Error Management Training and Adaptive Expertise in Learning Computed Tomography Interpretation: A Randomized Clinical Trial.

Importance: Adaptive expertise helps physicians apply their skills to novel clinical cases and reduce preventable errors. Error management training (EMT) has been shown to improve adaptive expertise with procedural skills; however, its application to cognitive skills in medical education is unclear. Objective: To evaluate whether EMT improves adaptive expertise when learning the cognitive skill of head computed tomography (CT) interpretation. Design, Setting, and Participants: This 3-arm randomized clinical trial was conducted from July 8, 2022, to March 30, 2023, in 7 geographically diverse emergency medicine residency programs. Participants were postgraduate year 1 through 4 emergency medicine residents masked to the hypothesis. Interventions: Participants were randomized 1:1:1 to a difficult EMT, easy EMT, or error avoidance training (EAT) control learning strategy for completing an online head CT curriculum. Both EMT cohorts received no didactic instruction before scrolling through head CT cases, whereas the EAT group did. The difficult EMT cohort answered difficult questions about the teaching cases, leading to errors, whereas the easy EMT cohort answered easy questions, leading to fewer errors. All 3 cohorts used the same cases. Main Outcomes and Measures: The primary outcome was a difference in adaptive expertise among the 3 cohorts, as measured using a head CT posttest. Secondary outcomes were (1) differences in routine expertise, (2) whether the quantity of errors during training mediated differences in adaptive expertise, and (3) the interaction between prior residency training and the learning strategies. Results: Among 212 randomized participants (mean [SD] age, 28.8 [2.0] years; 107 men [50.5%]), 70 were allocated to the difficult EMT, 71 to the easy EMT, and 71 to the EAT control cohorts; 150 participants (70.8%) completed the posttest. The difficult EMT cohort outperformed both the easy EMT and EAT cohorts on adaptive expertise cases (60.6% [95% CI, 56.1%-65.1%] vs 45.2% [95% CI, 39.9%-50.6%], vs 40.9% [95% CI, 36.0%-45.7%], respectively; P < .001), with a large effect size (η2 = 0.19). There was no significant difference in routine expertise. The difficult EMT cohort made more errors during training than the easy EMT cohort. Mediation analysis showed that the number of errors during training explained 87.2% of the difficult EMT learning strategy's effect on improving adaptive expertise (P = .01). The difficult EMT learning strategy was more effective in improving adaptive expertise for residents earlier in training, with a large effect size (η2 = 0.25; P = .002). Conclusions and Relevance: In this randomized clinical trial, the findings show that EMT is an effective method to develop physicians' adaptive expertise with cognitive skills. Trial Registration: ClinicalTrials.gov Identifier: NCT05284838.

Immersive medical training: a comprehensive longitudinal study of extended reality in emergency scenarios for large student groups.

Young healthcare professionals and medical graduates often fall short in the practical experience necessary for handling medical emergencies. This can not only lead to strained feelings of inadequacy and insecurity among future physicians and less experienced healthcare providers in general, but also to detrimental outcomes for patients as emergency medicine demands rapid decision-making with low tolerance for errors. New didactic modalities and approaches may be needed to effectively address this shortcoming. Immersive technologies are powerful novel educational tools with untapped potential in medical training, and may be particularly suitable for simulation trainings in the high-stakes field of emergency medicine.Herein, we systematically explored the educational potential of extended reality (XR) technology, particularly virtual reality (VR), in the management of patients presenting as medical emergencies, combining the use of the STEP-VR application with an untethered hardware setup.Importantly, we aimed at studying multiple, large cohorts of senior medical students involving a total of 529 participants and collecting data over a period of two years. We assessed students' acceptance of the training through a modified questionnaire measuring device handling, content complexity, degree of immersion, learning success, and seminar design.Our results show high, sustained acceptance and ease of use across different student cohorts and subgroups, with most students finding XR/VR engaging and beneficial for acquiring emergency medicine skills. Importantly, the prevalence of simulation sickness was minimal. Moreover, no major effect of the head-mounted displays (HMDs) price range was noted with regard to the learning experience. The results underscore the potential of XR/VR capabilities in effectively enhancing medical education, particularly in areas of high-stakes clinical scenarios and emergency care, by providing realistic and reproducible immersive training environments.In summary, our findings suggest that XR/VR-based training approaches could significantly contribute to preparing future physicians for the complexities of emergency medical care, encouraging the integration of such technologies into medical curricula. However, careful consideration must be given to its suitability for all students and the practical challenges of its implementation, highlighting the need for further research to harness its full potential for medical education.

Development of a bleeding arteriovenous fistula task trainer.

BACKGROUND: As end-stage renal disease becomes more prevalent in the United States, the number of Americans with arteriovenous (AV) fistulas continues to increase. One of the most feared complications of AV fistulas is life-threatening hemorrhage, as patients can exsanguinate within minutes. OBJECTIVES: As frontline healthcare workers, emergency medicine (EM) providers need to be able to provide rapid and effective treatment for this rare presentation. We developed a task trainer model to simulate AV fistula hemorrhage to prepare and train EM residents. METHODS: This task trainer model was constructed with readily available materials and takes about 30 minutes to make. Twenty-one EM residents participated in the training session. The session consisted of a brief didactic on AV fistula hemorrhage control followed by hands on usage of the task-trainer model. The participants filled out an anonymous survey afterwards rating the model. RESULTS: Residents completed anonymous postcourse surveys rating the session on a five-point Likert scale. Both the overall teaching session and the task trainer were rated very highly. Compared to precourse ratings, residents reported statistically significant postcourse improvements in their level of confidence in managing AV fistula hemorrhage. CONCLUSIONS: To our knowledge, this is the first published task trainer model to simulate a bleeding AV fistula for EM residents. The model was well received by our trainees, is relatively inexpensive, and made from easily sourced materials. We believe this model can be used for trainees of all disciplines to prepare them for this potentially catastrophic patient presentation.

Empowering medical students: bridging gaps with high-fidelity simulations; a mixed-methods study on self-efficacy.

BACKGROUND: High-fidelity simulations play a crucial role in preparing for high-mortality events like cardiopulmonary arrest, emphasizing the need for rapid and accurate intervention. Proficiency in cardiopulmonary resuscitation(CPR) requires a strong self-efficacy(SE); training for both is crucial. This study assesses the impact of Advanced Life Support(ALS) simulation on SE changes in final-year medical students. METHODS: This mixed-methods prospective simulation study involved medical students in emergency medicine internships, examining self-efficacy perceptions regarding ALS technical skills(ALS-SEP). A comparison was made between students who underwent scenario-based ALS simulation training and those who did not. Competencies in chest compression skills were assessed, and the concordance between ALS-SEP scores and observed CPR performances were evaluated. Focus group interviews were conducted and analyzed using content analysis techniques. RESULTS: The study involved 80 students, with 53 in the experimental group(EG) and 27 in the control group(CG). The EG, underwent simulation training, showed a significantly higher ALS-SEP change than the CG(p < 0.05). However, there was low concordance between pre-simulation SEP and actual performance. Compression skills success rates were inadequate. Qualitative analysis revealed main themes as"learning"(32.6%), "self-efficacy"(29%), "simulation method"(21.3%), and "development"(16.5%). DISCUSSION: Post-simulation, students reported improved SEP and increased readiness for future interventions. The findings and qualitative statements support the effectiveness of simulation practices in bridging the gap between SEP and performance. Utilizing simulation-based ALS training enhances learners' belief in their capabilities, raises awareness of their competencies, and encourages reflective thinking. Given the importance of high SEP for ALS, simulation trainings correlating self-efficacy perception and performance may significantly reduce potential medical errors stemming from a disparity between perceived capability and actual performance.

Retaining doctors in emergency medicine: an ethnographic study of emergency departments in England.

OBJECTIVES: To gain a deep understanding of factors driving retention in emergency medicine. To understand in detail the day-to-day lived experience of emergency medicine doctors, to identify and explore factors influencing retention, to situate these descriptions within the current educational and health policy contexts and to advance the debate and make policy and practice recommendations. DESIGN: Ethnography and semistructured interviews. SETTING: Two purposively sampled emergency departments in England, with additional interview participants recruited via social media and relevant stakeholder organisations. PARTICIPANTS: 41 interview participants comprising 21 emergency physicians across 2 sites, 10 former emergency physicians and 10 stakeholders, with 132 hours of observation over 11 weeks in one emergency department in England. RESULTS: Three key themes were developed as relevant to the day-to-day lived experience of work in the emergency department, presenting challenges to retention and opportunities for change. First, emergency physicians needed to develop workarounds to mitigate the sensory and material challenges of working in a difficult environment.Second, education influences retention through valuing, fostering competence and entrustment and supporting interdependence. These were primarily observable in the workplace through senior staff prioritising the education of more junior staff.Third, community was important for retention. Linked to education through communities of practice, it was built by brief interpersonal interactions between emergency department workers.Situating these descriptions in current policy contexts identified less than full-time working, portfolio careers and mentorship as retention strategies. Self-rostering and annualisation facilitated these retention strategies. CONCLUSIONS: The emergency department represents a difficult environment with many challenges, yet by focusing on how doctors navigate these difficulties, we can see the way in which retention occurs in everyday practices, and that valuing staff is critical for retention.

[Radiology and emergency medicine: pitfalls to avoid in traumatology]. / Radiologie en médecine d'urgence : pièges à éviter en traumatologie.

The management of trauma is a significant part of emergency medicine practice, in a context where the number of sports accidents is rising steadily every year, with a total of 430,000 people affected in Switzerland in 2023 according to the Swiss Accident Prevention Bureau. In addition to the physical examination, radiological assessment is a cornerstone of diagnosis. Radiology of the musculoskeletal system is the most frequently requested paraclinical examination in these situations. The consequences of not recognizing radiological lesions may result in short-term consequences (haemorrhagic or neurological injuries) or long-term consequences (chronic pain, functional impairment). We therefore present examples of "pitfalls in radiology" frequently encountered in our daily clinical practice, and the use of additional exams.

La traumatologie fait partie intégrante de la médecine d'urgence, ce d'autant plus que chaque année les accidents de sport augmentent, avec un total de 430 000 personnes touchées en Suisse en 2023 selon le Bureau suisse de prévention des accidents. Hormis l'examen clinique, le bilan radiologique est une pierre angulaire du diagnostic. La radiologie de l'appareil locomoteur est l'examen paraclinique le plus demandé dans ces situations. Les conséquences de la non-reconnaissance de lésions radiologiques peuvent engendrer des séquelles à court terme (lésions hémorragiques ou neurologiques) ou à long terme (douleur chronique, impotence fonctionnelle). Il nous semblait ainsi important de présenter quelques « pièges en radiologie ¼, fréquemment rencontrés dans notre pratique quotidienne, et les compléments nécessaires à la pose d'un diagnostic éclairé.

[Use of osteoarticular ultrasound by emergency physicians]. / Utilisation de l'échographie ostéo-articulaire par le médecin urgentiste.

The use of ultrasound by emergency physicians is now well established. It can be integrated as an extension of the clinical examination, providing diagnostic support during consultation in the emergency department. However, its use in osteoarticular pathologies remains less frequent, despite a growing body of literature demonstrating its value in a variety of pathologies. Ultrasound is operator-dependent, so its proper use requires dedicated training. In Switzerland, training opportunities in osteoarticular ultrasound are still poorly known and not widely used by emergency physicians. This article describes the possibilities of use in the case of osteoarticular pathologies frequently encountered in emergency departments.

L'utilisation de l'échographie par les urgentistes est actuellement bien établie. Elle peut être intégrée comme extension de l'examen clinique et apporte alors une aide au diagnostic lors d'une consultation dans le service des urgences. Son utilisation pour les pathologies ostéoarticulaires reste cependant moins fréquente, malgré une littérature croissante montrant son intérêt dans des pathologies variées. L'échographie est dépendante de l'opérateur et son utilisation adéquate nécessite une formation dédiée. Les possibilités de formation à l'échographie ostéoarticulaire en Suisse restent encore peu connues et peu suivies par les médecins urgentistes. Cet article décrit les possibilités d'utilisation pour des pathologies ostéoarticulaires fréquemment rencontrées aux urgences.

Pediatric Life Support in Prehospital Emergency Medicine: An Empirical Investigation in the Context of Taiwan's Critical Shortage of Pediatric Emergency Specialists.

BACKGROUND: This study aims to facilitate parental identification of designated emergency facilities for expeditious pediatric care within the framework of Taiwan's newly implemented "regional joint defense" approach to pediatric emergency services. The research seeks to elucidate the mechanisms by which this novel system can enhance timely access to appropriate emergency care for children, potentially improving health outcomes and resource utilization in acute pediatric situations. METHODS: Factor analysis (FA) and triangular entropy matrix (TEM) analyzed the appearance, breathing and skin of pediatric assessment triangle (ABC of PAT), three types of prehospital pediatric emergence condition (PPEC), five levels of Taiwan's pediatric emergency triage (TPET), and applied the social learning theory (SLT) in educational doctrine, using experts' weighted questionnaires. RESULTS: Firstly, to address deficiencies in Taiwan's pediatric prehospital emergency medicine (PEM) system, integrating emergency medical knowledge (EMK) and pediatric life support (PLS) into medical education, staff training, and the national handbook for new parents is crucial. This equips parents to manage children's illnesses and prevent emergencies. Then, in life-threatening situations, immediate emergency room (ER) transport is vital for symptoms like whitish or purple lips, cold limbs, mottled skin, cold sweat, convulsions, dyspnea, chest dimples, weak consciousness, and oxygen saturation below 94%. Finally, for non-life-threatening emergencies, seek medical evaluation if symptoms include wheezing, chest tightness, chest pain, persistent high fever over 39 degrees with convulsions, chills, cold sweats, not eating or urinating for over 12 hours, or fever lasting more than 48 hours. CONCLUSION: Parents must remain calm and provide their baby with a sense of security while observing the development of physical symptoms. This approach enables them to effectively determine the most appropriate time to take their children to the emergency room, thereby avoiding life-threatening emergencies. Prompt and proper measures and treatments not only alleviate various discomforts caused by illness or medical emergencies but also reduce systemic distress, life-threatening situations, and unfortunate incidents before hospitalization.

Sonographer Educator in the Emergency Department to Prevent POCUS Skills Attrition: A Novel Education Intervention.

BACKGROUND: Point-of-care ultrasound (POCUS) is a pivotal diagnostic tool for emergent conditions, yet the variable proficiency of emergency physicians (EPs) poses challenges. Inadequate skills may lead to care delays and suboptimal patient evaluation. This manuscript explores an innovative educational intervention deploying a Registered Diagnostic Medical Sonographer (RDMS) credentialed sonographer educator (SE) in a large academic Emergency Department (ED). We sought to evaluate the feasibility of using a SE to address POCUS skills deficiencies and attrition. METHODS: The study involved 26 EPs voluntarily participating in hands-on training with the SE between July 2021-June 2022. The educational sessions addressed machine operation, image acquisition, image interpretation, and electronic medical record documentation of POCUS results. Subjects who consented completed a survey on their comfort level with POCUS before and after the intervention.  Results: Survey data indicated increased comfort and competence among participants with basic machine operation, resident POCUS supervision, and ordering and documenting POCUS exams. Post-training, 44% of providers reported performing more POCUS exams, 44% reported documenting their POCUS in the EMR more often clinically, 57% were more likely to encourage residents to perform scans, and 14% were more likely to perform a POCUS before ordering a comprehensive ultrasound. The study also observed an increase in the number of scans performed post-intervention (more than double). The SE intervention addressed challenges such as resource limitations, and feedback from participants highlighted the program's positive impact, particularly in reducing intimidation and fostering a desire for further training. While self-reported data and limited survey completion pose limitations, the increase in POCUS scans and positive feedback underscore the intervention's potential.  Conclusions: This pilot study demonstrates the feasibility and initial impact of integrating a SE into an academic ED setting. Further research is warranted to assess the specific effects on provider comfort and clinical decision-making with POCUS. The findings support the value of a dedicated SE in enhancing EPs' POCUS proficiency, promoting ongoing education, and ultimately improving patient care.

The accuracy of Gemini, GPT-4, and GPT-4o in ECG analysis: A comparison with cardiologists and emergency medicine specialists.

INTRODUCTION: GPT-4, GPT-4o and Gemini advanced, which are among the well-known large language models (LLMs), have the capability to recognize and interpret visual data. When the literature is examined, there are a very limited number of studies examining the ECG performance of GPT-4. However, there is no study in the literature examining the success of Gemini and GPT-4o in ECG evaluation. The aim of our study is to evaluate the performance of GPT-4, GPT-4o, and Gemini in ECG evaluation, assess their usability in the medical field, and compare their accuracy rates in ECG interpretation with those of cardiologists and emergency medicine specialists. METHODS: The study was conducted from May 14, 2024, to June 3, 2024. The book "150 ECG Cases" served as a reference, containing two sections: daily routine ECGs and more challenging ECGs. For this study, two emergency medicine specialists selected 20 ECG cases from each section, totaling 40 cases. In the next stage, the questions were evaluated by emergency medicine specialists and cardiologists. In the subsequent phase, a diagnostic question was entered daily into GPT-4, GPT-4o, and Gemini Advanced on separate chat interfaces. In the final phase, the responses provided by cardiologists, emergency medicine specialists, GPT-4, GPT-4o, and Gemini Advanced were statistically evaluated across three categories: routine daily ECGs, more challenging ECGs, and the total number of ECGs. RESULTS: Cardiologists outperformed GPT-4, GPT-4o, and Gemini Advanced in all three groups. Emergency medicine specialists performed better than GPT-4o in routine daily ECG questions and total ECG questions (p = 0.003 and p = 0.042, respectively). When comparing GPT-4o with Gemini Advanced and GPT-4, GPT-4o performed better in total ECG questions (p = 0.027 and p < 0.001, respectively). In routine daily ECG questions, GPT-4o also outperformed Gemini Advanced (p = 0.004). Weak agreement was observed in the responses given by GPT-4 (p < 0.001, Fleiss Kappa = 0.265) and Gemini Advanced (p < 0.001, Fleiss Kappa = 0.347), while moderate agreement was observed in the responses given by GPT-4o (p < 0.001, Fleiss Kappa = 0.514). CONCLUSION: While GPT-4o shows promise, especially in more challenging ECG questions, and may have potential as an assistant for ECG evaluation, its performance in routine and overall assessments still lags behind human specialists. The limited accuracy and consistency of GPT-4 and Gemini suggest that their current use in clinical ECG interpretation is risky.

Benchmarking Emergency Physician EHR Time per Encounter Based on Patient and Clinical Factors.

This cross-sectional study assesses the associations between patient and clinical factors and variations in time emergency department physicians spend using electronic health record (EHR) systems.

The Impact of Changing Abortion Legislation on Emergency Medicine Residents in a State With Protected Abortion Rights.

Background The US Supreme Court's 2022 ruling in Dobbs v Jackson Women's Health Organization overturned Roe v Wade, allowing individual states to determine abortion restrictions, significantly impacting graduate medical education (GME). While focus has been on states enacting restrictions, the impacts in states where abortion rights are safeguarded are equally important. Emergency medicine (EM) serves as a safety net within the health care system, making it ideal for understanding the broader implications of these legal changes on GME. Objective To explore the experiences and perspectives of EM residents regarding changing abortion legislation in California, an abortion-protective state. Methods We conducted a qualitative study using transcendental phenomenology. Thirteen postgraduate year 4 EM residents from a single large university-based program in California participated in semistructured interviews in 2023. Data were analyzed using thematic analysis. Results Four themes were identified: (1) impact of changing abortion legislation on practice; (2) personal and professional decisions influenced by legislation; (3) navigating legal uncertainties in practice; and (4) advocacy and engagement beyond clinical practice. Residents reported varying levels of awareness and concern about the implications of abortion laws on EM practice, the influence of these laws on their career decisions, the need for legal guidance, and a commitment to advocacy. These themes highlight a complex interplay between legal changes, personal values, and professional responsibilities. Conclusions This study highlights the significant impact of the Dobbs decision on EM residents in California, revealing that residents face unique ethical, legal, and advocacy challenges that may affect their professional identity formation.

Improving pediatric procedural skills and EPA assessments through an acute care procedural skills curriculum.

INTRODUCTION: Acute procedural skill competence is expected by the end of pediatric residency training; however, the extent to which residents are actually competent is not clear. Therefore, a cross-sectional observational study was performed to examine the competency of pediatric residents in acute care procedures in emergency medicine. MATERIALS AND METHODS: Pediatric residents underwent didactic/hands-on "Acute Procedure Day" where they performed procedures with direct supervision and received entrustable professional activity (EPA) assessments (scores from 1-5) for each attempt. Procedures included: bag-valve mask (BVM) ventilation, intubation, intraosseous (IO) line insertion, chest tube insertion, and cardiopulmonary resuscitation (CPR) with defibrillation. Demographic information, perceived comfort level, and EPA data were collected. Descriptive statistics and Pearson correlation for postgraduate year (PGY) versus EPA scores were performed. RESULTS: Thirty-six residents participated (24 PGY 1-2, and 12 PGY 3-4). Self-reported prior clinical exposure was lowest for chest tube placement (n = 3, 8.3%), followed by IOs (n = 19, 52.8%). During the sessions, residents showed the highest levels of first attempt proficiency with IO placement (EPA 4-5 in 28 residents/33 who participated) and BVM (EPA 4-5 in 27/33), and the lowest for chest tube placement (EPA 4-5 in 0/35), defibrillation (EPA 4-5 in 5/31 residents) and intubation (EPA 4-5 in 17/31). There was a strong correlation between PGY level and EPA score for intubation, but not for other skills. DISCUSSION: Entrustability in acute care skills is not achieved with current pediatrics training. Research is needed to explore learning curves for skill acquisition and their relative importance.