Dimitrios Papanagnou

Academic Primer Series: Five Key Papers Fostering Educational Scholarship in Junior Academic Faculty

Introduction Scholarship is an essential part of academic success. Junior faculty members are often unfamiliar with the grounding literature that defines educational scholarship. In this article, the authors aim to summarize five key papers which outline education scholarship in the setting of academic contributions for emerging clinician educators. Methods The authors conducted a consensus-building process to generate a list of key papers that describe the importance and significance of academic scholarship, informed by social media sources. They then used a three-round voting methodology, akin to a Delphi study, to determine the most useful papers. Results A summary of the five most important papers on the topic of academic scholarship, as determined by this mixed group of junior faculty members and faculty developers, is presented in this paper. These authors subsequently wrote a summary of these five papers and discussed their relevance to both junior faculty members and faculty developers. Conclusion Five papers on education scholarship, deemed essential by the authors’ consensus process, are presented in this paper. These papers may help provide the foundational background to help junior faculty members gain a grasp of the academic scholarly environment. This list may also inform senior faculty and faculty developers on the needs of junior educators in the nascent stages of their careers.

Clinician-Performed Bedside Ultrasound in Improving Diagnostic Accuracy in Patients Presenting to the ED with Acute Dyspnea

Introduction Diagnosing acute dyspnea is a critical action performed by emergency physicians (EP). It has been shown that ultrasound (US) can be incorporated into the work-up of the dyspneic patient; but there is little data demonstrating its effect on decision-making. We sought to examine the impact of a bedside, clinician-performed cardiopulmonary US protocol on the clinical impression of EPs evaluating dyspneic patients, and to measure the change in physician confidence with the leading diagnosis before and after US. Methods We conducted a prospective observational study of EPs treating adult patients with undifferentiated dyspnea in an urban academic center, excluding those with a known cause of dyspnea after evaluation. Outcomes: 1) percentage of post-US diagnosis matching final diagnosis; 2) percentage of time US changed providers’ leading diagnosis; and 3) change in physicians’ confidence with the leading diagnosis before and after US. An US protocol was developed and standardized prior to the study. Providers (senior residents, fellows, attendings) were trained on US (didactics, hands on) prior to enrollment, and were supervised by an US faculty member. After patient evaluation, providers listed likely diagnoses, documenting their confidence level with their leading diagnosis (scale of 1–10). After US, providers revised their lists and their reported confidence level with their leading diagnosis. Proportions are reported as percentages with 95% confidence interval (CI) and continuous variables as medians with quartiles. We used the Wilcoxon signed-rank test and Cohen’s kappa statistics to analyze data. Results A total of 115 patients were enrolled (median age: 61 [51, 73], 59% female). The most common diagnosis before US was congestive heart failure (CHF) (41%, 95%CI, 32–50%), followed by chronic obstructive pulmonary disease (COPD) and asthma. CHF remained the most common diagnosis after US (46%, 95%CI, 38–55); COPD became less common (pre-US, 22%, 95%CI, 15–30%; post-US, 17%, 95%CI, 11–24%). Post-US clinical diagnosis matched the final diagnosis 63% of the time (95%CI, 53–70%), compared to 69% pre-US (95%CI, 60–76%). Fifty percent of providers changed their leading diagnosis after US (95%CI, 41–59%). Overall confidence of providers’ leading diagnosis increased after US (7 [6, 8]) vs. 9 [8, 9], p: 0.001). Conclusion Bedside US did not improve the diagnostic accuracy in physicians treating patients presenting with acute undifferentiated dyspnea. US, however, did improve providers’ confidence with their leading diagnosis.

Emergency Medicine Resident Perceptions About the Need for Increased Training in Communicating Diagnostic Uncertainty

Introduction Diagnostic uncertainty is common in healthcare encounters. Effective communication is important to help patients and providers navigate diagnostic uncertainty, especially at transitions of care. This study sought to assess the experience and training of emergency medicine (EM) residents with communication of diagnostic uncertainty. Methods This was a survey study of a national sample of EM residents. The survey questions elicited quantitative and qualitative responses about experiences with and educational preparation for communication with patients in the setting of diagnostic uncertainty. Results A sample of 263 emergency medicine residents who had trained at over 87 medical schools and 37 residency programs responded to the survey. Nearly half of participants noted they frequently encountered challenges with these conversations; 63% reported having been “somewhat” or less trained to have these conversations during residency, and 51% expressed a strong desire for more training in how to approach these discussions. Survey respondents reported that prior educational experiences in the communication of diagnostic uncertainty were largely informal and that many residents experience frustration in clinical encounters due to inability to meet patients’ expectations of reaching a diagnosis at the time of discharge. Conclusion This study found that emergency medicine residents frequently struggle in communicating with patients when there is diagnostic uncertainty upon emergency department discharge and perceived the need for training in how to communicate in these situations. The development of targeted educational strategies for improving communication in the setting of diagnostic uncertainty is consistent with emergency medicine core competencies and may improve patient and provider satisfaction with these clinical encounters.

Case-based Learning Outperformed Simulation Exercises in Disaster Preparedness Education Among Nursing Trainees in India: A Randomized Controlled Trial.

OBJECTIVE In resource-constrained environments, appropriately employing triage in disaster situations is crucial. Although both case-based learning (CBL) and simulation exercises (SEs) commonly are utilized in teaching disaster preparedness to adult learners, there is no substantial evidence supporting one as a more efficacious methodology. This randomized controlled trial (RCT) evaluated the effectiveness of CBL versus SEs in addition to standard didactic instruction in knowledge attainment pertaining to disaster triage preparedness. METHODS This RCT was performed during a one-day disaster preparedness course in Lucknow, India during October 2014. Following provision of informed consent, nursing trainees were randomized to knowledge assessment after didactic teaching (control group); didactic plus CBL (Intervention Group 1); or didactic plus SE (Intervention Group 2). The educational curriculum used the topical focus of triage processes during disaster situations. Cases for the educational intervention sessions were scripted, identical between modalities, and employed structured debriefing. Trained live actors were used for SEs. After primary assessment, the groups underwent crossover to take part in the alternative educational modality and were re-assessed. Two standardized multiple-choice question batteries, encompassing key core content, were used for assessments. A sample size of 48 participants was calculated to detect a ≥20% change in mean knowledge score (α=0.05; power=80%). Robustness of randomization was evaluated using X 2, anova, and t-tests. Mean knowledge attainment scores were compared using one- and two-sample t-tests for intergroup and intragroup analyses, respectively. RESULTS Among 60 enrolled participants, 88.3% completed follow-up. No significant differences in participant characteristics existed between randomization arms. Mean baseline knowledge score in the control group was 43.8% (standard deviation=11.0%). Case-based learning training resulted in a significant increase in relative knowledge scores at 20.8% (P=0.003) and 10.3% (P=.033) in intergroup and intragroup analyses, respectively. As compared to control, SEs did not significantly alter knowledge attainment scores with an average score increase of 6.6% (P=.396). In crossover intra-arm analysis, SEs were found to result in a 26.0% decrement in mean assessment score (P < .001). CONCLUSIONS Among nursing trainees assessed in this RCT, the CBL modality was superior to SEs in short-term disaster preparedness educational translation. Simulation exercises resulted in no detectable improvement in knowledge attainment in this population, suggesting that CBL may be utilized preferentially for adult learners in similar disaster training settings. Aluisio AR , Daniel P , Grock A , Freedman J , Singh A , Papanagnou D , Arquilla B . Case-based learning outperformed simulation exercises in disaster preparedness education among nursing trainees in India: a randomized controlled trial. Prehosp Disaster Med. 2016;31(5):516-523.

Emergency Ultrasound: A Survey Study of Fellowship Graduate Characteristics and Career Paths

There are sparse data on the career pathways of graduates of emergency ultrasound fellowships. The authors sought to define the characteristics of graduates and their reported career paths after training through this survey study.

Ice-man Down: Using Simulation to Practice the Safe Extrication of Collapsed Hockey Players in a Confined Space

Sporting event emergencies are common among both spectators and players, with unique sets of challenges associated with patient extrication in unfamiliar and chaotic environments. It is critical for sports physicians and trainers to deliberately train and prepare for emergent situations with limited resources during athletic events. One of the most difficult, yet commonly encountered challenges is determining when and how to safely remove an injured player’s helmet and sporting equipment, particularly if a spinal injury is highly suspected. We created a high-fidelity simulation case to practice the safe extrication of a hockey player who collapses on the bench in the player’s box, a space-restricted environment. The patient is a 25-year-old male hockey player who becomes unresponsive after a syncopal episode in the player’s box, and subsequently transferred to a medical center for further evaluation. Critical actions include extrication of the player at the scene, diagnosis of syncope, placement of the unconscious player on a backboard with cervical-spine precautions, removal of the player’s faceguard, removing the player off the ice, checking the electrocardiogram and glucose level, and transferring the player to a controlled environment. The learning objectives were to identify, evaluate, and manage the reversible causes of syncope, and demonstrate appropriate techniques for the optimal removal of sports equipment. Learner assessment was based on participation in the scenario and debriefing learners after the simulation. Post-simulation debriefing revealed that participants highly appreciated practicing not-so-commonly encountered hockey-related emergencies. Athletic trainers and emergency providers were able to effectively practice their management of the unresponsive hockey player. The participants were also able to deliberately practice their teamwork and communications skills with their peers. Learning points include proper c-spine immobilization techniques in a tight space and indication for gear-removal in an unconscious patient. As hockey continues to gain popularity, this simulation case will prepare athletic trainers and emergency providers to better address the reversible causes for syncope in hockey players, as well as safely and effectively extricate injured players from space-limiting sporting environments.

A Novel Approach to Debriefing Medical Simulations: The Six Thinking Hats

Simulation has become a standard training method in emergency medicine (EM). Specifically, post-simulation debriefings offer participants the opportunity for reflection while exposing their knowledge and practice gaps. The educational yield of these debriefings, however, is contingent on the debriefers skills. Without professional development, faculty and educators may not be equipped with supportive debriefing strategies. We propose the Six Thinking Hats (6TH), originally developed by Edward de Bono (1970) as a debriefing framework to support effective, high-yield debriefing conversations. The six colored hats represent six unique approaches to critical thinking. The white hat represents the facts; the green hat, creativity and next steps; the yellow hat, benefits/optimism; the red hat, emotions; the black hat, judgments; and the blue hat, facilitation. Four junior faculty members underwent a one-hour didactic and one-hour immersive workshop on the 6TH. Two simulation cases were randomly selected from archived simulation cases, which were used for the debriefing process. Each team consisted of one EM resident and one EM faculty. After each simulated case, the facilitator introduced the 6TH at the start of the debriefing, explaining the rules of engagement and the general sequence of hats to be used. Physical hats were worn by the facilitator at the beginning of the session and changed throughout stages of the debriefing, to remind participants of the type of thinking that was taking place at any given time. Participants who were provided with a colored hat prompt that physically described the type of thinking being employed throughout stages of the debriefing were better able to stay within that respective thinking frame during the discussion, compared to participants who were not provided this visual prompt. Participants of both simulation sessions agreed that the 6TH debriefing style was successful in creating a non-judgmental, comfortable environment that supported open discussion. The 6TH has the potential to be adopted as a debriefing framework, particularly for junior faculty members without extensive debriefing training. The 6TH is intuitive and has been marked by success in the organizational psychology literature. Faculty development on the 6TH will be essential if this framework is to be used as a debriefing model for educators in health care.

A Curious Researcher’s Guide on Successfully Publishing Scientific Manuscripts

Publishing a manuscript in an academic journal represents more than just ‘promotional currency.’ It provides the opportunity to provoke debate, share your experiences, and challenge the status quo on provider practices. Writing a manuscript relies on collaboration and shared responsibility from a research team, which can often challenge mentors as they supervise and guide its development. While there are numerous online resources and peer-reviewed journal articles on ‘How to write a scientific article,’ we aim to tackle an even larger and overarching theme that transcends specific journal categories, writing styles, and citation formatting. In order to guide new researchers in navigating the expansive ocean of scientific publications, we collected, reviewed, and revised 11 tips based on multiple focus-group discussions with junior and senior researchers to determine common barriers for publishing manuscript. The goal is to help mentors and mentees navigate the research and publication processes. The tips include: 1) recognizing leadership styles; 2) initiating the groundwork; 3) establishing backup plans; 4) making a deadline; 5) courting the editor; 6) determining authorship; 7) finding personal incentives; 8) writing what you know; 9) sharing with caution; 10) following directions; and 11) Consider open-access journals.

Neurosyphilis: A Simulation Case for Emergency Medicine Residents

Neurosyphilis is a dangerous and increasingly more prevalent sexually transmitted infection of the central nervous system caused by the bacterium Treponema pallidum that can present during the advanced stages of the disease (tertiary syphilis). Health care providers must remain vigilant in screening for syphilis in patients with high-risk behaviors as a delay in diagnosis and treatment may lead to symptom progression and debilitating sequelae years later. To date, there have been no published simulation case studies on neurosyphilis. This simulation case, based on a real patient encounter, is written for emergency medicine residents to diagnose and manage a patient presenting with the sequelae of neurosyphilis. This case was run for four separate iterations at a simulation center with two residents and an attending physician acting as confederates. Following the case, learners were provided with bedside debriefing, and a question and answer session. Based on post-simulation qualitative assessment, junior residents alone were less likely to perform a comprehensive integumentary exam without the presence of senior residents, although both groups failed to elicit pertinent sexual history until they discovered syphilitic lesions. After case completion and debriefing, all learners were able to demonstrate the understanding of the primary learning objectives.

Integrating Telehealth Emergency Department Follow-up Visits into Residency Training

Introduction Given the rapid expansion of telehealth (TH), there is an emerging need for trained professionals who can effectively deliver TH services. As there is no formal TH training program for residents, the Department of Emergency Medicine (DEM) at Thomas Jefferson University (TJU) developed a pilot training program for senior post-graduate-year three (PGY-3) residents that exposed them to TH practices. The objective of the study was to determine the feasibility of developing a resident-led, post-Emergency-Department (ED) visit TH follow-up program as an educational opportunity to 1) address patient satisfaction; and 2) expose senior residents to TH delivery. Methods During a one-month block in their third-year of training, EM residents were exposed to and educated on TH delivery and utility through on-the-job, just-in-time training. Residents spent four hours per week evaluating patients previously seen in the ED within the last 5-7 days in the form of TH follow-up visits. ED patients were screened to identify which patient chief complaints and presentations were appropriate for a follow-up visit, given a specific day and time for their TH encounter, facilitated by a resident, and supervised by a faculty member trained in TH. Demographic patient and visit data were collected. Residents then completed a brief survey at the end of the rotation to capture their educational experiences and recommendations for subsequent training improvement. Results Over 12 months, 197 TH follow-up visits were performed by 12 residents. One hundred twenty-six patients (64%) were female. Top chief complaints included extremity pain (11.2%); abdominal pain (8.1%); upper respiratory infections (8.1%); lacerations (7.6%), and motor vehicle accidents (7.6%). The average number of days between the ED visit and the TH follow-up call was 5.1 days (IQR 3-6). 44.7% of patients were compliant with their discharge instructions and medications. On a Likert scale low (1) to high (10)], average patient helpfulness rating was 8.2 (IQR 7.8-10) and the average patient likelihood to recommend a TH follow-up visit was 8.5 (IQR 8-10). Ten residents completed the follow-up survey on the educational experience of the rotation (response rate 83%), of which seven described there is value to have a TH rotation in the curriculum. Thematic analysis of open-ended responses yielded constructive feedback for programmatic improvement. Conclusion The authors propose a feasible TH training opportunity integrated into EM residency training to assist them with meeting a rapidly-growing demand for TH and prepare them for diverse job opportunities.