From inequity to access: Evidence-based institutional practices to enhance care for individuals with disabilities.

People with disabilities experience barriers to care in all facets of health care, from engaging with the provider in a clinical setting (attitudinal and communication barriers) to navigating a large institution in a complex health care environment (organizational and environmental barriers), culminating in significant health care disparities. Institutional policy, culture, and physical layout may be inadvertently fostering ableism, which can perpetuate health care inaccessibility and health disparities in the disability community. Here, we present evidence-based interventions at the provider and institutional levels to accommodate patients with hearing, vision, and intellectual disabilities. Institutional barriers can be met with strategies of universal design (i.e., accessible exam rooms and emergency alerts), maximizing electronic medical record accessibility/visibility, and institutional policy development to recognize and reduce discrimination. Barriers at the provider level can be met with dedicated training on care of patients with disabilities and implicit bias training specific to the surrounding patient demographics. Such efforts are crucial to ensuring equitable access to quality care for these patients.

A National Survey of Job Satisfaction and Workload Among Emergency Medicine (EM) Residency Faculty.

INTRODUCTION:  Faculty workload, and its relation to job satisfaction, has not been well studied in Emergency Medicine (EM).  Methods: A cross-sectional survey was conducted among EM physician faculty at 49 residency programs across the United States. We collected information on clinical and non-clinical (education, administration, and research) workload, demographics, and EM department characteristics, as well as job satisfaction measured using the Global Job Satisfaction (GJS) scale. Comparisons were made using Wilcox signed rank tests. Multivariable associations with job satisfaction were assessed in a regression model. RESULTS:  Of 1,791 surveys sent, 265 were completed. The quantity of contracted clinical and non-clinical hours was lower than the actual clinical (difference (95% confidence interval (CI)): 2.7 (1.5-4.1)) and non-clinical hours (6.0 (3.8-8.8)) worked. Respondents preferred a distribution of 50% clinical work. However, the actual percentage was 62% (difference (95% CI): 14.4% (10.8%-17.6%)). Identifying as core faculty and required logging of non-clinical hours were associated with improved job satisfaction while increased percentage of time spent in the clinical and administrative domains were associated with significant declines. CONCLUSIONS:  The estimated actual work performed by EM physician faculty is greater than contracted and misaligned with their preferred type of work, the latter of which is associated with decreased job satisfaction. Improved job satisfaction and faculty retention might be achieved by increasing the percentage of time devoted to education and research, by increasing the core faculty contingent and by implementing tracking of non-clinical efforts.

Structural competency in emergency medical education: A scoping review and operational framework.

Objectives: Existing curricula and recommendations on the incorporation of structural competency and vulnerability into medical education have not provided clear guidance on how best to do so within emergency medicine (EM). The goal of this scoping review and consensus building process was to provide a comprehensive overview of structural competency, link structural competency to educational and patient care outcomes, and identify existing gaps in the literature to inform curricular implementation and future research in EM. Methods: A scoping review focused on structural competency and vulnerability following Arksey and O'Malley's six-step framework was performed in concurrence with a multistep consensus process culminating in the 2021 SAEM Consensus Conference. Feedback was incorporated in developing a framework for a national structural competency curriculum in EM. Results: A literature search identified 291 articles that underwent initial screening. Of these, 51 were determined to be relevant to EM education. The papers consistently conceptualized structural competency as an interdisciplinary framework that requires learners and educators to consider historical power and privilege to develop a professional commitment to justice. However, the papers varied in their operationalization, and no consensus existed on how to observe or measure the effects of structural competency on learners or patients. None of the studies examined the structural constraints of the learners studied. Conclusions: Findings emphasize the need for training structurally competent physicians via national structural competency curricula focusing on standardized core competency proficiencies. Moreover, the findings highlight the need to assess the impact of such curricula on patient outcomes and learners' knowledge, attitudes, and clinical care delivery. The framework aims to standardize EM education while highlighting the need for further research in how structural competency interventions would translate to an ED setting and affect patient outcomes and experiences.

Program evaluation: An educator's portal into academic scholarship.

Program evaluation is an "essential responsibility" but is often not seen as a scholarly pursuit. While Boyer expanded what qualifies as educational scholarship, many still need to engage in processes that are rigorous and of a requisite academic standard to be labelled as scholarly. Many medical educators may feel that scholarly program evaluation is a daunting task due to the competing interests of curricular change, remediation, and clinical care. This paper explores how educators can take their questions around outcomes and efficacy of our programs and efficiently engage in education scholarship. The authors outline how educators can examine whether training programs have a desired impact and outcomes, and then how they might leverage this process into education scholarship.

Workplace-based Assessment Data in Emergency Medicine: A Scoping Review of the Literature.

OBJECTIVE: In the era of competency-based medical education (CBME), the collection of more and more trainee data is being mandated by accrediting bodies such as the Accreditation Council for Graduate Medical Education and the Royal College of Physicians and Surgeons of Canada. However, few efforts have been made to synthesize the literature around the current issues surrounding workplace-based assessment (WBA) data. This scoping review seeks to synthesize the landscape of literature on the topic of data collection and utilization for trainees' WBAs in emergency medicine (EM). METHODS: The authors conducted a scoping review in the style of Arksey and O'Malley, seeking to synthesize and map literature on collecting, aggregating, and reporting WBA data. The authors extracted, mapped, and synthesized literature that describes, supports, and substantiates effective data collection and utilization in the context of the CBME movement within EM. RESULTS: Our literature search retrieved 189 potentially relevant references (after removing duplicates) that were screened to 29 abstracts and papers relevant to collecting, aggregating, and reporting WBAs. Our analysis shows that there is an increasing temporal trend toward contributions in these topics, with the majority of the papers (16/29) being published in the past 3 years alone. CONCLUSION: There is increasing interest in the areas around data collection and utilization in the age of CBME. The field, however, is only beginning to emerge, leaving more work that can and should be done in this area.

Direct Observation Tools in Emergency Medicine: A Systematic Review of the Literature.

OBJECTIVES: Direct observation is important for assessing the competency of medical learners. Multiple tools have been described in other fields, although the degree of emergency medicine-specific literature is unclear. This review sought to summarize the current literature on direct observation tools in the emergency department (ED) setting. METHODS: We searched PubMed, Scopus, CINAHL, the Cochrane Central Register of Clinical Trials, the Cochrane Database of Systematic Reviews, ERIC, PsycINFO, and Google Scholar from 2012 to 2020 for publications on direct observation tools in the ED setting. Data were dual extracted into a predefined worksheet, and quality analysis was performed using the Medical Education Research Study Quality Instrument. RESULTS: We identified 38 publications, comprising 2,977 learners. Fifteen different tools were described. The most commonly assessed tools included the Milestones (nine studies), Observed Structured Clinical Exercises (seven studies), the McMaster Modular Assessment Program (six studies), Queen's Simulation Assessment Test (five studies), and the mini-Clinical Evaluation Exercise (four studies). Most of the studies were performed in a single institution, and there were limited validity or reliability assessments reported. CONCLUSIONS: The number of publications on direct observation tools for the ED setting has markedly increased. However, there remains a need for stronger internal and external validity data.

Wellness: Combating Burnout and Its Consequences in Emergency Medicine.

Medicine recognizes burnout as a threat to quality patient care and physician quality of life. This issue exists throughout medicine but is notably prevalent in emergency medicine (EM). Because the concept of "wellness" lacks a clear definition, attempts at ameliorating burnout that focus on achieving wellness make success difficult to achieve and measure. Recent work within the wellness literature suggests that the end goal should be to achieve a culture of wellness by addressing all aspects of the physician's environment. A review of the available literature on burnout and wellness interventions in all medical specialties reveals that interventions focusing on individual physicians have varying levels of success. Efforts to compare these interventions are hampered by a lack of consistent endpoints. Studies with consistent endpoints do not demonstrate clear benefits of achieving them because improving scores on various scales may not equate to improvement in quality of care or physician quality of life. Successful interventions have uncertain, long-term effects. Outside of EM, the most successful interventions focus on changes to systems rather than to individual physicians. Within EM, the number of well-structured interventions that have been studied is limited. Future work to achieve the desired culture of wellness within EM requires establishment of a consistent endpoint that serves as a surrogate for clinical significance, addressing contributors to burnout at all levels, and integrating successful interventions into the fabric of EM.

A Short History of Free Open Access Medical Education. The Past, Present, and Future.

Free Open Access Medical education (FOAM) has taken the emergency medicine and critical care worlds by storm in the past decade. This article represents one perspective on the stages of transition for FOAM from its humble beginnings as a grassroots movement to the more recent multiauthor blogs that are described in the peer-reviewed literature. In this article, the authors describe the following four distinct waves of people within the movement, with each wave creating a new stage in the evolution of the FOAM community: Creation by the Founders, Adoption by the Enthusiasts, Structure and Formalization by the Structuralists, and Engagement and Activity by the End Users. The authors contextualize some of the phenomena that have been observed within this field and highlight challenges for the field moving forward.

Curated Collections for Educators: Five Key Papers on Clinical Teaching.

The ability to teach in the clinical setting is of paramount importance. Clinical teaching is at the heart of medical education, irrespective of the learner's level of training. Learners desire and need effective, competent, and thoughtful clinical teaching from their instructors. However, many clinician-educators lack formal training on this important skill and thus may provide a variable experience to their learners. Although formal training of clinician-educators is standard and required in many other countries, the United States has yet to follow suit, leaving many faculty members to fend for themselves to learn these important skills.  In September 2018, the Academic Life in Emergency Medicine (ALiEM) 2018-2019 Faculty Incubator program discussed the topic of clinical teaching techniques. We gathered the titles of papers that were cited, shared, and recommended within our online discussion forum and compiled the articles pertaining to the topic of clinical teaching techniques. To augment the list, the authors did a formal literature search using the search terms "teaching techniques", "clinical teaching", "medical education", "medical students", and "residents" on Google Scholar and PubMed. Finally, we posted a call for important papers on the topic of clinical teaching techniques on Twitter. Through this process, we identified 48 core articles on the topic of clinical teaching. We conducted a modified Delphi methodology to identify the key papers on the topic. In this paper, we present the five highest-rated articles based on the relevance to junior faculty and faculty developers. This article will review and summarize the articles we found to be the most impactful to improve one's clinical teaching skills.

Curated Collections for Educators: Five Key Papers about Receiving Feedback in Medical Education.

Introduction Feedback is a complex, multi-component interaction that is essential for academic development and advancement. Successful feedback requires active involvement from both the giver and receiver. However, research and guidance on the subject mostly center on the role of the provider of feedback. But the receiver of feedback holds the true power in this interaction, choosing how to interpret the information and deciding whether or not to incorporate the feedback to instill behavioral change. In this article, the authors aim to summarize five key papers related to receiving feedback, in order to outline both relevant information for emerging clinician-educators and discern ways to use this information for faculty development. Methods In order to generate a list of key papers that describe the importance of receiving feedback, the authors conducted a consensus-building process informed by social media sources. Key articles on receiving feedback were aggregated through a literature search. This list was further augmented via an open call on Twitter for important papers regarding receiving feedback. Through these processes, a list of 43 papers was created on the topic of receiving feedback in medical education. After compiling this preliminary list, the authorship group engaged in a modified Delphi approach to build consensus on selecting papers that best described the process of receiving feedback. Results We present the group's five most highly rated papers on the topic of receiving feedback in medical education. These papers were deemed essential and have also been summarized based on their relevance to junior faculty members and faculty developers. Conclusion While giving and receiving feedback are both vital for growth and development, much of the research focuses solely on giving feedback. However, receiving feedback is equally, if not more, important for instilling change in the learner. We explore the power of receiving feedback in medical education through five key papers that analyze the subject. We believe these papers can serve as great learning resources for both junior faculty members and faculty developers. They can assist the junior faculty to cultivate the ability to receive feedback and also serve as resources to aid senior faculty in building faculty-development sessions.

Erratum: This Article Corrects: "Burnout, Drop Out, Suicide: Physician Loss in Emergency Medicine, Part 1".

[This corrects West J Emerg Med. 2019 January;20(3):485-494]

Curated Collections for Educators: Eight Key Papers about Feedback in Medical Education.

Feedback is an essential part of learning, growth, and academic success. Junior faculty members are often unfamiliar with the grounding literature that defines feedback. Many times they receive little education on providing and receiving feedback, resulting in unhelpful "feedback" for both learners and program leadership alike. This article aims to summarize eight key papers on feedback, to outline relevant information for emerging clinician educators, and identify ways to use these resources for the faculty development.  In order to generate a list of key papers that describes the importance and significance of feedback, the authors conducted a consensus-building process to identify the top papers. In August and September, 2018, the 2018-2019 Academic Life in Emergency Medicine (ALiEM) Faculty Incubator program discussed the topic of feedback in medical education. A number of papers on the topic was highlighted. This list of papers was further augmented using the suggestions and expertise of guest experts who are leaders in the field of medical education and feedback. The authors also used social media to conduct an open call on Twitter for important papers regarding feedback (utilizing #meded, #Feedback hashtags). Via this process, a list of 88 key papers was identified on the topic of feedback in medical education. After compiling these papers, the authorship group engaged in a modified Delphi approach to build consensus on the top eight papers on feedback. These papers were deemed essential by the authors and have been summarized with respect to their relevance to junior faculty members and to faculty developers. In this manuscript, we present eight key papers addressing feedback in medical education with discussions and applications for junior faculty members and faculty developers. This list of articles that can serve to help junior clinician educators grow in their ability to give effective feedback and also serve as resources upon which senior faculty can design the faculty development sessions.

Burnout, Drop Out, Suicide: Physician Loss in Emergency Medicine, Part I.

Each year more than 400 physicians take their lives, likely related to increasing depression and burnout. Burnout-a psychological syndrome featuring emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment-is a disturbingly and increasingly prevalent phenomenon in healthcare, and emergency medicine (EM) in particular. As self-care based solutions have proven unsuccessful, more system-based causes, beyond the control of the individual physicians, have been identified. Such system-based causes include limitations of the electronic health record, long work hours and substantial educational debt, all in a culture of "no mistakes allowed." Blame and isolation in the face of medical errors and poor outcomes may lead to physician emotional injury, the so-called "second victim" syndrome, which is both a contributor to and consequence of burnout. In addition, emergency physicians (EP) are also particularly affected by the intensity of clinical practice, the higher risk of litigation, and the chronic fatigue of circadian rhythm disruption. Burnout has widespread consequences, including poor quality of care, increased medical errors, patient and provider dissatisfaction, and attrition from medical practice, exacerbating the shortage and maldistribution of EPs. Burned-out physicians are unlikely to seek professional treatment and may attempt to deal with substance abuse, depression and suicidal thoughts alone. This paper reviews the scope of burnout, contributors, and consequences both for medicine in general and for EM in particular.

Professionalism Milestones Assessments Used by Emergency Medicine Residency Programs: A Cross-sectional Survey.

INTRODUCTION: Professionalism is a vital component of quality patient care. While competency in professionalism is Accreditation Council for Graduate Medical Education (ACGME)-mandated, the methods used to evaluate professionalism are not standardized, calling into question the validity of reported measurements. We aimed to determine the type and frequency of methods used by United States (US) -based emergency medicine (EM) residencies to assess accountability (Acc) and professional values (PV), as well as how often graduating residents achieve competency in these areas. METHODS: We created a cross-sectional survey exploring assessment and perceived competency in Acc and PV, and then modified the survey for content and clarity through feedback from emergency physicians not involved in the study. The final survey was sent to the clinical competency committee (CCC) chair or program director (PD) of the 185 US-based ACGME-accredited EM residencies. We summarized results using descriptive statistics and Fisher's exact testing. RESULTS: A total of 121 programs (65.4%) completed the survey. The most frequently used methods of assessment were faculty shift evaluation (89.7%), CCC opinion (86.8%), and faculty summative evaluation (76.4%). Overall, 37% and 42% of residency programs stated that nearly all (greater than 95%) of their graduating residents achieve mastery of Acc and PV non-technical skills, respectively. Only 11.2% of respondents felt their programs were very effective at determining mastery of non-technical skills. CONCLUSION: EM residency programs relied heavily on faculty shift evaluations and summative opinions to determine resident competency in professionalism, with feedback from peers, administrators, and other staff less frequently incorporated. Few residency programs felt their current methods of evaluating professionalism were very effective.

Association between blood alcohol concentration and mortality in critical illness.

OBJECTIVE: In animal models of renal, intestinal, liver, cardiac, and cerebral ischemia, alcohol exposure is shown to reduce ischemia-reperfusion injury. Inpatient mortality of trauma patients is shown to be decreased in a dose-dependent fashion relative to blood alcohol concentration (BAC) at hospital admission. In this study, we examined the association between BAC at hospital admission and risk of 30-day mortality in critically ill patients. DESIGN: We performed a 2-center observational study of patients treated in medical and surgical intensive care units in Boston, Massachusetts. SETTING: Medical and surgical intensive care units in 2 teaching hospitals in Boston, Massachusetts. PATIENTS: We studied 11850 patients, 18 years or older, who received critical care between 1997 and 2007. The exposure of interest was the BAC determined in the first 24 hours of hospital admission and categorized a priori as BAC less than 10 mg/dL (below level of detection), 10 to 80 mg/dL, 80 to 160 mg/dL, and greater than 160 mg/dL. The primary outcome was all-cause mortality in the 30 days after critical care initiation. Secondary outcomes included 90- and 365-day mortality after critical care initiation. Mortality was determined using the US Social Security Administration Death Master File, and 365-day follow-up was present in all cohort patients. Adjusted odds ratios (ORs) were estimated by multivariable logistic regression models with inclusion of covariate terms thought to plausibly interact with both BAC and mortality. Adjustment included age, sex, race (white or nonwhite), type (surgical vs medical), Deyo-Charlson index, sepsis, acute organ failure, trauma, and chronic liver disease. RESULTS: Thirty-day mortality of the cohort was 13.7%. Compared to patients with BAC levels less than 10 mg/dL, patients with levels greater than or equal to 10 mg/dL had lower odds of 30-day mortality; for BAC levels 10 to 79.9 mg/dL, the OR was 0.53 (95% confidence interval [CI], 0.40-0.70); for BAC levels 80 to 159.9 mg/dL, it was 0.36 (95% CI, 0.26-0.49); and for BAC levels greater than or equal to 160 mg/dL, it was 0.35 (95% CI, 0.27-0.44). After multivariable adjustment, the OR of 30-day mortality was 0.97 (0.72-1.31), 0.79 (0.57-1.10), and 0.69 (0.54-0.90), respectively. When the cohort was analyzed with sepsis as the outcome of interest, the multivariable adjusted odds of sepsis in patients with BAC 80 to 160 mg/dL or greater than 160 mg/dL were 0.72 (0.50-1.04) or 0.68 (0.51-0.90), respectively, compared to those with BAC less than 10 mg/dL. In a subset of patients with blood cultures drawn (n=4065), the multivariable adjusted odds of bloodstream infection in patients with BAC 80 to 160 mg/dL or greater than 160 mg/dL were 0.53 (0.27-1.01) or 0.49 (0.29-0.83), respectively, compared to those with BAC less than 10 mg/dL. CONCLUSIONS: Analysis of 11850 adult patients showed that having a detectable BAC at hospitalization was associated with significantly decreased odds of 30-day mortality after critical care. Furthermore, BAC greater than 160 mg/dL is associated with significantly decreased odds of developing sepsis and bloodstream infection.

A rational approach to the treatment of alcohol withdrawal in the ED.

Approximately 7% of the US population abuses or is dependent on alcohol. Patients with alcohol disorders often seek medical attention in Emergency Departments (EDs) for complications directly related to alcohol use or due to other medical issues associated with alcohol use. Because of increasing lengths of stay in EDs, alcohol-dependent patients are at high risk of developing alcohol withdrawal syndrome (AWS) during their ED visit. This article reviews the physiology of alcohol withdrawal as well as the symptoms of this potentially deadly illness for the practicing emergency physician (EP). We provide evidence-based guidelines for the appropriate ED treatment of moderate to severe AWS, including pharmacologic interventions, adjunctive therapies, and disposition of these patients.

Bedside method to estimate actual body weight in the Emergency Department.

BACKGROUND: Actual body weight (ABW) is important for accurate drug dosing in emergency settings. Oftentimes, patients are unable to stand to be weighed accurately or clearly state their most recent weight. OBJECTIVE: Develop a bedside method to estimate ABW using simple anthropometric measurements. METHODS: Prospective, blinded, cross-sectional convenience sampling of adult Emergency Department (ED) patients. A multiple linear regression equation from Derivation Phase (n = 208: 121 males, 87 females) found abdominal and thigh circumferences (AC and TC) had the best fit and an inter-rater correlation of 0.99 and 0.96, respectively: Male ABW (kg) = -47.8 + 0.78 ∗ (AC) + 1.06 ∗ (TC); Female ABW = -40.2 + 0.47 ∗ (AC) + 1.30 ∗ (TC). RESULTS: Derivation phase: Number of patients (%) with a body weight estimation (BWE) > 10 kg from ABW for males/females were: 7 (6%)/1 (1%) for Patients, 46 (38%)/28 (32%) for Doctors, 38 (31%)/24 (27%) for Nurses, 75 (62%)/43 (49%) for 70 kg/60 kg convention, and 14 (12%)/8 (9%) using the anthropometric regression model. For validation phase (55 males, 44 females): Gold standard ABW mean (SD) male/female = 83.6 kg (14.3)/71.5 kg (18.9) vs. anthropometric regression model = 86.3 kg (14.7)/73.3 kg (15.1). R(2) = 0.89, p < 0.001. The number (%) for males/females with a BWE > 10 kg using the anthropometric regression model = 8 (15%)/11 (27%). CONCLUSIONS: For male patients, a regression model using supine thigh and abdominal circumference measurements seems to provide a useful and more accurate alternative to physician, nurse, or standard 70-kg male conventional estimates, but was less accurate for use in female patients.

The use of the radiographic appearance of the azygos vein to assess volume status in trauma patients.

BACKGROUND: The assessment of hypovolemia in victims of trauma is a critical aspect of resuscitation and care in the initial presentation of a patient. This study attempted to validate the use of the appearance of the azygos vein (AV) on initial chest radiographs as a parameter that may add to this initial assessment. METHODS: The design involved a blinded independent assessment of serial chest radiographs from consecutive trauma cases from January 21, 2008, until September 13, 2008, by a trained Radiologist and a Trauma Team Leader (TTL) and then comparing this assessment to mean arterial pressure (MAP) and heart rate estimates of volume status in serial severe trauma patients. This is an insensitive but specific measure of volume status. RESULTS: In this population with high prevalence of hypovolemia, the presence of an AV ≤ 0.5 cm yielded a sensitivity of 4.9% and 9.8% for the TTL and Radiologist, respectively, in patients with a mean arterial pressure <70 and heart rate >100. The specificity was 98.8% and 91.6%, which translates into a positive likelihood ratio of 4.08 and 1.17 for the TTL and Radiologist, respectively. The Kappa score for agreement between the two readers was 0.4. CONCLUSION: When a small AV can be seen by the TTL, it may be a useful adjunct to the assessment of volume status.