Better together: A multistakeholder approach to developing specialty-wide entrustable professional activities in emergency medicine.

Purpose: Entrustable professional activities (EPAs) are a widely used framework for curriculum and assessment, yet the variability in emergency medicine (EM) training programs mandates the development of EPAs that meet the needs of the specialty as a whole. This requires eliciting and incorporating the perspectives of multiple stakeholders (i.e., faculty, residents, and patients) in the development of EPAs. Without a shared understanding of what a resident must be able to do upon graduation, we run the risk of advancing ill-prepared residents that may provide inconsistent care. Methods: In an effort to address these challenges, beginning in February 2020, the authors assembled an advisory board of 25 EM faculty to draft and reach consensus on a final list of EPAs that can be used across all training programs within the specialty of EM. Using modified Delphi methodology, the authors came to consensus on an initial list of 22 EPAs. The authors presented these EPAs to faculty supervisors, residents, and patients for refinement. The authors collated and analyzed feedback from focus groups of residents and patients using thematic analysis. The EPAs were subsequently refined based on this feedback. Results: Stakeholders in EM residency training endorsed a final revised list of 22 EPAs. Stakeholder focus groups highlighted two main thematic considerations that helped shape the finalized list of EM EPAs: attention to the meaningful nuances of EPA language and contextualizing the EPAs and viewing them developmentally. Conclusions: To foreground all key stakeholders within the EPA process for EM, the authors chose within the development process to draft; come to consensus; and refine EPAs for EM in collaboration with relevant faculty, patient, and resident stakeholders. Each stakeholder group contributed meaningfully to the content and intended implementation of the EPAs. This process may serve as a model for others in developing stakeholder-responsive EPAs.

Leveraging Electronic Health Record Data and Measuring Interdependence in the Era of Precision Education and Assessment.

PURPOSE: The era of precision education is increasingly leveraging electronic health record (EHR) data to assess residents' clinical performance. But precision in what the EHR-based resident performance metrics are truly assessing is not fully understood. For instance, there is limited understanding of how EHR-based measures account for the influence of the team on an individual's performance-or conversely how an individual contributes to team performances. This study aims to elaborate on how the theoretical understandings of supportive and collaborative interdependence are captured in residents' EHR-based metrics. METHOD: Using a mixed methods study design, the authors conducted a secondary analysis of 5 existing quantitative and qualitative datasets used in previous EHR studies to investigate how aspects of interdependence shape the ways that team-based care is provided to patients. RESULTS: Quantitative analyses of 16 EHR-based metrics found variability in faculty and resident performance (both between and within resident). Qualitative analyses revealed that faculty lack awareness of their own EHR-based performance metrics, which limits their ability to act interdependently with residents in an evidence-informed fashion. The lens of interdependence elucidates how resident practice patterns develop across residency training, shifting from supportive to collaborative interdependence over time. Joint displays merging the quantitative and qualitative analyses showed that residents are aware of variability in faculty's practice patterns and that viewing resident EHR-based measures without accounting for the interdependence of residents with faculty is problematic, particularly within the framework of precision education. CONCLUSIONS: To prepare for this new paradigm of precision education, educators need to develop and evaluate theoretically robust models that measure interdependence in EHR-based metrics, affording more nuanced interpretation of such metrics when assessing residents throughout training.

Exploring How House Staff Unions Impact the Program Director-Resident Educational Alliance.

ABSTRACT: In 1999, the National Labor Relations Board determined that residents function as employees, thereby allowing them to freely unionize. From 2020 to 2023, house staff (i.e., resident physicians and fellows) unions have significantly increased, and 8 physician training centers, representing nearly 4,000 house staff, have unionized since March 2021. While unions provide residents with an important tool in effecting change in their workplace, their introduction into the educational milieu has the potential to alter the program director (PD)-resident relationship. In this article, the authors use the educational alliance framework to detail 3 factors required to support a quality educational relationship between a resident and their PD. They also elaborate on how the introduction of unions may impact the PD-resident relationship and explore the potential unintended consequences of unionization as it pertains to this relationship. The authors then use 2 social psychology theories, naïve realism and motivated reasoning, to describe common framing dynamics that lead to conflict during collective bargaining processes. They conclude by offering strategies that PDs may use to mitigate tensions that arise in contract negotiations, even without a direct seat at the table. Ultimately, PDs should anticipate continued growth of resident unions and prepare themselves and their programs for the tensions that may arise from this action. The PD role as a neutral third party ought to be preserved, which is possible if all parties set reasonable expectations for the changes in the PD's role and responsibilities under a union. PDs should understand the 3 core aspects of the educational alliance and the importance of establishing credibility with their residents early on to build a strong foundation.

The Inconspicuous Learner Handover: An Exploratory Study of U.S. Emergency Medicine Program Directors' Perceptions of Learner Handovers from Medical School to Residency.

Phenomenon: Central to competency-based medical education is the need for a seamless developmental continuum of training and practice. Trainees currently experience significant discontinuity in the transition from undergraduate (UME) to graduate medical education (GME). The learner handover is intended to smooth this transition, but little is known about how well this is working from the GME perspective. In an attempt to gather preliminary evidence, this study explores U.S. program directors (PDs) perspective of the learner handover from UME to GME. Approach: Using exploratory qualitative methodology, we conducted semi-structured interviews with 12 Emergency Medicine PDs within the U.S. from October to November, 2020. We asked participants to describe their current perception of the learner handover from UME to GME. Then we performed thematic analysis using an inductive approach. Findings: We identified two main themes: The inconspicuous learner handover and barrier to creating a successful UME to GME learner handover. PDs described the current state of the learner handover as "nonexistent," yet acknowledged that information is transmitted from UME to GME. Participants also highlighted key challenges preventing a successful learner handover from UME to GME. These included: conflicting expectations, issues of trust and transparency, and a dearth of assessment data to actually hand over. Insights: PDs highlight the inconspicuous nature of learner handovers, suggesting that assessment information is not shared in the way it should be in the transition from UME to GME. Challenges with the learner handover demonstrate a lack of trust, transparency, and explicit communication between UME and GME. Our findings can inform how national organizations establish a unified approach to transmitting growth-oriented assessment data and formalize transparent learner handovers from UME to GME.

Considering the Secondary Use of Clinical and Educational Data to Facilitate the Development of Artificial Intelligence Models.

ABSTRACT: Medical training programs and health care systems collect ever-increasing amounts of educational and clinical data. These data are collected with the primary purpose of supporting either trainee learning or patient care. Well-established principles guide the secondary use of these data for program evaluation and quality improvement initiatives. More recently, however, these clinical and educational data are also increasingly being used to train artificial intelligence (AI) models. The implications of this relatively unique secondary use of data have not been well explored. These models can support the development of sophisticated AI products that can be commercialized. While these products have the potential to support and improve the educational system, there are challenges related to validity, patient and learner consent, and biased or discriminatory outputs. The authors consider the implications of developing AI models and products using educational and clinical data from learners, discuss the uses of these products within medical education, and outline considerations that should guide the appropriate use of data for this purpose. These issues are further explored by examining how they have been navigated in an educational collaborative.

Implementing Workplace-Based Assessments at Scale: The SIMPL Approach.

Over the past decade, medical education has shifted from a time-based approach to a competency-based approach for surgical training. This transition presents many new systemic challenges. The Society for Improving Medical Professional Learning (SIMPL) was created to respond to these challenges through coordinated collaboration across an international network of medical educators. The primary goal of the SIMPL network was to implement a workplace-based assessment and feedback platform. To date, SIMPL has developed, implemented, and sustained a platform that represents the earliest and largest effort to support workplace-based assessment at scale. The SIMPL model for collaborative improvement demonstrates a potential approach to addressing other complex systemic problems in medical education.

Patient handoffs and multi-specialty trainee perspectives across an institution: informing recommendations for health systems and an expanded conceptual framework for handoffs.

BACKGROUND: Safe and effective physician-to-physician patient handoffs are integral to patient safety. Unfortunately, poor handoffs continue to be a major cause of medical errors. Developing a better understanding of challenges faced by health care providers is critical to address this continued patient safety threat. This study addresses the gap in the literature exploring broad, cross-specialty trainee perspectives around handoffs and provides a set of trainee-informed recommendations for both training programs and institutions. METHODS: Using a constructivist paradigm, the authors conducted a concurrent/embedded mixed method study to investigate trainees' experiences with patient handoffs across Stanford University Hospital, a large academic medical center. The authors designed and administered a survey instrument including Likert-style and open-ended questions to solicit information about trainee experiences from multiple specialties. The authors performed a thematic analysis of open-ended responses. RESULTS: 687/1138 (60.4%) of residents and fellows responded to the survey, representing 46 training programs and over 30 specialties. There was wide variability in handoff content and process, most notably code status not being consistently mentioned a third of the time for patients who were not full code. Supervision and feedback about handoffs were inconsistently provided. Trainees identified multiple health-systems level issues that complicated handoffs and suggested solutions to these threats. Our thematic analysis identified five important aspects of handoffs: (1) handoff elements, (2) health-systems-level factors, (3) impact of the handoff, (4) agency (duty), and (5) blame and shame. CONCLUSIONS: Health systems, interpersonal, and intrapersonal issues affect handoff communication. The authors propose an expanded theoretical framework for effective patient handoffs and provide a set of trainee-informed recommendations for training programs and sponsoring institutions. Cultural and health-systems issues must be prioritized and addressed, as an undercurrent of blame and shame permeates the clinical environment.

TRainee Attributable & Automatable Care Evaluations in Real-time (TRACERs): A Scalable Approach for Linking Education to Patient Care.

Competency-based medical education (CBME) is an outcomes-based approach to education and assessment that focuses on what competencies trainees need to learn in order to provide effective patient care. Despite this goal of providing quality patient care, trainees rarely receive measures of their clinical performance. This is problematic because defining a trainee's learning progression requires measuring their clinical performance. Traditional clinical performance measures (CPMs) are often met with skepticism from trainees given their poor individual-level attribution. Resident-sensitive quality measures (RSQMs) are attributable to individuals, but lack the expeditiousness needed to deliver timely feedback and can be difficult to automate at scale across programs. In this eye opener, the authors present a conceptual framework for a new type of measure - TRainee Attributable & Automatable Care Evaluations in Real-time (TRACERs) - attuned to both automation and trainee attribution as the next evolutionary step in linking education to patient care. TRACERs have five defining characteristics: meaningful (for patient care and trainees), attributable (sufficiently to the trainee of interest), automatable (minimal human input once fully implemented), scalable (across electronic health records [EHRs] and training environments), and real-time (amenable to formative educational feedback loops). Ideally, TRACERs optimize all five characteristics to the greatest degree possible. TRACERs are uniquely focused on measures of clinical performance that are captured in the EHR, whether routinely collected or generated using sophisticated analytics, and are intended to complement (not replace) other sources of assessment data. TRACERs have the potential to contribute to a national system of high-density, trainee-attributable, patient-centered outcome measures.

Developing and authenticating an electronic health record-based report card for assessing residents' clinical performance.

Purpose: The electronic health record (EHR) is frequently identified as a source of assessment data regarding residents' clinical performance. To better understand how to harness EHR data for education purposes, the authors developed and authenticated a prototype resident report card. This report card used EHR data exclusively and was authenticated with various stakeholders to understand individuals' reactions to and interpretations of EHR data when presented in this way. Methods: Using principles derived from participatory action research and participatory evaluation, this study brought together residents, faculty, a program director, and medical education researchers (n = 19) to develop and authenticate a prototype report card for residents. From February to September 2019, participants were invited to take part in a semistructured interview that explored their reactions to the prototype and provided insights about how they interpreted the EHR data. Results: Our results highlighted three themes: data representation, data value, and data literacy. Participants varied in terms of the best way to present the various EHR metrics and felt pertinent contextual information should be included. All participants agreed that the EHR data presented were valuable, but most had concerns about using it for assessment. Finally, participants had difficulties interpreting the data, suggesting that these data could be presented more intuitively and that residents and faculty may require additional training to fully appreciate these EHR data. Conclusions: This work demonstrated how EHR data could be used to assess residents' clinical performance, but it also identified areas that warrant further consideration, especially pertaining to data representation and subsequent interpretation. Providing residents and faculty with EHR data in a resident report card was viewed as most valuable when used to guide feedback and coaching conversations.

From Battles to Burnout: Investigating the Role of Interphysician Conflict in Physician Burnout.

PURPOSE: Despite the recognized importance of collaborative communication among physicians, conflict at transitions of care remains a pervasive issue. Recent work has underscored how poor communication can undermine patient safety and organizational efficiency, yet little is known about how interphysician conflict (I-PC) impacts the physicians forced to navigate these tensions. The goal of this study was to explore the social processes and interpersonal interactions surrounding I-PC and their impact, using conversations regarding admission between internal medicine (IM) and emergency medicine (EM) as a lens to explore I-PC in clinical practice. METHOD: The authors used constructivist grounded theory to explore the interpersonal and social dynamics of I-PC. They used purposive sampling to recruit participants, including EM resident and attending physicians and IM attending physicians. The authors conducted hour-long, semistructured interviews between June and October 2020 using the Zoom video conferencing platform. Interviews were coded in 3 phases: initial line-by-line coding, focused coding, and recording. Constant comparative analysis was used to refine emerging codes, and the interview guide was iteratively updated. RESULTS: The authors interviewed 18 residents and attending physicians about how engaging in I-PC led to both personal and professional harm. Specifically, physicians described how I-PC resulted in emotional distress, demoralization, diminished sense of professional attributes, and job dissatisfaction. Participants also described how emotional residue attached to past I-PC events primed the workplace for future conflict. CONCLUSIONS: I-PC may represent a serious yet underrecognized source of harm, not only to patient safety but also to physician well-being. Participants described both the personal and professional consequences of I-PC, which align with the core tenets of burnout. Burnout is a well-established threat to the physician workforce, but unlike many other contributors to burnout, I-PC may be modifiable through improved education that equips physicians with the skills to navigate I-PC throughout their careers.

The fundamentals of Artificial Intelligence in medical education research: AMEE Guide No. 156.

The use of Artificial Intelligence (AI) in medical education has the potential to facilitate complicated tasks and improve efficiency. For example, AI could help automate assessment of written responses, or provide feedback on medical image interpretations with excellent reliability. While applications of AI in learning, instruction, and assessment are growing, further exploration is still required. There exist few conceptual or methodological guides for medical educators wishing to evaluate or engage in AI research. In this guide, we aim to: 1) describe practical considerations involved in reading and conducting studies in medical education using AI, 2) define basic terminology and 3) identify which medical education problems and data are ideally-suited for using AI.

Using learning analytics in clinical competency committees: Increasing the impact of competency-based medical education.

Graduate medical education (GME) and Clinical Competency Committees (CCC) have been evolving to monitor trainee progression using competency-based medical education principles and outcomes, though evidence suggests CCCs fall short of this goal. Challenges include that evaluation data are often incomplete, insufficient, poorly aligned with performance, conflicting or of unknown quality, and CCCs struggle to organize, analyze, visualize, and integrate data elements across sources, collection methods, contexts, and time-periods, which makes advancement decisions difficult. Learning analytics have significant potential to improve competence committee decision making, yet their use is not yet commonplace. Learning analytics (LA) is the interpretation of multiple data sources gathered on trainees to assess academic progress, predict future performance, and identify potential issues to be addressed with feedback and individualized learning plans. What distinguishes LA from other educational approaches is systematic data collection and advanced digital interpretation and visualization to inform educational systems. These data are necessary to: 1) fully understand educational contexts and guide improvements; 2) advance proficiency among stakeholders to make ethical and accurate summative decisions; and 3) clearly communicate methods, findings, and actionable recommendations for a range of educational stakeholders. The ACGME released the third edition CCC Guidebook for Programs in 2020 and the 2021 Milestones 2.0 supplement of the Journal of Graduate Medical Education (JGME Supplement) presented important papers that describe evaluation and implementation features of effective CCCs. Principles of LA underpin national GME outcomes data and training across specialties; however, little guidance currently exists on how GME programs can use LA to improve the CCC process. Here we outline recommendations for implementing learning analytics for supporting decision making on trainee progress in two areas: 1) Data Quality and Decision Making, and 2) Educator Development.

Supportive and collaborative interdependence: Distinguishing residents' contributions within health care teams.

INTRODUCTION: Individual assessments disregard team contributions, while team assessments disregard an individual's contributions. Interdependence has been put forth as a conceptual bridge between our educational traditions of assessing individual performance and our imminent challenge of assessing team-based performance without losing sight of the individual. The purpose of this study was to develop a more refined conceptualisation of interdependence to inform the creation of measures that can assess the interdependence of residents within health care teams. METHODS: Following a constructivist grounded theory approach, we conducted 49 semi-structured interviews with various members of health care teams (e.g. physicians, nurses, pharmacists, social workers and patients) across two different clinical specialties-Emergency Medicine and Paediatrics-at two separate sites. Data collection and analysis occurred iteratively. Constant comparative inductive analysis was used, and coding consisted of three stages: initial, focused and theoretical. RESULTS: We asked participants to reflect upon interdependence and describe how it exists in their clinical setting. All participants acknowledged the existence of interdependence, but they did not view it as part of a linear spectrum where interdependence becomes independence. Our analysis refined the conceptualisation of interdependence to include two types: supportive and collaborative. Supportive interdependence occurs within health care teams when one member demonstrates insufficient expertise to perform within their scope of practice. Collaborative interdependence, on the other hand, was not triggered by lack of experience/expertise within an individual's scope of practice, but rather recognition that patient care requires contributions from other team members. CONCLUSION: In order to assess a team's collective performance without losing sight of the individual, we need to capture interdependent performances and characterise the nature of such interdependence. Moving away from a linear trajectory where independence is seen as the end goal can also help support efforts to measure an individual's competence as an interdependent member of a health care team.

Using Resident-Sensitive Quality Measures Derived From Electronic Health Record Data to Assess Residents' Performance in Pediatric Emergency Medicine.

PURPOSE: Traditional quality metrics do not adequately represent the clinical work done by residents and, thus, cannot be used to link residency training to health care quality. This study aimed to determine whether electronic health record (EHR) data can be used to meaningfully assess residents' clinical performance in pediatric emergency medicine using resident-sensitive quality measures (RSQMs). METHOD: EHR data for asthma and bronchiolitis RSQMs from Cincinnati Children's Hospital Medical Center, a quaternary children's hospital, between July 1, 2017, and June 30, 2019, were analyzed by ranking residents based on composite scores calculated using raw, unadjusted, and case-mix adjusted latent score models, with lower percentiles indicating a lower quality of care and performance. Reliability and associations between the scores produced by the 3 scoring models were compared. Resident and patient characteristics associated with performance in the highest and lowest tertiles and changes in residents' rank after case-mix adjustments were also identified. RESULTS: 274 residents and 1,891 individual encounters of bronchiolitis patients aged 0-1 as well as 270 residents and 1,752 individual encounters of asthmatic patients aged 2-21 were included in the analysis. The minimum reliability requirement to create a composite score was met for asthma data (α = 0.77), but not bronchiolitis (α = 0.17). The asthma composite scores showed high correlations ( r = 0.90-0.99) between raw, latent, and adjusted composite scores. After case-mix adjustments, residents' absolute percentile rank shifted on average 10 percentiles. Residents who dropped by 10 or more percentiles were likely to be more junior, saw fewer patients, cared for less acute and younger patients, or had patients with a longer emergency department stay. CONCLUSIONS: For some clinical areas, it is possible to use EHR data, adjusted for patient complexity, to meaningfully assess residents' clinical performance and identify opportunities for quality improvement.

Belongingness among first-generation students at Stanford School of Medicine.

Background: Nationally, underrepresented minorities represent a significant proportion of the first-generation student population. These students also tend to report lower levels of belongingness compared to their peers, which may impact their wellness and be an important factor in their academic success. This study aimed to explore whether status as a first-generation student was associated with belongingness amongst medical students. Methods: In 2019, a previously validated 16-item survey was used to examine potential disparities in belongingness amongst groups of first-generation medical students. Differences between groups were assessed using a Mann-Whitney U-test for each individual item and three composite groupings of items regarding social belonging, academic belonging, and institutional support. Results: First-generation to college and first-generation to graduate school students reported lower belongingness across most individual items as well as in all three composite groups. Conclusions: Given that peer relationships and institutional support play an important role in medical student belonging, these findings represent an opportunity to address the specific needs of individuals from underrepresented groups in medicine. Doing so can support the academic and professional success of first-generation students and help close the diversity gap in medicine.

"Faces on a screen": A qualitative study of the virtual and in-person conference experience.

Introduction: The strengths and weaknesses of virtual and in-person formats within continuing professional development (CPD) are incompletely understood. This study sought to explore attendees' perspectives across multiple specialties regarding benefits and limitations of conference formats and strategies for successful virtual and hybrid (i.e., in-person conferences with a virtual option) conferences. Methods: From December 2020 to January 2021, semistructured interviews were conducted with participants who attended both virtual and in-person CPD conferences. Purposive sampling was utilized to ensure diverse representation of gender, years in practice, location, academic rank, specialty, and practice type. Multiple specialties were intentionally sought to better understand the broader experience among physicians in general, rather than among a specific specialty. Using modified grounded theory approach with a constructivist-interpretivist paradigm, two investigators independently analyzed all interview transcripts. Discrepancies were resolved by in-depth discussion and negotiated consensus. Results: Twenty-six individuals across 16 different specialties were interviewed. We identified three overarching concepts: motivations to attend conferences, benefits and limitations of different conference formats, and strategies to optimize virtual and hybrid conferences. Specific motivators included both professional and personal factors. Benefits of in person included networking/community, immersion, and wellness, while the major limitation was integration with personal life. Benefits of virtual were flexibility, accessibility, and incorporation of technology, while limitations included technical challenges, distractions, limitations for tactile learning, and communication/connection. Benefits of hybrid included more options for access, while limitations included challenges with synchrony of formats and dilution of experiences. Strategies to improve virtual/hybrid conferences included optimizing technology/production, facilitating networking and engagement, and deliberate selection of content. Conclusions: This study identified several benefits and limitations of each medium as well as strategies to optimize virtual and hybrid CPD conferences. This may help inform future CPD conference planning for both attendees and conference planners alike.

The next generation of researchers: One-year outcome data from the SAEM Advanced Research Methodology Evaluation and Design in Medical Education (ARMED MedEd) program.

Introduction: As the field of medical education evolves, there is a need to increase the quality of education scholarship and develop a cadre of research scholars; however, clinician educators (CEs) considering this career transition have limited formal training in education research methodology to heed this call. Therefore, a program that provides more advanced training in education scholarship for CEs without the financial and resource barriers of fellowships and masters programs is needed. Methods: The SAEM Advanced Research Methodology Evaluation and Design in Medical Education (ARMED MedEd) program is a longitudinal program for the beyond-beginner CE, seeking advanced training in education research. The program was created using a comprehensive needs assessment and included longitudinal training; small-group projects; dedicated project mentors; and integrated diversity, equity, and inclusion initiatives. Program participants applied for a grant upon program completion. Results: Twenty-one participants completed the course with 100% completing the baseline survey and 67% (14/21) completing the end-of-program survey. Participants reported improved perception of knowledge across all of the topics with a medium to large effect size, ranging from 0.40 to 0.62. When asked about impact on their network of potential collaborators, participants reported a median of 7 (interquartile range [IQR] 5-8) out of 9. When asked about the impact on their community of practice, participants reported a median of 7 (IQR 5-7) out of 9. When asked about the impact on their professional identity, participants reported a median of 7 (IQR 4-9) out of 9. Participants also reported an increase in both the quantity (mean of 2 ± 1 new mentors) and the quality (median score 7 [IQR 5-8] out of 9) of new research mentorship as a result of the program. Open-ended feedback was generally positive, with 100% reporting they would advise others to take this program. Conclusions: The SAEM ARMED MedEd program represents a proof of concept for an advanced education research program seeking to fill the research training gap for the beyond-beginner Clinician educators.

Effectiveness, safety, and efficiency of a drive-through care model as a response to the COVID-19 testing demand in the United States.

Objectives: Here we report the clinical performance of COVID-19 curbside screening with triage to a drive-through care pathway versus main emergency department (ED) care for ambulatory COVID-19 testing during a pandemic. Patients were evaluated from cars to prevent the demand for testing from spreading COVID-19 within the hospital. Methods: We examined the effectiveness of curbside screening to identify patients who would be tested during evaluation, patient flow from screening to care team evaluation and testing, and safety of drive-through care as 7-day ED revisits and 14-day hospital admissions. We also compared main ED efficiency versus drive-through care using ED length of stay (EDLOS). Standardized mean differences (SMD) >0.20 identify statistical significance. Results: Of 5931 ED patients seen, 2788 (47.0%) were walk-in patients. Of these patients, 1111 (39.8%) screened positive for potential COVID symptoms, of whom 708 (63.7%) were triaged to drive-through care (with 96.3% tested), and 403 (36.3%) triaged to the main ED (with 90.5% tested). The 1677 (60.2%) patients who screened negative were seen in the main ED, with 440 (26.2%) tested. Curbside screening sensitivity and specificity for predicting who ultimately received testing were 70.3% and 94.5%. Compared to the main ED, drive-through patients had fewer 7-day ED revisits (3.8% vs 12.5%, SMD = 0.321), fewer 14-day hospital readmissions (4.5% vs 15.6%, SMD = 0.37), and shorter EDLOS (0.56 vs 5.12 hours, SMD = 1.48). Conclusion: Curbside screening had high sensitivity, permitting early respiratory isolation precautions for most patients tested. Low ED revisit, hospital readmissions, and EDLOS suggest drive-through care, with appropriate screening, is safe and efficient for future respiratory illness pandemics.

Filling the Core EPA 10 assessment void: A framework for individual assessment of Core Entrustable professional activity 10 competencies in medical students.

Objectives: The goal of this study was to develop and evaluate a novel curriculum and assessment tool for Core Entrustable Professional Activity (EPA) 10 competencies and entrustment scoring in a cohort of medical students in their emergency medicine (EM) clerkship using a framework of individualized, ad hoc, formative assessment. Core EPA 10 is an observable workplace-based activity for graduating medical students to recognize a patient requiring urgent or emergent care and initiate evaluation and management. Methods: This is a prospective, pretest-posttest study of medical students during their EM clerkship. Using the Thomas and Kern framework, we created a curriculum of simulation cases about chest pain/cardiac arrest and respiratory distress, which included novel assessment checklists, and instructional videos about recognizing and managing emergencies. Students were individually pretested on EPA 10 competencies using the simulation cases. Two raters scored students using standardized checklists. Students then watched instructional videos, underwent a posttest with the simulation cases, and were scored again by the two raters using the checklists. Differences between pretest and posttest scores were analyzed using paired t-tests and Wilcoxon signed-rank tests. Results: Seventy-three out of 85 (86%) students completed the curriculum. Mean scores from pretest to final posttest in the chest pain/cardiac arrest and respiratory distress cases significantly improved from 14.8/19 (SD 1.91), to 17.1/19 (SD = 1.00), t(68) = 10.56, p < 0.001, and 8.5/13 (SD 1.79), to 11.1/13(SD 0.89), t(67) = 11.15, p < 0.001, respectively. The kappa coefficients were 0.909 (n = 2698, p < 0.001) and 0.931 (n = 1872, p < 0.001). Median modified Chen entrustment scores improved from 1b (i.e., "Watch me do this") to 2b (i.e., "I'll watch you") for the chest pain/cardiac arrest case (p < 0.001) and 1b/2a (i.e., "Watch me do this"/ "Let's do this together") to 3a (i.e. "You go ahead, and I'll double-check all of your findings") for the respiratory distress case (p < 0.001). Conclusion: A new directed curriculum of standardized simulation cases and asynchronous instructional videos improved medical student performance in EPA 10 competencies and entrustment scores. This study provides a curricular framework to support formative individualized assessments for EPA 10.

Facilitating Residents' Understanding of Electronic Health Record Report Card Data Using Faculty Feedback and Coaching.

PURPOSE: Feedback continues to present a challenge for competency-based medical education. Clear, consistent, and credible feedback is vital to supporting one's ongoing development, yet it can be difficult to gather clinical performance data about residents. This study sought to determine whether providing residents with electronic health record (EHR)-based report cards, as well as an opportunity to discuss these data with faculty trained using the R2C2 model, can help residents understand and interpret their clinical performance metrics. METHOD: Using action research methodology, the author team collected EHR data from July 2017 to February 2020, for all residents (n = 21) in one 5-year Emergency Medicine program and created personalized report cards for each resident. During October 6-17, 2020, 8 out of 17 eligible residents agreed to have their feedback conversations recorded and participate in a subsequent interview with a nonphysician member of the research team. Data were analyzed using thematic analysis, and the authors used inductive analysis to identify themes in the data. RESULTS: In analyzing both the feedback conversations as well as the individual interviews with faculty and residents, the authors identified 2 main themes: (1) Reactions and responses to receiving personalized EHR data and (2) The value of EHR data for assessment and feedback purposes. All participants believed that EHR data metrics are useful for prompting self-reflection, and many pointed to their utility in providing suggestions for actionable changes in their clinical practice. For faculty, having a tool through which underperforming residents can be shown "objective" data about their clinical performance helps underscore the need for improvement, particularly when residents are resistant. CONCLUSIONS: The EHR is a valuable source of educational data, and this study demonstrates one of the many thoughtful ways it can be used for assessment and feedback purposes.