Measuring and Predicting Faculty Consensus Rankings of Standardized Letters of Evaluation.

Background Standardized letters of evaluation (SLOE) are becoming more widely incorporated into the residency application process to make the letter of recommendation, an already critical component in a residency application packet, more objective. However, it is not currently known if the reviewers of these letters share consensus regarding the strength of an applicant determined by their SLOE. Objective We measured the level of faculty agreement regarding applicant competitiveness as determined by SLOEs and the ability of 2 algorithms to predict faculty consensus rankings. Methods Using data from the 2021-2022 Match cycle from the Council of Residency Directors in Emergency Medicine SLOE Database as a blueprint, authors created 50 fictional SLOEs representative of the national data. Seven faculty then rated these SLOEs in order of applicant competitiveness, defined as suggested rank position. Consensus was evaluated using cutoffs established a priori, and 2 prediction models, a point-based system and a linear regression model, were tested to determine their ability to predict consensus rankings. Results There was strong faculty consensus regarding the interpretation of SLOEs. Within narrow windows of agreement, faculty demonstrated similar ranking patterns with 83% and 93% agreement for "close" and "loose" agreement, respectively. Predictive models yielded a strong correlation with the consensus ranking (point-based system r=0.97, linear regression r=0.97). Conclusions Faculty displayed strong consensus regarding the competitiveness of applicants via SLOEs, adding further support to the use of SLOEs for selection and advising. Two models predicted consensus competitiveness rankings with a high degree of accuracy.

Away Rotation Applications in Emergency Medicine: Medical Student Behaviors, Outcomes, and Stressors.

BACKGROUND: Completing an emergency medicine (EM) away rotation is integral to matching successfully into an EM residency program. The demand for EM away rotations (ARs) drives students to submit numerous applications without evidence-based recommendations to guide stakeholders on the approach or number to submit. OBJECTIVES: We conducted a survey study of EM-bound fourth-year medical students to gain insight into their AR application experiences, outcomes, and perceptions. METHODS: We distributed a 40-item questionnaire to EM applicants in Fall 2018 via e-mail through the Clerkship Directors in Emergency Medicine, Council of Residency Directors in EM, and Emergency Medicine Residents' Association listservs. Responses were evaluated using quantitative and qualitative analysis. Primary outcomes were the number of AR applications submitted and AR offers received by students. Secondary outcomes were students' self-assessment of their competitiveness, differences in AR application numbers by degree type, sources of student advising, and student perceptions of the AR application process. RESULTS: There were 253 respondents, consisting of 192 allopathic (MD) and 61 osteopathic (DO) medical students, who met the inclusion criteria, representing about 10% of the applicant pool. On average, students submitted 13.97 applications (95% confidence interval [CI] 11.59-16.35), received 3.25 offers (95% CI 3.01-3.49), and accepted 2.22 offers (95% CI 2.08-2.36). DO candidates submitted twice as many applications as MD candidates while experiencing a similar rate of offers received. Peer influence (n = 154, 61%), peer online advising networks (n = 83, 33%), and self-assessment (n = 114, 45%) were the most often reported causes of increased applications; cost (n = 104, 41%) and geographic limitations (n = 114, 45%) were the most often reported causes of decreased applications. Open-response analysis revealed frustration with lack of standardization (n = 44, 29.5%), insufficient transparency on available positions (n = 37, 24.8%), limited communication (n = 30, 20.1%), and cost (n = 12, 8.1%). CONCLUSIONS: This study showed that, as a whole, students received one away rotation offer for every four to five applications submitted. It clarified factors contributing to increased EM away rotation application submissions and associated stressors inherent in the application experience. Our findings offer insights to inform advising recommendations. They also suggest that stakeholders consider standardizing the process and improve communication over spot availability and application status.

Advising special population emergency medicine residency applicants: a survey of emergency medicine advisors and residency program leadership.

BACKGROUND: The objective of this study was to determine the advising and emergency medicine (EM) residency selection practices for special population applicant groups for whom traditional advice may not apply. METHODS: A survey was distributed on the Council of Residency Directors in EM and Clerkship Directors in EM Academy listservs. Multiple choice, Likert-type scale, and fill-in-the-blank questions addressed the average EM applicant and special population groups (osteopathic; international medical graduate (IMG); couples; at-risk; re-applicant; dual-accreditation applicant; and military). Percentages and 95% confidence intervals [CI] were calculated. RESULTS: One hundred four surveys were completed. Of respondents involved in the interview process, 2 or more standardized letters of evaluation (SLOEs) were recommended for osteopathic (90.1% [95% CI 84-96]), IMG (82.5% [73-92]), dual-accreditation (46% [19-73]), and average applicants (48.5% [39-58]). Recommendations for numbers of residency applications to submit were 21-30 (50.5% [40.7-60.3]) for the average applicant, 31-40 (41.6% [31.3-51.8]) for osteopathic, and > 50 (50.9% [37.5-64.4]) for IMG. For below-average Step 1 performance, 56.0% [46.3-65.7] were more likely to interview with an average Step 2 score. 88.1% [81.8-94.4] will consider matching an EM-EM couple. The majority were more likely to interview a military applicant with similar competitiveness to a traditional applicant. Respondents felt the best option for re-applicants was to pursue the Supplemental Offer and Acceptance Program (SOAP) for a preliminary residency position. CONCLUSION: Advising and residency selection practices for special population applicants differ from those of traditional EM applicants. These data serve as an important foundation for advising these distinct applicant groups in ways that were previously only speculative. While respondents agree on many advising recommendations, outliers exist.

COVID-19: A Driver for Disruptive Innovation of the Emergency Medicine Residency Application Process.

The coronavirus disease (COVID-19) pandemic has had a significant impact on undergraduate medical education with limitation of patient care activities and disruption to medical licensing examinations. In an effort to promote both safety and equity, the emergency medicine (EM) community has recommended no away rotations for EM applicants and entirely virtual interviews during this year's residency application cycle. These changes affect the components of the EM residency application most highly regarded by program directors - Standardized Letters of Evaluation from EM rotations, board scores, and interactions during the interview. The Council of Residency Directors in Emergency Medicine Application Process Improvement Committee suggests solutions not only for the upcoming year but also to address longstanding difficulties within the process, encouraging residency programs to leverage these challenges as an opportunity for disruptive innovation.

Addressing Challenges in Obtaining Emergency Medicine Away Rotations and Standardized Letters of Evaluation Due to COVID-19 Pandemic.

The Council of Residency Directors in Emergency Medicine (CORD) Advising Students Committee in Emergency Medicine (ASC-EM) anticipates institutional and regional variability in both the spread and response to COVID-19. Travel restrictions and host institution rotation closures will impact the number of emergency medicine (EM) rotations EM-bound medical students can complete in an unprecedented manner. They may prevent students from completing any away rotations this academic cycle, challenging the students' ability to obtain EM Standardized Letters of Evaluation (SLOEs). EM's emphasis on residency group SLOEs over other letter types creates an undue burden on these vulnerable students and makes the application process intrinsically inequitable. This inequity warrants a reevaluation of the current application practice. This article outlines ASC-EM's proposed recommendations for all stakeholders, including EM program leadership, medical schools, and EM-bound medical students, to consider for the upcoming EM application cycle.

More Is More: Drivers of the Increase in Emergency Medicine Residency Applications.

INTRODUCTION: The average number of applications per allopathic applicant to emergency medicine (EM) residency programs in the United States (US) has increased significantly since 2014. This increase in applications has caused a significant burden on both programs and applicants. Our goal in this study was to investigate the drivers of this application increase so as to inform strategies to mitigate the surge. METHODS: An expert panel designed an anonymous, web-based survey, which was distributed to US allopathic senior applicants in the 2017-2018 EM match cycle via the Council of Residency Directors in Emergency Medicine and the Emergency Medicine Residents Association listservs for completion between the rank list certification deadline and release of match results. The survey collected descriptive statistics and factors affecting application decisions. RESULTS: A total of 532 of 1748 (30.4%) US allopathic seniors responded to the survey. Of these respondents, 47.3% felt they had applied to too many programs, 11.8% felt they had applied to too few, and 57.7% felt that their perception of their own competitiveness increased their number of applications. Application behavior of peers going into EM was identified as the largest external factor driving an increase in applications (61.1%), followed by US Medical Licensing Exam scores (46.9%) - the latter was most pronounced in applicants who self-perceived as "less competitive." The most significant limiter of application numbers was the cost of using the Electronic Residency Application Service (34.3%). CONCLUSION: A substantial group of EM applicants identified that they were over-applying to residencies. The largest driver of this process was individual applicant response to the behavior of their peers who were also going into EM. Understanding these motivations may help inform solutions to overapplication.

Curricula for empathy and compassion training in medical education: A systematic review.

BACKGROUND: Empathy and compassion are vital components of health care quality; however, physicians frequently miss opportunities for empathy and compassion in patient care. Despite evidence that empathy and compassion training can be effective, the specific behaviors that should be taught remain unclear. We synthesized the biomedical literature on empathy and compassion training in medical education to find the specific curricula components (skills and behaviors) demonstrated to be effective. METHODS: We searched CENTRAL, MEDLINE, EMBASE, and CINAHL using a previously published comprehensive search strategy. We screened reference lists of the articles meeting inclusion criteria to identify additional studies for potential inclusion. Study inclusion criteria were: (1) intervention arm in which subjects underwent an educational curriculum aimed at enhancing empathy and/or compassion; (2) clearly defined control arm in which subjects did not receive the curriculum; (3) curriculum was tested on physicians (or physicians-in-training); and (4) outcome measure assessing the effect of the curriculum on physician empathy and/or compassion. We performed a qualitative analysis to collate and tabulate effects of tested curricula according to recommended methodology from the Cochrane Handbook. We used the Cochrane Collaboration's tool for assessing risk of bias. RESULTS: Fifty-two studies (total n = 5,316) met inclusion criteria. Most (75%) studies found that the tested curricula improved physician empathy and/or compassion on at least one outcome measure. We identified the following key behaviors to be effective: (1) sitting (versus standing) during the interview; (2) detecting patients' non-verbal cues of emotion; (3) recognizing and responding to opportunities for compassion; (4) non-verbal communication of caring (e.g. eye contact); and (5) verbal statements of acknowledgement, validation, and support. These behaviors were found to improve patient perception of physician empathy and/or compassion. CONCLUSION: Evidence suggests that training can enhance physician empathy and compassion. Training curricula should incorporate the specific behaviors identified in this report.

Elective Naloxone-Induced Opioid Withdrawal for Rapid Initiation of Medication-Assisted Treatment of Opioid Use Disorder.

We present a case of elective naloxone-induced opioid withdrawal followed by buprenorphine rescue to initiate opioid use disorder treatment in the emergency department. This strategy may represent a safe alternative to prescribing buprenorphine for outpatient initiation, a method that puts the patient at risk for complications of unmonitored opioid withdrawal, including relapse. After confirmation that the naloxone-induced withdrawal was adequately treated with buprenorphine, the patient was discharged with prescribed buprenorphine to follow up in an addiction medicine clinic, where he was treated 2 days later.

Curricula and methods for physician compassion training: protocol for a systematic review.

INTRODUCTION: Compassionate patient care has been associated with improved clinical outcomes for patients. However, current evidence suggests that healthcare is experiencing a compassion crisis, with physicians frequently overlooking opportunities to treat patients with compassion. Although there is evidence that compassionate care can be enhanced through training interventions, it is currently unclear what specific skills and behaviours ought to be taught and how best to transfer this information to the learner. The objectives of this systematic review are to collate the world's literature on compassion training to determine (1) the specific skills and behaviours that should be taught (curriculum), and (2) the methods of training that are most effective at improving compassionate patient care. METHODS AND ANALYSIS: We will perform a qualitative systematic review of studies aimed at improving compassionate patient care among physicians and physicians in training. We will comprehensively search CENTRAL, MEDLINE, EMBASE and CINAHL. Additional recommended techniques for systematic reviews of complex evidence will be performed including pursuing selected 'references of references', electronic citation tracking and consulting experts in the field. Two investigators will independently review all search results. After identification and inclusion of papers, we will use a standardised form for data extraction. We will use tables to describe the study populations, interventions tested (including specific skill/behaviours taught and training methods used), outcome measures and effects of interventions on outcome measures compared with control groups. Where appropriate, meta-analysis will be used for quantitative analysis of the data. ETHICS AND DISSEMINATION: The proposed systematic review does not require ethical approval since no individual patient-level data will be collected. Results of this study will contribute to the understanding of compassion training and help inform the development of compassion training curricula. PROSPERO REGISTRATION NUMBER: CRD42018095040.

Relationship Between Institutional Standardized Letter of Evaluation Global Assessment Ranking Practices, Interviewing Practices, and Medical Student Outcomes.

BACKGROUND: Emergency medicine (EM) program directors rely largely on the standardized letter of evaluation (SLOE) to help determine which applicants to interview in the face of an increasing number of applications. To further characterize the SLOE's role in the EM application process, particularly the global assessment (GA) ranking and its effect on interviewing practices and medical student outcomes, the leaders of EM programs were surveyed regarding their experiences in both generating and utilizing the SLOE. METHODS: Individuals on the Council of Emergency Medicine Residency Directors (CORD) and Clerkship Directors in Emergency Medicine (CDEM) Academy listservs were anonymously surveyed from March 21-30, 2015, with 18 questions in multiple-choice and fill-in-the-blank formats. RESULTS: There were 99 respondents. Only 39 respondents (39%) reported adhering strictly to SLOE guidelines by evenly placing their students into thirds (top, middle, lower) on the SLOE GA. Most respondents interviewed individuals ranked in the lower third. Programs adhering strictly to ranking guidelines were more likely to interview students in the lower third than those adhering loosely or not at all. There was no relationship between a program's self-reported adherence to the SLOE ranking guidelines and the number of unmatched students in EM during the 2014 and 2015 academic years. CONCLUSION: Many SLOE writers do not strictly adhere to CORD's SLOE writing guidelines when using the GA ranking, due to the fear of adversely impacting an applicant's ability to successfully match into EM. This calls into question the validity of the SLOE as it is currently used. However, this study suggests that adhering to recommended SLOE ranking guidelines is unlikely to substantially increase the risk that students will fail to match. If more evaluators were to adhere to the guidelines, the SLOE could become the valid evaluation instrument that graduate medical education has long been pursuing.