Linda Regan

Scholarly Tracks in Emergency Medicine

Over the past decade, some residency programs in emergency medicine (EM) have implemented scholarly tracks into their curricula. The goal of the scholarly track is to identify a niche in which each trainee focuses his or her scholarly work during residency. The object of this paper is to discuss the current use, structure, and success of resident scholarly tracks. A working group of residency program leaders who had implemented scholarly tracks into their residency programs collated their approaches, implementation, and early outcomes through a survey disseminated through the Council of Emergency Medicine Residency Directors (CORD) list-serve. At the 2009 CORD Academic Assembly, a session was held and attended by approximately 80 CORD members where the results were disseminated and discussed. The group examined the literature, discussed the successes and challenges faced during implementation and maintenance of the tracks, and developed a list of recommendations for successful incorporation of the scholarly track structure into a residency program. Our information comes from the experience at eight training programs (five 3-year and three 4-year programs), ranging from 8 to 14 residents per year. Two programs have been working with academic tracks for 8 years. Recommendations included creating clear goals and objectives for each track, matching track topics with faculty expertise, protecting time for both faculty and residents, and providing adequate mentorship for the residents. In summary, scholarly tracks encourage the trainee to develop an academic or clinical niche within EM during residency training. The benefits include increased overall resident satisfaction, increased success at obtaining faculty and fellowship positions after residency, and increased production of scholarly work. We believe that this model will also encourage increased numbers of trainees to choose careers in academic medicine.

RESIDENT TO RESIDENT HANDOFFS IN THE EMERGENCY DEPARTMENT: AN OBSERVATIONAL STUDY

BACKGROUND Despite patient handoffs being well recognized as a potentially dangerous time in the care of patients in the emergency department (ED), there is no established standard and little supporting research on how to optimize the process. Minimizing handoff risks is particularly important at teaching hospitals, where residents often provide the majority of patient handoffs. OBJECTIVE Our aim was to identify hazards to patient safety and barriers to efficiency related to resident handoffs in the ED. METHODS An observational study was completed using the Systems Engineering Initiative for Patient Safety model to assess the safety and efficiency of resident handoffs. Thirty resident handoffs were observed with residents in emergency medicine over 16 weeks. RESULTS Residents were interrupted, on average, every 8.5 min. The most common deficit in relaying the plan of care strategy was failing to relay medications administered (32%). In addition, there were ambiguities related to medication administration, such as when the medication was next due or why a medication was chosen, in 56% of handoffs observed. Ninety percent of residents observed took handwritten notes. A small percentage (11%) also completed free texted computer progress notes. Ten percent of residents took no notes. CONCLUSIONS The existing system allows for a clear summary of the patients visit. Two major deficits-frequent interruptions and inconsistent communication regarding medications administered-were noted. There is inconsistency in how information is recorded at the time of handoff. Future studies should focus on handoff improvement and error reduction.

Remediation Methods for Milestones Related to Interpersonal and Communication Skills and Professionalism

A program director receives the following complaint from 2 members of the faculty: a postgraduate year (PGY) 3 resident seems argumentative during patient handoffs and is neither receptive to discussions about patient care concerns nor to feedback about their interactions. Under these circumstances, how should the program director approach this problem, which reflects deficiencies in interpersonal and communication skills (ICS) and professionalism competencies? What remediation strategies should be considered and can the milestones guide the remediation? Are there any best practice recommendations that can serve as a template across specialties for professionalism and ICS that program directors can use for their residents? As part of the new accreditation system, the Accreditation Council for Graduate Medical Education developed the Milestone Project, which includes specialty-specific subcompetencies and milestones under each of the 6 competencies. The milestones allow programs to determine the progression of each resident’s knowledge, skills, and attitudes during the course of training. With the understanding that subcompetencies and milestones for competencies, such as patient care and medical knowledge, might vary significantly among specialties, we posed the question as to whether or not those for ICS and professionalism share common content themes. If unifying standards for the house of medicine for these competencies did exist, it should follow that suggested approaches to remediation could be applicable across specialties. It is the authors’ hope that the best practice recommendations to follow will allow a program director to expand his or her toolbox for remediation of these competencies, while also developing a broader understanding of approaches to successful remediation. In addition, a remediation approach using targeted strategies mapped to subcompetency proficiency levels is presented for the authors’ specialty of emergency medicine (provided as online supplemental material).

Educational Value Units: A Mission-based Approach to Assigning and Monitoring Faculty Teaching Activities in an Academic Medical Department.

PROBLEM Increasing emphasis on revenue generation could jeopardize the fundamental notion of what it means to be faculty. Despite being a core mission, education is often marginalized in academic medical departments, and expectations of faculty effort in this area are often vague. A potential solution is mission-based budgeting (MBB), which refers to the allocation of resources based on core-mission-related priorities. APPROACH From December 2012 to March 2013, the authors developed an educational value unit (EVU) system (using an MBB approach) to assign and monitor teaching activities related to the core departmental educational mission at the Department of Emergency Medicine, Johns Hopkins Medicine. EVUs were based on learner contact time, with one EVU equal to roughly one hour of in-person time with medical students or residents. Core education faculty vetted the proposed system; educational leaders determined the total EVUs needed and assessed the impact of their equitable distribution among faculty; and faculty members selected preferences and were assigned EVU obligations. OUTCOMES For academic year 2013-2014, 5,896 EVUs were distributed among 54 faculty. At the end of the year, complete EVU data were available for 47 faculty. Of these, only 6 failed to complete their assigned EVU obligations. All core teaching activities were covered, and educational efforts were distributed more equitably across faculty. NEXT STEPS The system is being refined, with an emphasis on incorporating learner outcome metrics, refining the teaching grid, incorporating failure to meet EVU obligations into yearly faculty evaluations, and disseminating the system to other departments and institutions.

The Development of Best Practice Recommendations to Support the Hiring, Recruitment, and Advancement of Women Physicians in Emergency Medicine

BACKGROUND Women in medicine continue to experience disparities in earnings, promotion, and leadership roles. There are few guidelines in place defining organization-level factors that promote a supportive workplace environment beneficial to women in emergency medicine (EM). We assembled a working group with the goal of developing specific and feasible recommendations to support womens professional development in both community and academic EM settings. METHODS We formed a working group from the leadership of two EM womens organizations, the Academy of Women in Academic Emergency Medicine (AWAEM) and the American Association of Women Emergency Physicians (AAWEP). Through a literature search and discussion, working group members identified four domains where organizational policies and practices supportive of women were needed: 1) global approaches to supporting the recruitment, retention, and advancement of women in EM; 2) recruitment, hiring, and compensation of women emergency physicians; 3) supporting development and advancement of women in EM; and 4) physician health and wellness (in the context of pregnancy, childbirth, and maternity leave). Within each of these domains, the working group created an initial set of specific recommendations. The working group then recruited a stakeholder group of EM physician leaders across the country, selecting for diversity in practice setting, geographic location, age, race, and gender. Stakeholders were asked to score and provide feedback on each of the recommendations. Specific recommendations were retained by the working group if they achieved high rates of approval from the stakeholder group for importance and perceived feasibility. Those with >80% agreement on importance and >50% agreement on feasibility were retained. Finally, recommendations were posted in an open online forum (blog) and invited public commentary. RESULTS An initial set of 29 potential recommendations was created by the working group. After stakeholder voting and feedback, 16 final recommendations were retained. Recommendations were refined through qualitative comments from stakeholders and blog respondents. CONCLUSIONS Using a consensus building process that included male and female stakeholders from both academic and community EM settings, we developed recommendations for organizations to implement to create a workplace environment supportive of women in EM that were perceived as acceptable and feasible. This process may serve as a model for other medical specialties to establish clear, discrete organization-level practices aimed at supporting women physicians.

An Assessment Tool for the Placement of Ultrasound-Guided Peripheral Intravenous Access.

Background Ultrasound-guided peripheral intravenous line (USGPIV) placement is becoming an important tool in current clinical practice. Many residency programs utilize unstructured clinical observation to evaluate residents in this and other procedural skills. Simulation-based assessment permits educators to make objective, standardized observations, and may be ideal for assessment of important procedural competencies. Objective We created a simulation-based assessment tool for the skill of USGPIV placement. Methods A checklist tool was developed by a review of relevant literature and an expert review in accordance with established guidelines. Emergency medicine residents were recruited and surveyed on previous experience with USGPIV placement. Blinded, independent reviewers then utilized the checklist to assess residents as they made up to 3 attempts at USGPIV placement on a simulated pediatric arm. Results Of the 26 residents enrolled in our study, 26 participated (100%). A best attempt checklist score greater than or equal to 9 out of 10 correlated with expert performance (P < .001). Agreement between independent raters on first-attempt USGPIV placement score was determined by weighted kappa statistics to be 0.93 (95% CI 086-1.00). Conclusions The checklist assessment tool has acceptable interrater reliability and ability to distinguish performance at differing levels of competence. We propose this tool as a valuable component in the assessment of USGPIV access, and we hope this article serves as a roadmap for other educators to create similar assessment tools.

Keeping up with emergency department ultrasound.

I began my emergency medicine (EM) residency training just over 10 years ago. I trained at a time when ultrasound was just beginning its rise in popularity and found myself just as enamored as the rest of my colleagues. At times I felt like I was cheating the system—not waiting for the ultrasound to confirm pregnancy, finding the inflamed gallbladder or the free fluid indicative of the ruptured ectopic in a young woman who presented with syncope. My excitement stemmed mainly from witnessing the perceived facilitation of my patients’ care, as I was able to take control over diagnostic studies that were ordinarily not within my purview. Later, I found that ultrasound could assist me in placing hard-to-find peripheral access as well as more reliably find the vessel for central venous access. As a residency educator, I believe I fall into the group of the somewhat older physician, but certainly not the type who is unable or unwilling to learn new things. Recently, I found myself asking my residents to help guide me through ultrasound procedures such as evaluating for deep vein thrombosis or diagnosing retinal detachments, both of which have become ‘‘core emergency ultrasound applications.’’ I found myself somewhat uncomfortable, not because my residents were more knowledgeable than I or that I was concerned technology had passed me by. Rather, I was struck with the recognition that the most inexperienced person in the department was, in some way, guiding the care of the patient without the benefit of the attending. Why were we as attendings willing to accept this backseat role to residents whose ultrasound skills were better than ours? I could think of no other area in which this would be acceptable. Use of bedside emergency department (ED) ultrasound continues to generate heated debate, both from critics such as Welch and supporters such as Chiricolo and Noble. It was not surprising for me to find that Dr. Welch has been in practice for over 20 years and Drs. Chiricolo and Noble both less than 10. This is not a criticism of older physicians, but simply a statement that younger practioners are more likely to be wooed by the newness of technology and innovation. A recent commentary entitled ‘‘All that glistens is not gold’’ discussed the difference between early and late adopters. In general, emergency physicians are more likely to be early adopters. We are the group who are more willing to try new devices or use new drugs, often as a ‘‘trial’’ in hopes they will benefit our patients or ourselves in our ever-crowded, overwhelmed system. Of all emergency physicians, the more junior physician is the most susceptible. This is the opposite of the well-known adage about old dogs and new tricks—our residents and new graduates are the playful ‘‘puppies,’’ if we are to stay on theme, who are excited and willing to try new things. For junior physicians, there is little ‘‘standard practice’’ already ingrained, and as such they often have no clear practice pattern that needs to be changed. In addition, they often have no experience with unanticipated side effects or bad outcomes associated with using new drugs or devices. They are the least likely to be gun-shy and the most likely to be the least educated. One could imagine where this perfect storm could lead. As I read this article, it was clear that the authors are enamored with ultrasound. [The Resident Portfolio is written in the singular, but is co-authored by two chief residents—Ed.] They freely admit that their initial emotion of fascination with ultrasound only later, with time and experience, grew into respect and admiration. This fascination is what we in medical education often describe as ‘‘the spark’’ that grabs a resident and often leads to a career choice. Fascination can be a powerful sentiment, especially when the object (in this case ultrasound) allows one to provide not only medical care but to gain the proverbial ‘‘upper hand’’ with the grizzled trauma surgeon. Ultrasound, however, is the only area I can think of where the object of fascination is not simply knowledge of a certain topic, such as toxicology, or a niche, such as disaster relief, but an actual concrete thing. Residents do not become fascinated with the procedural skill of putting in an IV, tapping a joint, or inserting a chest tube. No one makes their career solely around such skills. Ultrasound as a ‘‘field’’ encompasses not just the technical skill, but the knowledge of how and when to incorporate that skill into daily practice. I have witnessed fascination with ultrasound impede residents from achieving efficiency. I have witnessed them rely on questionable literature and their own noncredentialed skills as support for not pursuing further imaging. These instances have given me concern. I wonder at their ability to differentiate motivation linked to the allure of ultrasound, from motivation linked to evidence. Please do not misunderstand me—I am by no means implying that ultrasound is a useless bandwagon without evidence to support its use. I will state openly that I use it

Perceptions of Emergency Medicine Residency and Hand Surgery Fellowship Program Directors in the Appropriate Disposition of Upper Extremity Emergencies.

PURPOSE To survey emergency medicine (EM) residency and hand surgery fellowship program directors (PDs) to identify consensus in their perceptions of appropriate emergency care of upper extremity emergencies. METHODS We created a framework to group common upper extremity emergency diagnoses and surveyed PDs to evaluate the training background--EM, general orthopedic or plastic surgery, or hand fellowship--most appropriate to provide acute, point-of-care management for each of these diagnostic groupings. Responses were pooled and consensus was established with greater than 75% agreement between groups. RESULTS We received 79 responses from hand fellowship PDs (90% response rate) and 151 responses from EM PDs (49% response rate). We identified consensus for the training background that PDs in both specialties felt was appropriate to care for 17 of 21 diagnostic groupings in the framework. CONCLUSIONS There was a high level of consensus between EM and hand surgery PDs regarding diagnoses that acutely require training in hand surgery versus those that can be managed by an EM physician. Our diagnostic framework may help reduce unnecessary hand surgery consultation and may help to identify patients who do not require more specialized acute care and thus decrease unnecessary transfers. TYPE OF STUDY/LEVEL OF EVIDENCE Economic and Decision Analyses IV.

Crazy Paving on Computed Tomography after Marijuana Use

A 28-year-old man presented to the Emergency Department with 1 day of shortness of breath, pleuritic chest pain, and scant hemoptysis that started suddenly after smoking marijuana the day prior. He denied fever, chills, runny nose, or other infectious symptoms. The patient was previously incarcerated, with exposure to tuberculosis 10 years prior, and subsequent prophylactic therapy. Physical examination including lung examination and

Do End-of-Rotation and End-of-Shift Assessments Inform Clinical Competency Committees’ (CCC) Decisions?

Introduction Clinical Competency Committees (CCC) require reliable, objective data to inform decisions regarding assignment of milestone proficiency levels, which must be reported to the Accreditation Council for Graduate Medical Education. After the development of two new assessment methods, the end-of-shift (EOS) assessment and the end-of-rotation (EOR) assessment, we sought to evaluate their performance. We report data on the concordance between these assessments, as well as how each informs the final proficiency level determined in biannual CCC meetings. We hypothesized that there would be a high concordance level between the two assessment methods, including concordance of both the EOS and EOR with the final proficiency level designation by the CCC. Methods The residency program is an urban academic four-year emergency medicine residency with 48 residents. After their shifts in the emergency department (ED), residents handed out EOS assessment forms asking about individual milestones from 15 subcompetencies to supervising physicians, as well as triggered electronic EOR-doctor (EORd) assessments to supervising doctors and EOR-nurse (EORn) to nurses they had worked with after each two-week ED block. EORd assessments contained the full proficiency level scale from 16 subcompetencies, while EORn assessments contained four subcompetencies. Data reports were generated after each six-month assessment period and data was aggregated. We calculated Spearman’s rank order correlations for correlations between assessment types and between assessments and final CCC proficiency levels. Results Over 24 months, 5,234 assessments were completed. The strongest correlations with CCC proficiency levels were the EORd for the immediate six-month assessment period prior (rs 0.71–0.84), and the CCC proficiency levels from the previous six-months (rs 0.83–0.92). EOS assessments had weaker correlations (rs 0.49 to 0.62), as did EORn (rs 0.4 to 0.73). Conclusion End-of-rotation assessments completed by supervising doctors are most highly correlated with final CCC proficiency level designations, while end-of-shift assessments and end-of-rotation assessments by nurses did not correlate strongly with final CCC proficiency levels, both with overestimation of levels noted. Every level of proficiency the CCC assigned appears to be highly correlated with the designated level in the immediate six-month period, perhaps implying CCC members are biased by previous level assignments.