Perceptions about dementia clinical trials among underrepresented populations: A nationally representative survey of U.S. dementia caregivers.

Background: The research community has historically failed to enroll diverse groups of participants in dementia clinical trials. A unique aspect of dementia care research is the requirement of a study partner, who can attest to the care recipient's clinical and functional capacity. The aim of this study is to assess racial and ethnic differences and the importance of various trial considerations among dementia caregivers, in their decision to participate in clinical research as study partners. Method: We embedded a vignette about a hypothetical dementia clinical trial in a nationally representative survey of U.S. dementia caregivers, oversampling non-Hispanic Black and Hispanic caregivers. Dementia caregivers were asked about their willingness to participate in the trial with their care recipient and rated the importance of nine considerations in hypothetical decisions to participate. Caregiver demographic characteristics were analyzed as predictors of trial participation in a base demographic model. In a second reasons model caregiver demographic characteristics and the rated importance of the nine considerations were separately analyzed as predictors; both models used survey-weighted logistic regression. Result: The sample consisted of 610 dementia caregivers, including 156 non-Hispanic Black and 122 Hispanic caregiver participants. In the base demographic model, hypothetical trial participation was negatively associated with older caregiver age (OR (odds ratio) = 0.72, p = < 0.001). In the reasons model, the rated importance of a social responsibility to help others by participating in research was significantly associated with participation (OR = 1.56, p = 0.049), while the importance of the possibility of the care recipient experiencing serious side effects was negatively associated with participation (OR = 0.51, p = 0.003). In both models there was no significant difference in hypothetical participation between non-Hispanic Black and non-Hispanic White caregivers, or between Hispanic and non-Hispanic White caregivers. Conclusion: Hispanic and non-Hispanic Black dementia caregivers were not less likely than non-Hispanic White dementia caregivers to participate in a hypothetical dementia clinical trial. Our study suggests that failures to recruit diverse populations in dementia clinical research are not attributable to less willingness among members of underrepresented groups but may instead reflect structural barriers and historic exclusion from trial participation.

Socioeconomic differences between medically and surgically treated prolactinomas: a retrospective review of 598 patients.

OBJECTIVE: Socioeconomic status (SES) is known to affect presentations and outcomes in pituitary neuroendocrine tumor resections, but there is a paucity of literature examining its impact specifically on patients with prolactinomas, who may be treated medically or surgically. The authors sought to determine whether SES was associated with differences in treatment choice or outcomes for prolactinoma patients. METHODS: The authors retrospectively reviewed patient records at a high-volume academic pituitary center for prolactinoma diagnoses. Patients were split into medically and surgically treated cohorts. Race, ethnicity, insurance status, primary care physician (PCP) status, and zip code-based income data were collected and examined as socioeconomic covariates. Outcomes of interest included pretreatment likelihood of surgical cure, medical versus surgical treatment allocation, and posttreatment remission rates. RESULTS: The authors analyzed 568 prolactinoma patients (351 medically treated and 217 surgically treated). Patients receiving surgery were more likely to have Medicaid or private insurance (p < 0.001) and have lower incomes (p < 0.001) than medically treated patients. Lower-income surgical patients were more likely to require surgical intervention for an indication such as tumor decompression than higher-income patients (p = 0.023). Surgical patients with a PCP had a higher estimated likelihood of surgical cure (p = 0.008), while no SES-based differences in surgical remission likelihood existed in the medical cohort. After surgery, surgical patients who achieved remission had significantly higher income than those who did not (p < 0.001). Other SES factors were not associated with surgical remission, and among medically treated patients, remission rates were not affected by any SES factor. Income was inversely related to prolactinoma size in both cohorts (surgical, p < 0.001; medical, p = 0.005) but was associated more prominently in surgical patients (surgical, -0.65 mm per $10,000; medical, -0.37 mm per $10,000). CONCLUSIONS: While surgical prolactinoma patients were prone to income and PCP-related disparities, no SES disparities were found among medically treated patients. Income had a more pronounced association with tumor size in the surgical cohort and likely contributed to the increased need for surgical intervention seen in low-income surgical patients. Addressing socioeconomic healthcare disparities is needed among surgical prolactinoma patients to increase rates of early presentation and improve the outcomes of low-SES populations.

Culinary cultural immersion: A qualitative analysis of resident knowledge, attitudes, and behavioral changes following a brief Somali cultural immersion experience.

Background: Teaching cultural humility is required by the Accreditation Council for Graduate Medical Education and can improve patient satisfaction and health care outcomes. Because one-third of the 150,000 Somali immigrants and refugees in the United States live in Minnesota, we aimed to determine whether a brief cultural immersion experience, where small groups of residents share a meal with Somali interpreters at a Somali restaurant, would affect resident knowledge, attitudes, and behaviors when caring for Somali patients in a Minnesota emergency department. Methods: From October 2017 to September 2018, emergency medicine residents were invited to dinners held outside of regular clinical/academic hours. Dinners took place at a Somali restaurant and were facilitated by a Somali interpreter and a faculty physician. While they were designed as learner-driven sessions, facilitators were encouraged to discuss specific themes. In addition to an evaluation survey, participants underwent semistructured interviews after the experiences, and a qualitative analysis of derived themes is reported. Results: Six dinners were hosted for a total of 20 residents, with 17 (85%) completing the evaluation survey and interview. Residents strongly agreed that this experience was worth their time and would recommend the program. Residents reported an increase in their knowledge of Somali culture, health care paradigms, and diet. Behavioral changes were described, including how residents greet patients, tailor clinical visits to patient expectations, and use interpreters as cultural brokers. Attitudinal changes were reported to a lesser degree but included an increased acceptance of cultural differences and an increased sense of connectedness to this population. Finally, residents reported that the benefits of this program were due to the authenticity of the experience, the informal small-group setting, and their sense of being in the minority during the dinners. Conclusions: A brief immersion experience at a Somali restaurant was sufficient to result in increased knowledge, attitudinal, and behavioral changes when caring for Somali patients.

On the validity of summative entrustment decisions.

Health care revolves around trust. Patients are often in a position that gives them no other choice than to trust the people taking care of them. Educational programs thus have the responsibility to develop physicians who can be trusted to deliver safe and effective care, ultimately making a final decision to entrust trainees to graduate to unsupervised practice. Such entrustment decisions deserve to be scrutinized for their validity. This end-of-training entrustment decision is arguably the most important one, although earlier entrustment decisions, for smaller units of professional practice, should also be scrutinized for their validity. Validity of entrustment decisions implies a defensible argument that can be analyzed in components that together support the decision. According to Kane, building a validity argument is a process designed to support inferences of scoring, generalization across observations, extrapolation to new instances, and implications of the decision. A lack of validity can be caused by inadequate evidence in terms of, according to Messick, content, response process, internal structure (coherence) and relationship to other variables, and in misinterpreted consequences. These two leading frameworks (Kane and Messick) in educational and psychological testing can be well applied to summative entrustment decision-making. The authors elaborate the types of questions that need to be answered to arrive at defensible, well-argued summative decisions regarding performance to provide a grounding for high-quality safe patient care.

Entrustment Decision Making: Extending Miller's Pyramid.

The iconic Miller's pyramid, proposed in 1989, characterizes 4 levels of assessment in medical education ("knows," "knows how," "shows how," "does"). The frame work has created a worldwide awareness of the need to have different assessment approaches for different expected outcomes of education and training. At the time, Miller stressed the innovative use of simulation techniques, geared at the third level ("shows how"); however, the "does" level, assessment in the workplace, remained a largely uncharted area. In the 30 years since Miller's conference address and seminal paper, much attention has been devoted to procedures and instrument development for workplace-based assessment. With the rise of competency-based medical education (CBME), the need for approaches to determine the competence of learners in the clinical workplace has intensified. The proposal to use entrustable professional activities as a framework of assessment and the related entrustment decision making for clinical responsibilities at designated levels of supervision of learners (e.g., direct, indirect, and no supervision) has become a recent critical innovation of CBME at the "does" level. Analysis of the entrustment concept reveals that trust in a learner to work without assistance or supervision encompasses more than the observation of "doing" in practice (the "does" level). It implies the readiness of educators to accept the inherent risks involved in health care tasks and the judgment that the learner has enough experience to act appropriately when facing unexpected challenges. Earning this qualification requires qualities beyond observed proficiency, which led the authors to propose adding the level "trusted" to the apex of Miller's pyramid.

Non-invasive zero-heat-flux technology compared with traditional core temperature measurements in the emergency department.

INTRODUCTION: Core temperatures (Tcore) are often invasive, and can be underutilized. Peripheral temperatures are easier to obtain, but are often less accurate. A zero-heat-flux thermometer (ZHF) is a non-invasive method to obtain core temperatures (TZHF), and has been accurate when compared to Tcore in the operating room. We aimed to determine whether TZHF accurately and reliably measures Tcore in emergency department (ED) patients when compared to rectal, bladder or esophageal temperatures. METHODS: We conducted a prospective observational quality improvement project, with concurrent TZHF and Tcore measurements. The primary outcome was whether one device detected a fever (≥38.1 °C) when the other device did not. Unadjusted linear regression was used to determine the relationship between temperature differences between devices. RESULTS: 268 patients were included. Mean temperatures were 36.6 °C for Tcore and 36.3 °C for TZHF. 16 of 52 patients with fever identified by Tcore were not detected by TZHF, 13 with an infectious etiology. The mean temperature difference between Tcore and TZHF increased as the patient's temperature increased; the difference was 0.2 °C in afebrile patients, but 0.7 °C in febrile patients. CONCLUSION: While we found overall concordance between Tcore and TZHF, the ZHF did not detect fever in 25% of patients presenting with fever of infectious origin. Measurements between Tcore and TZHF varied more as temperatures increased, with TZHF consistently reporting lower values. Although more study is needed, these findings call into question the use of TZHF in the ED where detection of fever frequently guides patient evaluation and management.

Efficacy of Laryngeal Tube versus Bag Mask Ventilation by Inexperienced Providers.

INTRODUCTION: Bag mask ventilation (BMV) and extraglottic devices (EGDs) are two common methods of providing rescue ventilation. BMV can be difficult to perform effectively, especially for inexperienced providers and in patients with difficult airway characteristics. There is some evidence that the laryngeal tube (LT) can be successfully placed by inexperienced providers to provide effective ventilation. However, it is unclear whether ventilation provided by LT is superior to that of BMV, especially in the hands of inexperienced airway providers. Therefore, we aimed to compare ventilation efficacy of inexperienced airway providers with BMV versus LT by primarily measuring tidal volumes and secondarily measuring peak pressures on a simulated model. METHODS: We performed a crossover study first year emergency medicine residents and third and fourth year medical students. After a brief instructional video followed by hands on practice, participants performed both techniques in random order on a simulated model for two minutes each. Returned tidal volumes and peak pressures were measured. RESULTS: Twenty participants were enrolled and 1200 breaths were measured, 600 per technique. The median ventilation volumes were 194 milliliters (mL) for BMV, and 387 mL for the laryngeal tube, with a median absolute difference of 170 mL (95% confidence interval [CI] 157-182 mL) (mean difference 148 mL [95% CI, 138-158 mL], p<0.001). The median ventilation peak pressures were 23 centimeters of water (cm H2O) for BMV, and 30 cm H2O for the laryngeal tube, with a median absolute difference of 7 cm H2O (95% CI, 6-8 cm H2O) (mean difference 8 cm H2O [95% CI, 7-9 cm H2O], p<0.001). CONCLUSION: Inexperienced airway providers were able to provide higher ventilation volumes and peak pressures with the LT when compared to BMV in a manikin model. Inexperienced providers should consider using an LT when providing rescue ventilations in obtunded or hypoventilating patients without intact airway reflexes. Further study is required to understand whether these findings are generalizable to live patients.

A randomised controlled trial evaluating the effectiveness of Facebook compared to leaflets in raising awareness of melanoma and harmful sun-related behaviour among young adults.

This study describes a randomised control trial investigating whether printed leaflets or social media are more effective in increasing knowledge of the risks of sun exposure and melanoma in people aged 18-29. The study participants were 18-29-year-old university students or graduates, recruited in London. A baseline level of knowledge was measured using the Skin Cancer and Sun Knowledge questionnaire. Study participants were then randomised into either a leaflet arm or Facebook arm. Identical information was delivered through a SunSafe campaign via either posted leaflets or Facebook during a 10-day exposure window. Following this, participants repeated the Skin Cancer and Sun Knowledge questionnaire. Following the SunSafe intervention, the mean knowledge score improved in both groups to a statistically significant degree (Facebook = 1.82, leaflets = 3.04, P < 0.001). Moreover, the improvement in knowledge score of the leaflet arm was statistically significantly greater than in the Facebook arm (95% confidence interval: 0.35-2.09, P = 0.0059). Participants of lighter skin colour demonstrated greater levels of knowledge about skin cancer and sun exposure at baseline (P = 0.005; P < 0.05). There was no correlation between sex and baseline knowledge (P = 0.7725). There was no significant effect of skin tone or sex on the knowledge change (P = 0.139 and 0.643). The findings suggest that printed information in the form of leaflets is more impactful in increasing knowledge than online platforms such as Facebook among a young adult demographic in the UK. These findings should be considered when designing public health campaigns, acting as a reminder to not neglect traditional media in health promotion.

Maturation of Brain Microstructure and Metabolism Associates with Increased Capacity for Self-Regulation during the Transition from Childhood to Adolescence.

Children ages 9-12 years face increasing social and academic expectations that require mastery of their thoughts, emotions, and behavior. Little is known about the development of neural pathways integral to these improving capacities during the transition from childhood to adolescence. Among 234 healthy, inner-city male and female youth (species Homo sapiens) 9-12 years of age followed by the Columbia Center for Children's Environmental Health, we acquired diffusion tensor imaging, multiplanar chemical shift imaging, and cognitive measures requiring self-regulation. We found that increasing age was associated with increased fractional anisotropy and decreased apparent diffusion coefficient, most prominently in the frontal and cingulate cortices, striatum, thalamus, deep white matter, and cerebellum. Additionally, we found increasing age was associated with increased N-acetyl-l-aspartate (NAA) in the anterior cingulate and insular cortices, and decreased NAA in posterior cingulate and parietal cortices. Age-associated changes in microstructure and neurometabolite concentrations partially mediated age-related improvements in performance on executive function tests. Together, these findings suggest that maturation of key regions within cortico-striatal-thalamo-cortical circuits subserve the emergence of improved self-regulatory capacities during the transition from childhood to adolescence.SIGNIFICANCE STATEMENT Few imaging studies of normal brain development have focused on a population of inner-city, racial/ethnic minority youth during the transition from childhood to adolescence, a period when self-regulatory capacities rapidly improve. We used DTI and MPCSI to provide unique windows into brain maturation during this developmental epoch, assessing its mediating influences on age-related improvement in performance on self-regulatory tasks. Our findings suggest that rapid maturation of cortico-striato-thalamo-cortical circuits, represented as progressive white-matter maturation (increasing FA and increasing NAA, Ch, Cr concentrations accompanying advancing age) in frontal regions and related subcortical projections and synaptic pruning (decreasing NAA, Ch, Cr, Glx) in posterior regions, support age-related improvements in executive functioning and self-regulatory capacities in youth 9-12 years of age.

Comparison of the Standardized Video Interview and Interview Assessments of Professionalism and Interpersonal Communication Skills in Emergency Medicine.

OBJECTIVES: The Association of American Medical Colleges Standardized Video Interview (SVI) was recently added as a component of emergency medicine (EM) residency applications to provide additional information about interpersonal communication skills (ICS) and knowledge of professionalism (PROF) behaviors. Our objective was to ascertain the correlation between the SVI and residency interviewer assessments of PROF and ICS. Secondary objectives included examination of 1) inter- and intrainstitutional assessments of ICS and PROF, 2) correlation of SVI scores with rank order list (ROL) positions, and 3) the potential influence of gender on interview day assessments. METHODS: We conducted an observational study using prospectively collected data from seven EM residency programs during 2017 and 2018 using a standardized instrument. Correlations between interview day PROF/ICS scores and the SVI were tested. A one-way analysis of variance was used to analyze the association of SVI and ROL position. Gender differences were assessed with independent-groups t-tests. RESULTS: A total of 1,264 interview-day encounters from 773 unique applicants resulted in 4,854 interviews conducted by 151 interviewers. Both PROF and ICS demonstrated a small positive correlation with the SVI score (r = 0.16 and r = 0.17, respectively). ROL position was associated with SVI score (p < 0.001), with mean SVI scores for top-, middle-, and bottom-third applicants being 20.9, 20.5, and 19.8, respectively. No group differences with gender were identified on assessments of PROF or ICS. CONCLUSIONS: Interview assessments of PROF and ICS have a small, positive correlation with SVI scores. These residency selection tools may be measuring related, but not redundant, applicant characteristics. We did not identify gender differences in interview assessments.

Integration of Entrustable Professional Activities with the Milestones for Emergency Medicine Residents.

INTRODUCTION: Medical education is moving toward a competency-based framework with a focus on assessment using the Accreditation Council for Graduate Medical Education Milestones. Assessment of individual competencies through milestones can be challenging. While competencies describe characteristics of the person, the entrustable professional activities (EPAs) concept refers to work-related activities. EPAs would not replace the milestones but would be linked to them, integrating these frameworks. Many core specialties have already defined EPAs for resident trainees, but EPAs have not yet been created for emergency medicine (EM). This paper describes the development of milestone-linked EPAs for EM. METHODS: Ten EM educators from across North America formed a consensus working group to draft EM EPAs, using a modified Glaser state-of-the-art approach. A reactor panel with EPA experts from the United States, Canada and the Netherlands was created, and an iterative process with multiple revisions was performed based on reactor panel input. Following this, the EPAs were sent to the Council of Residency Directors for EM (CORD-EM) listserv for additional feedback. RESULTS: The product was 11 core EPAs that every trainee from every EM program should be able to perform independently by the time of graduation. Each EPA has associated knowledge, skills, attitudes and behaviors (KSAB), which are either milestones themselves or KSABs linked to individual milestones. We recognize that individual programs may have additional focus areas or work-based activities they want their trainees to achieve by graduation; therefore, programs are also encouraged to create additional program-specific EPAs. CONCLUSION: This set of 11 core, EM-resident EPAs can be used as an assessment tool by EM residency programs, allowing supervising physicians to document the multiple entrustment decisions they are already making during clinical shifts with trainees. The KSAB list within each EPA could assist supervisors in giving specific, actionable feedback to trainees and allow trainees to use this list as an assessment-for-learning tool. Linking each KSAB to individual EM milestones allows EPAs to directly inform milestone assessment for clinical competency committees. These EPAs serve as another option for workplace-based assessment, and are linked to the milestones to create an integrated framework.

Simulation-based Remediation in Emergency Medicine Residency Training: A Consensus Study.

INTRODUCTION: Resident remediation is a pressing topic in emergency medicine (EM) training programs. Simulation has become a prominent educational tool in EM training and been recommended for identification of learning gaps and resident remediation. Despite the ubiquitous need for formalized remediation, there is a dearth of literature regarding best practices for simulation-based remediation (SBR). METHODS: We conducted a literature search on SBR practices using the terms "simulation," "remediation," and "simulation based remediation." We identified relevant themes and used them to develop an open-ended questionnaire that was distributed to EM programs with experience in SBR. Thematic analysis was performed on all subsequent responses and used to develop survey instruments, which were then used in a modified two-round Delphi panel to derive a set of consensus statements on the use of SBR from an aggregate of 41 experts in simulation and remediation in EM. RESULTS: Faculty representing 30 programs across North America composed the consensus group with 66% of participants identifying themselves as simulation faculty, 32% as program directors, and 2% as core faculty. The results from our study highlight a strong agreement across many areas of SBR in EM training. SBR is appropriate for a range of deficits, including procedural, medical knowledge application, clinical reasoning/decision-making, communication, teamwork, and crisis resource management. Simulation can be used both diagnostically and therapeutically in remediation, although SBR should be part of a larger remediation plan constructed by the residency leadership team or a faculty expert in remediation, and not the only component. Although summative assessment can have a role in SBR, it needs to be very clearly delineated and transparent to everyone involved. CONCLUSION: Simulation may be used for remediation purposes for certain specific kinds of competencies as long as it is carried out in a transparent manner to all those involved.

Does Implementation of a Corporate Wellness Initiative Improve Burnout?

INTRODUCTION: Burnout affects over 50% of all physicians. Nearly 70% of emergency physicians are affected, and it has been found to be as high as 76% in resident physicians overall. Previous wellness initiatives have yielded variable results; therefore, we looked for interventions that could potentially be effective at reversing this trend. We explored effective wellness programs originating from other industries. Our objective was to implement a corporate wellness program with previous evidence of success in other healthcare provider populations. We aimed to investigate whether this program would be effective in decreasing burnout in emergency medicine (EM) residents. METHODS: This program was conducted during required EM resident conference hours from 2016-2017. The Maslach Burnout Inventory was completed before and after the series of sessions, and we collected reactions-level data following completion of the six sessions. RESULTS: Post-intervention scores revealed a small trend toward increased emotional exhaustion and depersonalization scores, and with increased personal accomplishment scores. The overall satisfaction rating for this program was low, at 1.5 on a 5-point scale. Forty-three percent of residents stated that this intervention subjectively worsened their overall burnout, with another 39% stating it did not improve their burnout at all. A similar trend was seen for effects on wellness. CONCLUSION: We found that a corporate wellness intervention that had previously been shown to be successful with other types of healthcare providers did not objectively improve burnout and was subjectively perceived as paradoxically worsening burnout for many residents. This result may be related to the type of intervention chosen (individual vs. systems-focused), the design of the intervention itself, or the unique stressors faced by the resident population. [West J Emerg Med.2019;20(1)138-144.].

Augmenting Atrial Fibrillation Care After an Emergency Department Visit: Implementing Telephone Practice.

BACKGROUND: Between 2010 and 2012, the Heart Rhythm team in a tertiary care hospital completed a retrospective study that found that atrial fibrillation (AF) care can be episodic and heavily reliant on hospital resources, particularly the emergency department (ED). PROBLEM: Patients who attend the ED with AF are at high risk of hospital admission. APPROACH: A nurse practitioner (NP) was added to the Heart Rhythm team to create a program to improve AF care after an ED visit. Telephone practice was one of the many processes created. OUTCOMES: Findings revealed that 37 of 90 patients presented to the ED with AF prior to telephone contact and 7 of 90 patients did so post-telephone contact (P < .001). CONCLUSION: Telephone practice led by an NP provides an opportunity to improve assessment and management of patient with AF and offers a promising cost-effective method to reduce ED visits in the AF patient population.

Implementation of a Novel Conference Series on Clinical Practice Variations Provides an Opportunity for Constructive Discussion of Faculty Practice Patterns: Do as We Say? or Do as We Do?

BACKGROUND: Although evidence-based medicine (EBM) is routinely used to guide management in the emergency department, there is still considerable variation in clinical practice. Trainees may not fully appreciate the reasons for these clinical practice variations (CPVs) and may find it frustrating when they encounter them. We used areas of CPV among our faculty as the basis for resident educational sessions and assessed the perceived utility of these sessions. METHODS: Topics were identified when residents noticed significant variability among the faculty in their management of particular clinical presentations. Sessions were conducted by facilitator-led reviews of EBM guidelines, by faculty panel discussions of their management rationale where EBM guidelines are not available, or by pro-con debates. Residents were surveyed after the initial sessions to assess the utility of this series and changes in their understanding of CPV. RESULTS: There was a 72% response rate. The percentage of residents who were frustrated with CPV decreased from 64% to 35%; the percentage who felt that the presence of CPV enhanced their learning increased from 19% to 48%. Sixty-five percent felt that the educational series contributed to decreased frustration, 77% felt that the sessions helped them understand why CPV occurs, and 93% felt that they helped their overall learning. CONCLUSION: Explicit discussion and exploration of CPV in an educational setting can provide multiple benefits. Trainees may gain a better understanding of why CPV occurs and of the rationale behind practice variations. Faculty may benefit from analyzing CPV to determine whether these truly represent the "art of medicine."

Emergency Medicine Resident Shift Work Preferences: A Comparison of Resident Scheduling Preferences and Recommended Schedule Design for Shift Workers.

BACKGROUND: Shift work can negatively impact an individual's health, wellness, and quality of work. Optimal schedule design can mitigate some of these effects. The American College of Emergency Physicians has published schedule design guidelines to increase wellness and longevity in the field, but these guidelines are difficult to apply to emergency medicine (EM) residents given their high shift burdens and other scheduling constraints. Little is known is known about EM resident scheduling preferences or ideal schedule design in the context of residency training. OBJECTIVES: The objectives were to determine whether EM resident schedule design preferences are consistent with current scheduling guidelines for shift workers and to gather information on scheduling practices that are important to residents. METHODS: We surveyed residents at four allopathic EM residency programs and assessed residents' preferences on various schedule design features including shift length, circadian scheduling, night shift scheduling, and impact of schedule design on personal wellness. RESULTS: Of the 144 residents surveyed, 98% of residents felt that their shift schedule was a key factor in their overall wellness. Residents agreed with shift work guidelines regarding the importance of circadian scheduling (65% favorable), although rated the ability to request a day off and have a full weekend off as more important (84 and 78% favorable responses, respectively). Recommended guidelines promote shorter shifts, but only 24% of residents preferred 8-hour shifts compared to 57, 71, and 43% of residents preferring 9-, 10-, and 12-hour shifts, respectively. Sixty-seven percent of residents preferred their nights to be scheduled in one sequence per 4-week period, a night scheduling strategy most at odds with recommended guidelines. CONCLUSIONS: Emergency medicine resident scheduling preferences are not universally consistent with shift work guidelines, likely due to the distinct circumstances of residency training. Residents identify schedule design as a significant factor in their overall wellness.

Simulation-based Education to Ensure Provider Competency Within the Health Care System.

The acquisition and maintenance of individual competency is a critical component of effective emergency care systems. This article summarizes consensus working group deliberations and recommendations focusing on the topic "Simulation-based education to ensure provider competency within the healthcare system." The authors presented this work for discussion and feedback at the 2017 Academic Emergency Medicine Consensus Conference on "Catalyzing System Change Through Healthcare Simulation: Systems, Competency, and Outcomes," held on May 16, 2017, in Orlando, Florida. Although simulation-based training is a quality and safety imperative in other high-reliability professions such as aviation, nuclear power, and the military, health care professions still lag behind in applying simulation more broadly. This is likely a result of a number of factors, including cost, assessment challenges, and resistance to change. This consensus subgroup focused on identifying current gaps in knowledge and process related to the use of simulation for developing, enhancing, and maintaining individual provider competency. The resulting product is a research agenda informed by expert consensus and literature review.

Simulation for Assessment of Milestones in Emergency Medicine Residents.

OBJECTIVES: All residency programs in the United States are required to report their residents' progress on the milestones to the Accreditation Council for Graduate Medical Education (ACGME) biannually. Since the development and institution of this competency-based assessment framework, residency programs have been attempting to ascertain the best ways to assess resident performance on these metrics. Simulation was recommended by the ACGME as one method of assessment for many of the milestone subcompetencies. We developed three simulation scenarios with scenario-specific milestone-based assessment tools. We aimed to gather validity evidence for this tool. METHODS: We conducted a prospective observational study to investigate the validity evidence for three mannequin-based simulation scenarios for assessing individual residents on emergency medicine (EM) milestones. The subcompetencies (i.e., patient care [PC]1, PC2, PC3) included were identified via a modified Delphi technique using a group of experienced EM simulationists. The scenario-specific checklist (CL) items were designed based on the individual milestone items within each EM subcompetency chosen for assessment and reviewed by experienced EM simulationists. Two independent live raters who were EM faculty at the respective study sites scored each scenario following brief rater training. The inter-rater reliability (IRR) of the assessment tool was determined by measuring intraclass correlation coefficient (ICC) for the sum of the CL items as well as the global rating scales (GRSs) for each scenario. Comparing GRS and CL scores between various postgraduate year (PGY) levels was performed with analysis of variance. RESULTS: Eight subcompetencies were chosen to assess with three simulation cases, using 118 subjects. Evidence of test content, internal structure, response process, and relations with other variables were found. The ICCs for the sum of the CL items and the GRSs were >0.8 for all cases, with one exception (clinical management GRS = 0.74 in sepsis case). The sum of CL items and GRSs (p < 0.05) discriminated between PGY levels on all cases. However, when the specific CL items were mapped back to milestones in various proficiency levels, the milestones in the higher proficiency levels (level 3 [L3] and 4 [L4]) did not often discriminate between various PGY levels. L3 milestone items discriminated between PGY levels on five of 12 occasions they were assessed, and L4 items discriminated only two of 12 times they were assessed. CONCLUSION: Three simulation cases with scenario-specific assessment tools allowed evaluation of EM residents on proficiency L1 to L4 within eight of the EM milestone subcompetencies. Evidence of test content, internal structure, response process, and relations with other variables were found. Good to excellent IRR and the ability to discriminate between various PGY levels was found for both the sum of CL items and the GRSs. However, there was a lack of a positive relationship between advancing PGY level and the completion of higher-level milestone items (L3 and L4).

An Interactive Session to Help Faculty Manage Difficult Learner Behaviors in the Didactic Setting.

Introduction: The transition to more active learning during residency didactics has made the skill of managing difficult learner behaviors essential: Just one learner exhibiting difficult behavior can derail the educational experience for the room. Many educators feel uncomfortable handling these learners in real time and after the session. Methods: We created an interactive session for a mixed group of educators at a medical education boot camp. After learning about a framework for addressing difficult learner behaviors, participants were paired and presented with the case of a withdrawn learner. For each pair, the cause of the behavior was different. With one of the pair role-playing the learner, they were asked to identify the problem and solutions together. Multiple etiologies for the identical behavior reinforced the need to address underlying causes to create an effective plan for behavior change. Strategies to address difficult behaviors in real time were also discussed in large-group format. Results: Participants gave the session a mean score of 4.5 out of 5, indicating a high likelihood of changing their teaching practice. Free-response comments remarked on the role-play's educational value and the enjoyability of the session overall. Discussion: This session was effective in giving participants a framework for dealing with difficult learner behaviors, as well as hands-on practice with these skills. While this was a short (30-minute), single session, its success with participants with a wide variety of experience levels suggests it would be highly adaptable to other settings and may benefit from future expansion into the clinical setting.

Training and Assessing Critical Airway, Breathing, and Hemorrhage Control Procedures for Trauma Care: Live Tissue Versus Synthetic Models.

INTRODUCTION: Optimal teaching and assessment methods and models for emergency airway, breathing, and hemorrhage interventions are not currently known. The University of Minnesota Combat Casualty Training consortium (UMN CCTC) was formed to explore the strengths and weaknesses of synthetic training models (STMs) versus live tissue (LT) models. In this study, we compare the effectiveness of best in class STMs versus an anesthetized caprine (goat) model for training and assessing seven procedures: junctional hemorrhage control, tourniquet (TQ) placement, chest seal, needle thoracostomy (NCD), nasopharyngeal airway (NPA), tube thoracostomy, and cricothyrotomy (Cric). METHODS: Army combat medics were randomized to one of four groups: 1) LT trained-LT tested (LT-LT), 2) LT trained-STM tested (LT-STM), 3) STM trained-LT tested (STM-LT), and 4) STM trained-STM tested (STM-STM). Participants trained in small groups for 3 to 4 hours and were evaluated individually. LT-LT was the "control" to which other groups were compared, as this is the current military predeployment standard. The mean procedural scores (PSs) were compared using a pairwise t-test with a Dunnett's correction. Logistic regression was used to compare critical fails (CFs) and skipped tasks. RESULTS: There were 559 subjects included. Junctional hemorrhage control revealed no difference in CFs, but LT-tested subjects (LT-LT and STM-LT) skipped this task more than STM-tested subjects (LT-STM and STM-STM; p < 0.05), and STM-STM had higher PSs than LT-LT (p < 0.001). For TQ, both STM-tested groups (LT-STM and STM-STM) had more CFs than LT-LT (p < 0.001) and LT-STM had lower PSs than LT-LT (p < 0.05). No differences were seen for chest seal. For NCD, LT-STM had more CFs than LT-LT (p = 0.001) and lower PSs (p = 0.001). There was no difference in CFs for NPA, but all groups had worse PSs versus LT-LT (p < 0.05). For Cric, we were underpowered; STM-LT trended toward more CFs (p = 0.08), and STM-STM had higher PSs than LT-LT (p < 0.01). Tube thoracostomy revealed that STM-LT had higher CFs than LT-LT (p < 0.05), but LT-STM had lower PSs (p < 0.05). An interaction effect (making the subjects who trained and tested on different models more likely to CF) was only found for TQ, chest seal, and Cric; however, of these three procedures, only TQ demonstrated any significant difference in CF rates. CONCLUSION: Training on STM or LT did not demonstrate a difference in subsequent performance for five of seven procedures (junctional hemorrhage, TQ, chest seal, NPA, and NCD). Until STMs are developed with improved anthropomorphic and tissue fidelity, there may still be a role for LT for training tube thoracostomy and potentially Cric. For assessment, our STM appears more challenging for TQ and potentially for NCD than LT. For junctional hemorrhage, the increased "skips" with LT may be explained by the differences in anatomic fidelity. While these results begin to uncover the effects of training and assessing these procedures on various models, further study is needed to ascertain how well performance on an STM or LT model translates to the human model.