Steven A. McLaughlin

Human simulation in emergency medicine training: a model curriculum.

The authors propose a three-year curriculum for emergency medicine residents using human simulation both to teach and to assess the Accreditation Council for Graduate Medical Education (ACGME) core competencies. Human simulation refers to a variety of technologies that allow residents to work through realistic patient problems so as to allow them to make mistakes, learn, and be evaluated without exposing a real patient to risk. This curriculum incorporates 15 simulated patient encounters with gradually increasing difficulty, complexity, and realism into a three-year emergency medicine residency. The core competencies are incorporated into each case, focusing on the areas of patient care, interpersonal skills and communication, professionalism, and practice based learning and improvement. Because of the limitations of current assessment tools, the demonstration of resident competence is used only for formative evaluations. Limitations of this proposal and difficulties in implementation are discussed, along with a description of the organization and initiation of the simulation program.

Improving Teamwork and Communication in Trauma Care Through In Situ Simulations

OBJECTIVES Teamwork and communication often play a role in adverse clinical events. Due to the multidisciplinary and time-sensitive nature of trauma care, the effects of teamwork and communication can be especially pronounced in the treatment of the acutely injured patient. Our hypothesis was that an in situ trauma simulation (ISTS) program (simulating traumas in the trauma bay with all members of the trauma team) could be implemented in an emergency department (ED) and that this would improve teamwork and communication measured in the clinical setting. METHODS This was an observational study of the effect of an ISTS program on teamwork and communication during trauma care. The authors observed a convenience sample of 39 trauma activations. Cases were selected by their presenting to the resuscitation bay of a Level I trauma center between 09:00 and 16:00, Monday through Thursday, during the study period. Teamwork and communication were measured using the previously validated Clinical Teamwork Scale (CTS). The observers were three Trauma Nursing Core Course certified RNs trained on the CTS by observing simulated and actual trauma cases and following each of these cases with a discussion of appropriate CTS scores with two certified Advanced Trauma Life Support instructors/emergency physicians. Cases observed for measurement were scored in four phases: 1) preintervention phase (baseline); 2) didactic-only intervention, the phase following a lecture series on teamwork and communication in trauma care; 3) ISTS phase, real trauma cases scored during period when weekly ISTSs were performed; and 4) potential decay phase, observations following the discontinuation of the ISTSs. Multirater agreement was assessed with Krippendorfs alpha coefficient; agreement was excellent (mean agreement = 0.92). Nonparametric procedures (Kruskal-Wallis) were used to test the hypothesis that the scores observed during the various phases were different and to compare each individual phase to baseline scores. RESULTS The ISTS program was implemented and achieved regular participation of all components of our trauma team. Data were collected on 39 cases. The scores for 11 of 14 measures improved from the baseline to the didactic phase, and the mean and median scores of all CTS component measures were greatest during the ISTS phase. When each phase was compared to baseline scores, using the baseline as a control, there were no significant differences seen during the didactic or the decay phases, but 12 of the 14 measures showed significant improvements from the baseline to the simulation phase. However, when the Kruskal-Wallis test was used to test for differences across all phases, only overall communication showed a significant difference. During the potential decay phase, the scores for every measure returned to baseline phase values. CONCLUSIONS This study shows that an ISTS program can be implemented with participation from all members of a multidisciplinary trauma team in the ED of a Level I trauma center. While teamwork and communication in the clinical setting were improved during the ISTS program, this effect was not sustained after ISTS were stopped.

Factors That Influence Medical Student Selection of an Emergency Medicine Residency Program: Implications for Training Programs

OBJECTIVES An understanding of student decision-making when selecting an emergency medicine (EM) training program is essential for program directors as they enter interview season. To build upon preexisting knowledge, a survey was created to identify and prioritize the factors influencing candidate decision-making of U.S. medical graduates. METHODS This was a cross-sectional, multi-institutional study that anonymously surveyed U.S. allopathic applicants to EM training programs. It took place in the 3-week period between the 2011 National Residency Matching Program (NRMP) rank list submission deadline and the announcement of match results. RESULTS Of 1,525 invitations to participate, 870 candidates (57%) completed the survey. Overall, 96% of respondents stated that both geographic location and individual program characteristics were important to decision-making, with approximately equal numbers favoring location when compared to those who favored program characteristics. The most important factors in this regard were preference for a particular geographic location (74.9%, 95% confidence interval [CI] = 72% to 78%) and to be close to spouse, significant other, or family (59.7%, 95% CI = 56% to 63%). Factors pertaining to geographic location tend to be out of the control of the program leadership. The most important program factors include the interview experience (48.9%, 95% CI = 46% to 52%), personal experience with the residents (48.5%, 95% CI = 45% to 52%), and academic reputation (44.9%, 95% CI = 42% to 48%). Unlike location, individual program factors are often either directly or somewhat under the control of the program leadership. Several other factors were ranked as the most important factor a disproportionate number of times, including a rotation in that emergency department (ED), orientation (academic vs. community), and duration of training (3-year vs. 4-year programs). For a subset of applicants, these factors had particular importance in overall decision-making. CONCLUSIONS The vast majority of applicants to EM residency programs employed a balance of geographic location factors with individual program factors in selecting a residency program. Specific program characteristics represent the greatest opportunity to maximize the success of the immediate interview experience/season, while others provide potential for strategic planning over time. A working knowledge of these results empowers program directors to make informed decisions while providing an appreciation for the limitations in attracting applicants.