but were reduced by $782 in year 2 (CI, -$1313 to -$187; P = 0.01). When years 1 and 2 were combined or when year 1 was analyzed alone, 30-day mortality was not significantly different for hospitalists and nonhospitalists; however, 30-day mortality was 4.2% for hospitalists compared with 6.0% for nonhospitalists in year 2 (CI for difference, 1.8 percentage points [-3.6 to -0.1 percentage points]; P = 0.04) and the adjusted relative risk was 0.65 (CI, 0.44 to 0.96; P = 0.03). In multivariate analyses, resource use decreased with the physician's cumulative experience in caring for a patient's primary diagnosis. Mortality showed a similar pattern. CONCLUSIONS: Hospitalist care was associated with lower costs and short-term mortality in the second but not the first year of hospitalists' experience. Disease-specific physician experience may reduce resource use and improve patient outcomes; in addition, it may be an important determinant of the effectiveness of hospitalists.