Rebecca Smith-Coggins

Gender-Associated Differences in Emergency Department Pain Management

STUDY OBJECTIVE To determine whether patient or provider gender is associated with the number, type, and strength of medications received by emergency department patients with headache, neck pain, or back pain. DESIGN Prospective cohort study. SETTING Stanford University Hospital ED PARTICIPANTS: Patients 18 years and older who arrived at the ED with a chief complaint of headache, neck pain, or back pain between February 1, 1993, and September 30, 1993. Provider participants included medical students, interns, residents, nurse practitioners, and attending physicians. RESULTS ED administration of analgesic versus no analgesic, strength of analgesic administered, and administration of multiple medications. The study group consisted of 190 patients, 110 of them female. The patients were evaluated by 84 providers, 60 of them male. According to the providers surveyed, female patients described more pain than did male patients (P < .01) and were perceived by providers to experience more pain (P = .03). Female patients received more medications (P < .01) and were less likely to receive no medication (P = .01). Female patients also received more potent analgesics (P = .03). Linear and logistic regression analysis showed that patient perception of pain was the strongest predictor of the number and strength of medications given; patient gender was not a predictor. CONCLUSION Female patients with headache, neck pain, or back pain describe more pain and are perceived by providers to have more pain than male patients in the ED. Female patients also receive more medications and stronger analgesics. In this study, severity of patient pain rather than gender stereotyping appeared to correlate most with pain-management practices.

Use of Ultrasound Guidance for Central Venous Catheter Placement: Survey From the American Board of Emergency Medicine Longitudinal Study of Emergency Physicians

OBJECTIVES The objective was to survey practicing emergency physicians (EPs) across the United States regarding the frequency of using ultrasound (US) guidance in central venous catheter (CVC) placement and, secondarily, to determine factors associated with the use or barriers to the use of US guidance. METHODS This was a cross-sectional survey mailed to presumed practicing EPs as part of the American Board of Emergency Medicine (ABEM)s longitudinal study of EPs. The selection process used stratified, random sampling of cohorts thought to represent four different stages within the development of the specialty of emergency medicine (EM). Multivariable logistic regression was used to identify independent factors associated with both high comfort using US guidance and high-percentage usage of US guidance. RESULTS The survey was mailed to 1,165 subjects, and the response rate was 79%. The median number of years of practice was 20 (interquartile range [IQR]=7 to 28 years). As their primary practice setting, 64% work in private or community hospitals, 60% received training in US-guided vascular access, and 44% never use US guidance in placing CVCs. Barriers differed in those who never use US and those who sometimes or always used US guidance. In those who never use US, top barriers were insufficient training (67%) and lack of equipment (25%). In those who use US, top barriers were the perceptions that US was too time-consuming (27%) and that the preferred site was not amenable to US (24%). Independent factors associated with high comfort and high-percentage use of US guidance were training in US-guided vascular access (adjusted odds ratio=5.1 [high comfort]; 95% confidence interval [CI]=2.6 to 10.1; adjusted odds ratio 11.1=(high percentage); 95% CI=5.0 to 24.8) and being a recent residency graduate. CONCLUSIONS Among EPs, the translation of evidence to clinical practice regarding the benefits of US guidance for CVC placement is poor and still faces many barriers. Training and education are potentially the best ways to overcome such barriers.

Night Shifts in Emergency Medicine: The American Board of Emergency Medicine Longitudinal Study of Emergency Physicians

BACKGROUND Night shift work is an integral component of the practice of emergency medicine (EM). Previous studies have demonstrated the challenges of night shift work to health and well being among health care providers. OBJECTIVE This study was undertaken to describe the self-reported experience of emergency physicians regarding night shift work with respect to quality of life and career satisfaction. METHODS The 2008 American Board of Emergency Medicine (ABEM) Longitudinal Study of Emergency Physicians (LSEP) was administered by mail to 1003 ABEM diplomates. RESULTS Among 819 participants in the 2008 LSEP Physician Survey, most participants responded that night shift work negatively influenced job satisfaction with a moderate or major negative influence (58%; n = 467/800). Forty-three percent of participants indicated that night shifts had caused them to think about leaving EM (n = 344/809). Most participants responded that working night shifts has had mild negative effects (51%; n = 407/800) or major negative effects (9%; n = 68) on their health. Respondents were asked to describe how working night shifts has affected their health. Common themes included fatigue (36%), poor quality of sleep (35%), mood decrement/irritability (29%), and health maintenance challenges (19%). Among participants in the 2008 LSEP Retired Physician Survey, night shifts were a factor in the decision to retire for 56% of participants. CONCLUSIONS Emergency physicians report negative impacts of night shift work, including fatigue, poor quality of sleep, mood decrement, irritability, and health challenges. Night shifts have a negative influence on job satisfaction and can be a factor in the decision to retire.

Duty hours in emergency medicine: Balancing patient safety, resident wellness, and the resident training experience: A consensus response to the 2008 institute of medicine resident duty hours recommendations

Representatives of emergency medicine (EM) were asked to develop a consensus report that provided a review of the past and potential future effects of duty hour requirements for EM residency training. In addition to the restrictions made in 2003 by the Accreditation Council for Graduate Medical Education (ACGME), the potential effects of the 2008 Institute of Medicine (IOM) report on resident duty hours were postulated. The elements highlighted include patient safety, resident wellness, and the resident training experience. Many of the changes and recommendations did not affect EM as significantly as other specialties. Current training standards in EM have already emphasized patient safety by requiring continuous on-site supervision of residents. Resident fatigue has been addressed with restrictions of shift lengths and limitation of consecutive days worked. One recommendation from the IOM was a required 5-hour rest period for residents on call. Emergency department (ED) patient safety becomes an important concern with the decrease in the availability and in the patient load of a resident consultant that may result from this recommendation. Of greater concern is the already observed slower throughput time for admitted patients waiting for resident care, which will increase ED crowding and decrease patient safety in academic institutions. A balance between being overly prescriptive with duty hour restrictions and trying to improve resident wellness was recommended. Discussion is included regarding the appropriate length of EM training programs if clinical experiences were limited by new duty hour regulations. Finally, this report presents a review of the financing issues associated with any changes.

Generational Influences in Academic Emergency Medicine: Structure, Function, and Culture (Part II)

Strategies for approaching generational issues that affect teaching and learning, mentoring, and technology in emergency medicine (EM) have been reported. Tactics to address generational influences involving the structure and function of the academic emergency department (ED), organizational culture, and EM schedule have not been published. Through a review of the literature and consensus by modified Delphi methodology of the Society for Academic Emergency Medicine Aging and Generational Issues Task Force, the authors have developed this two-part series to address generational issues present in academic EM. Understanding generational characteristics and mitigating strategies can address some common issues encountered in academic EM. By understanding the differences and strengths of each of the cohorts in academic EM departments and considering simple mitigating strategies, faculty leaders can maximize their cooperative effectiveness and face the challenges of a new millennium.

Zero Tolerance: Implementation and Evaluation of the Stanford Medical Student Mistreatment Prevention Program

The discussion of student mistreatment in medical schools is a new phenomenon, though the issue has been present for decades. The remedy is perplexing to medical educators. The fact that mistreatment is not unique to American medical colleges suggests the problem lies in the culture of medical training that transcends continents [1]. A number of factors contribute to the perpetuation of this problem. These include the power differential inherent in the medical community, highly stressful work environments, and social pressure to appear strong. Furthermore, once the learners become the teachers, the cycle of mistreatment often repeats with residents and physicians treating students as they were treated [2]. Mistreatment is particularly problematic during clinical rotations [3]. Students perceive more mistreatment in certain specialties (e.g., surgery, obstetrics, and gynecology) suggesting that there is something about the culture of these disciplines that may lead to higher rates of mistreatment or is uncomfortable for students [4]. Some traumatic incidents on clinical rotations, such as exposure to patient suffering and death, can lead to personal growth in medical students whereas personal mistreatment may have only adverse effects [5]. For students, the consequences of experiencing mistreatment are varied. Previous research has shown that mistreatment can lead to posttraumatic stress and less interest in pursuing a career in academic medicine [6, 7]. Many students accept mistreatment as an unavoidable part of the socialization process. They do not report incidents or address them directly because they do not know how, fear repercussions, or believe that nothing will be done if they report them. Educational interventions to improve the learning environment and reduce mistreatment have included lectures and case vignettes, role-playing, and professionalism training. One of the most comprehensive initiatives to date was implemented at the David Geffen School of Medicine at the University of California, Los Angeles. Their 13-year effort involved developing policies to prevent mistreatment, safe reporting procedures, and educational materials to raise awareness and facilitate discussion. They were disappointed to learn that this effort did not reduce the frequency of student mistreatment that was reported [8]. In 2010, our Dean and Senior Associate Dean for Medical Education were concerned that the rate of mistreatment reported by our graduating medical students on the annual Association of American Medical Colleges Graduation Questionnaire (AAMC GQ) had increased over prior years. This prompted the school leadership to redouble efforts to improve the learning climate for students, underscoring our school’s zero tolerance for inappropriate treatment of learners. This article describes the policy, procedures and institution-wide framework established to address medical student mistreatment. We also summarize our key metrics collected subsequent to the introduction of our interventions. This study was submitted to the Stanford University institutional review board and qualified for an exemption. * Rebecca Smith-Coggins smithcog@stanford.edu

Mothball composition: three simple tests for distinguishing paradichlorobenzene from naphthalene

We describe three analytical procedures that can be used to distinguish naphthalene from the less toxic mothball component paradichlorobenzene. An initial presumptive identification can be made by noting the characteristic aroma of the two substances. This can be followed by one of the three analytical tests, each of which is simple to perform, gives an answer in seconds to minutes, and is definitive enough to eliminate the need for costly additional testing at an analytical reference laboratory. These tests have as additional advantages that the endpoints are dramatic and the reagents are commonly available.

American Board of Emergency Medicine Report on Residency Training Information (2014-2015)

The American Board of Emergency Medicine (ABEM) gathers extensive background information on emergency medicine residency programs and the residents in those programs. We present the 2015 annual report on the status of US emergency medicine training programs.

Report on residency training information (2011-2012), American Board of Emergency Medicine.

The American Board of Emergency Medicine (ABEM) gathers extensive background information on emergency medicine residency training programs and the residents in those programs. We present the 2012 annual report on the status of US emergency medicine training programs.

Duty Hours in Emergency Medicine: Balancing Patient Safety, Resident Wellness, and the Resident Training Experience: A Consensus Response to the 2008 Institute of Medicine Resident Duty Hours Recommendations

BACKGROUND Representatives of emergency medicine (EM) were asked to develop a consensus report that provided a review of the past and potential future effects of duty hour requirements for EM residency training. In addition to the restrictions made in 2003 by the Accreditation Council for Graduate Medical Education, the potential effects of the 2008 Institute of Medicine (IOM) report on resident duty hours were postulated. DISCUSSION The elements highlighted include patient safety, resident wellness, and the resident training experience. Many of the changes and recommendations did not affect EM as significantly as other specialties. Current training standards in EM have already emphasized patient safety by requiring continuous onsite supervision of residents. Resident fatigue has been addressed with restrictions of shift lengths and limitation of consecutive days worked. CONCLUSION One recommendation from the IOM was a required 5-h rest period for residents on call. Emergency department (ED) patient safety becomes an important concern with the decrease in the availability and in the patient load of a resident consultant that may result from this recommendation. Of greater concern is the already observed slower throughput time for admitted patients waiting for resident care, which will increase ED crowding and decrease patient safety in academic institutions. A balance between being overly prescriptive with duty hour restrictions and trying to improve resident wellness was recommended. Discussion is included regarding the appropriate length of EM training programs if clinical experiences were limited by new duty hour regulations. Finally, this report presents a review of the financing issues associated with any changes.