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INTRODUCTION: While females make up more than half of medical school matriculants, they only comprise about one third of emergency medicine (EM) residents. We examined EM residency cohorts with entering years of 2014-2017 to estimate the ratio of males to females among residents and program leadership to determine what correlation existed, if any, between program leadership and residency gender distributions. METHODS: We identified 171 accredited EM residency programs in the United States with resident cohorts entering between 2014-2017 with publicly available data that were included in the study. The number of male and female residents and program directors were counted. We then confirmed the counts by contacting the programs directly to confirm accuracy of the data collected from program websites. RESULTS: Within the included 171 programs, the overall male to female EM resident ratio was 1.78:1. Individual program ratios ranged from 0.85-8.0. Only eight programs (5.6%) had a female-predominant ratio. Among program directors, the overall male to female ratio was 2.17:1. TThe gender of the program director did not have a statistically significant correlation with the male to female ratio among its residents (P = .93). CONCLUSION: Within 171 residency programs across the US with entering cohorts between 2014-2017, the average male to female ratio among residents is nearly 2:1. No significant correlation exists between the gender distribution among a program's leadership and its residents.
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Medicina de Emergência , Internato e Residência , Masculino , Feminino , Humanos , Estados Unidos , Estudos Retrospectivos , Medicina de Emergência/educação , Faculdades de Medicina , Coleta de DadosRESUMO
BACKGROUND: Patient simulators are an increasingly important part of medical training. They have been shown to be effective in teaching procedural skills, medical knowledge, and clinical decision-making. Recently, virtual and augmented reality simulators are being produced, but there is no research on whether these more realistic experiences cause problematic and greater stress responses as compared to standard manikin simulators. OBJECTIVE: The purpose of this research is to examine the psychological and physiological effects of augmented reality (AR) in medical simulation training as compared to traditional manikin simulations. METHODS: A within-subjects experimental design was used to assess the responses of medical students (N=89) as they completed simulated (using either manikin or AR) pediatric resuscitations. Baseline measures of psychological well-being, salivary cortisol, and galvanic skin response (GSR) were taken before the simulations began. Continuous GSR assessments throughout and after the simulations were captured along with follow-up measures of emotion and cortisol. Participants also wrote freely about their experience with each simulation, and narratives were coded for emotional word use. RESULTS: Of the total 86 medical students who participated, 37 (43%) were male and 49 (57%) were female, with a mean age of 25.2 (SD 2.09, range 22-30) years and 24.7 (SD 2.08, range 23-36) years, respectively. GSR was higher in the manikin group adjusted for day, sex, and medications taken by the participants (AR-manikin: -0.11, 95% CI -0.18 to -0.03; P=.009). The difference in negative affect between simulation types was not statistically significant (AR-manikin: 0.41, 95% CI -0.72 to 1.53; P=.48). There was no statistically significant difference between simulation types in self-reported stress (AR-manikin: 0.53, 95% CI -2.35 to 3.42; P=.71) or simulation stress (AR-manikin: -2.17, 95% CI -6.94 to 2.59; P=.37). The difference in percentage of positive emotion words used to describe the experience was not statistically significant between simulation types, which were adjusted for day of experiment, sex of the participants, and total number of words used (AR-manikin: -4.0, 95% CI -0.91 to 0.10; P=.12). There was no statistically significant difference between simulation types in terms of the percentage of negative emotion words used to describe the experience (AR-manikin: -0.33, 95% CI -1.12 to 0.46; P=.41), simulation sickness (AR-manikin: 0.17, 95% CI -0.29 to 0.62; P=.47), or salivary cortisol (AR-manikin: 0.04, 95% CI -0.05 to 0.13; P=.41). Finally, preexisting levels of posttraumatic stress disorder, perceived stress, and reported depression were not tied to physiological responses to AR. CONCLUSIONS: AR simulators elicited similar stress responses to currently used manikin-based simulators, and we did not find any evidence of AR simulators causing excessive stress to participants. Therefore, AR simulators are a promising tool to be used in medical training, which can provide more emotionally realistic scenarios without the risk of additional harm.
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BACKGROUND: Gamification in medical education has gained popularity over the past several years. We describe a virtual escape box in emergency medicine clerkship didactics to teach chest pain and abdominal pain and compare this instructional method to a traditional flipped classroom format. METHODS: A virtual escape box was designed at our institution and incorporated into the mandatory two-week emergency medicine clerkship. The game consisted of a PDF with four cases containing puzzles to unlock a final clue. Likert scale surveys were administered to assess participants' perceptions of the escape box format; of clerkship didactics as a whole; and of the clerkship overall. These responses were compared to the prior year's evaluations on flipped classroom didactics and clerkship. RESULTS: One hundred thirty-four learners participated in the escape box and completed the survey. Eighty-six percent strongly agreed with feeling more engaged with the escape box, 84% strongly agreed with learning something new, 81% strongly agreed with finding the escape box to be satisfying, 78% strongly agreed with being able to apply knowledge gained, and 74% strongly agreed with wanting more escape boxes incorporated into medical education. The escape box showed a higher average score (3.6 ± 0.63) compared to chest pain (3.5 ± 0.67) and abdominal pain (3.2 ± 0.77) flipped classroom sessions (p = 0.0491) for the category of "lecturer explaining content clearly and at the proper level of complexity." For the category of "lecturer provided effective instructional materials," the escape box showed higher scores (3.6 ± 0.63) compared to flipped classroom for chest pain (3.4 ± 0.77) and abdominal pain (3.1 ± 0.80) (p < 0.001). CONCLUSIONS: Escape boxes are adaptable to a virtual format and can teach abstract concepts such as teamwork and communication in addition to traditional lecture content. Ratings of didactics were higher for the escape box compared to the flipped classroom, while ratings of overall clerkship experience were not found to change significantly.
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Medicina de Emergência , Estudantes de Medicina , Dor Abdominal , Dor no Peito/terapia , Humanos , Satisfação PessoalRESUMO
Introduction: Lectures are a standard aspect across all realms of medical education. Previous studies have shown that visual design of presentation slides can affect learner outcomes. The purpose of this study was to develop a slide design rubric grounded in evidence-based, multimedia principles to enable objective evaluation of slide design. Method: Using the principles described in Mayers' Principles of Multimedia Learning and Duarte's Slide:ology, the authors extracted nineteen items important for slide design. We developed an online, rank-item, survey tool to identify the importance of each item among medical educators. Respondents selected which slide design principles they felt were important when attending a lecture/didactic session and ranked their relative importance. Results: We received 225 responses to the survey. When asked to specifically rank elements from most important to least important, participants gave the most weight to "readability of figures and data" and "[lack of] busy-ness of slide." The lowest ranked elements were "transitions and animations" and "color schemes". Using the results of the survey, including the free response, we developed a rubric with relative weighting that followed our survey data. Conclusion: With this information we have applied values to the various aspects of the rubric for a total score of 100. We hope that this rubric can be used for self-assessment or to evaluate and improve slides for educators. Future research will be focused on implementing and validating the slide design survey and ensuring it is easily usable with a high inter-rater reliability and whether self-assessment with the rubric improves presentation design and education quality.
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BACKGROUND: Females make up more than half of medical school matriculants but only one-third of emergency medicine (EM) residents. Various factors may contribute to why fewer females choose the field of EM, such as the existing presence of females in the specialty. OBJECTIVE: This study is a follow-up to previous work, and a survey is used to assess current residents' attitudes and perceptions on various factors, including those relating to sex and gender on creating rank lists as medical students and in perceived effects on residency education. METHODS: A web-based survey consisting of Likert scale questions regarding a variety of factors influencing a student's decision to create a rank list and in perceived effects on residency education was sent to current EM residents in 2020. RESULTS: Residents from 17 programs participated in the survey with an 18.2% (138/758) response rate. The most important factors in creating a rank list were the personality of residents in the program, location, and facility type. For factors specifically related to gender, respondents who answered affirmatively to whether the gender composition of residents affected the selection of a program in making a rank list were more likely to also answer affirmatively to subsequent questions related to the gender of program leadership (P<.001) and gender composition of attending physicians (P<.001). The personality of residents was also the most important factor perceived to affect residency education. For factors influencing rank list and residency education, female respondents placed higher importance on subcategories related to gender (ie, gender composition of the residents, of the program leadership, and of the attending physicians) to a significant degree compared with their male counterparts. CONCLUSIONS: Although factors such as location and resident personality show the most importance in influencing residency selection, when stratifying based on respondent sex, females tend to indicate that factors relating to gender have more influence on rank list and residency education compared with males.
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PURPOSE: Technological advances are changing how students approach learning. The traditional note-taking methods of longhand writing have been supplemented and replaced by tablets, smartphones, and laptop note-taking. It has been theorized that writing notes by hand requires more complex cognitive processes and may lead to better retention. However, few studies have investigated the use of tablet-based note-taking, which allows the incorporation of typing, drawing, highlights, and media. We therefore sought to confirm the hypothesis that tablet-based note-taking would lead to equivalent or better recall as compared to written note-taking. METHODS: We allocated 68 students into longhand, laptop, or tablet note-taking groups, and they watched and took notes on a presentation on which they were assessed for factual and conceptual recall. A second short distractor video was shown, followed by a 30-minute assessment at the University of California, Irvine campus, over a single day period in August 2018. Notes were analyzed for content, supplemental drawings, and other media sources. RESULTS: No significant difference was found in the factual or conceptual recall scores for tablet, laptop, and handwritten note-taking (P=0.61). The median word count was 131.5 for tablets, 121.0 for handwriting, and 297.0 for laptops (P=0.01). The tablet group had the highest presence of drawing, highlighting, and other media/tools. CONCLUSION: In light of conflicting research regarding the best note-taking method, our study showed that longhand note-taking is not superior to tablet or laptop note-taking. This suggests students should be encouraged to pick the note-taking method that appeals most to them. In the future, traditional note-taking may be replaced or supplemented with digital technologies that provide similar efficacy with more convenience.
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Estudantes de Medicina , Compreensão , Humanos , Aprendizagem , Microcomputadores , Smartphone , Estados UnidosRESUMO
BACKGROUND: The COVID-19 pandemic has revealed the importance of teaching medical students pandemic preparedness and COVID-19 related clinical knowledge. To fill the gap of COVID-19 instruction backed by evaluation data, we present a comprehensive COVID-19 pilot curriculum with multiple levels of evaluation data. METHODS: In the spring of 2020, the University of California, Irvine (UCI) School of Medicine piloted a two-week, primarily asynchronous COVID-19 elective course for medical students. The goal of the course is to provide a foundation in clinical care for COVID-19 while introducing students to emerging issues of a modern pandemic. Objectives align with institutional objectives, and instruction is delivered in thematic modules. Our curriculum utilizes numerous instructional strategies effective in distance learning including independent learning modules (ILM), reading, video lectures, discussion board debates, simulation and evidence-based argument writing. We designed a three-level, blended evaluation plan grounded in the Kirkpatrick and Kirkpatrick evaluation model that assessed student satisfaction, relevance, confidence, knowledge and behavior. RESULTS: Our end of course survey revealed that students had high levels of satisfaction with the curriculum, and felt the course was relevant to their clinical education. Various assessment tools showed excellent levels of knowledge attainment. All respondents rated themselves as highly confident with the use of personal protective equipment, though fewer were confident with ventilator management. CONCLUSION: Overall our pilot showed that we were able to deliver relevant, satisfying COVID-19 instruction while allowing students to demonstrate knowledge and desired behaviors in COVID-19 patient care.
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COVID-19 , Estudantes de Medicina , Currículo , Humanos , Pandemias , SARS-CoV-2RESUMO
PURPOSE: Medical schools must have clear policies and procedures for promotion and tenure (P&T) of faculty. Social media and digital scholarship (SMDS) is an emerging form of scholarship capable of reaching audiences quickly, conveniently, and in a wide variety of formats. It is unclear how frequently SMDS is considered during P&T reviews. The authors sought to determine whether current P&T guidelines at medical schools consider SMDS. METHOD: The authors acquired P&T guidelines from any U.S. Liaison Committee on Medical Education-accredited medical school (or their governing university) that were available online between October and December 2020. Using an iterative process, they developed a bank of keywords that were specific to SMDS or that could include SMDS between October and December 2020. The authors searched each school's guidelines for each keyword and determined whether the word was being used in relation to crediting faculty for SMDS in the context of P&T procedures. The primary outcome measure was the dichotomous presence or absence of SMDS-specific keywords in each school's P&T guidelines. RESULTS: The authors acquired P&T guidelines from 145/154 (94%) medical schools. After removing duplicate documents, the authors considered 139 guidelines. The keyword bank included 59 terms, of which 49 were specific to SMDS and 10 were umbrella terms that could be inclusive of SMDS. Of the 139 guidelines, 121 (87%) contained at least 1 SMDS-specific keyword. Schools had a median of 3 SMDS-specific keywords in their P&T guidelines. CONCLUSIONS: As the presence and impact of SMDS increase, schools should provide guidance on its role in the P&T process. Faculty should receive clear guidance on how to document quality SMDS for their promotion file.
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Educação Médica , Mídias Sociais , Docentes , Docentes de Medicina , Bolsas de Estudo , Humanos , Faculdades de MedicinaRESUMO
BACKGROUND: Due to challenges related to the COVID-19 pandemic, residency programs in the United States conducted virtual interviews during the 2020-2021 application season. As a result, programs and applicants may have relied more heavily on social media-based communication and dissemination of information. OBJECTIVE: We sought to determine social media's impact on residency applicants during an entirely virtual application cycle. METHODS: An anonymous electronic survey was distributed to 465 eligible 2021 Match applicants at 4 University of California Schools of Medicine in the United States. RESULTS: A total of 72 participants (15.5% of eligible respondents), applying to 16 specialties, responded. Of those who responded, 53% (n=38) reported following prospective residency accounts on social media, and 89% (n=34) of those respondents were positively or negatively influenced by these accounts. The top three digital methods by which applicants sought information about residency programs included the program website, digital conversations with residents and fellows of that program, and Instagram. Among respondents, 53% (n=38) attended virtual information sessions for prospective programs. A minority of applicants (n=19, 26%) adjusted the number of programs they applied to based on information found on social media, with most (n=14, 74%) increasing the number of programs to which they applied. Survey respondents ranked social media's effectiveness in allowing applicants to learn about programs at 6.7 (SD 2.1) on a visual analogue scale from 1-10. Most applicants (n=61, 86%) felt that programs should use social media in future application cycles even if they are nonvirtual. CONCLUSIONS: Social media appears to be an important tool for resident recruitment. Future studies should seek more information on its effect on later parts of the application cycle and the Match.
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INTRODUCTION: As part of its Next Accreditation System, the Accreditation Council for Graduate Medical Education and the American Board of Emergency Medicine describe 6 competencies containing 23 sub-competencies graded by milestones ranging from level 1 (expected of an incoming intern) to level 5 (demonstrates abilities of an attending) that are used to track resident training progression. To the best of our knowledge, there have been no studies introducing a milestones-based curriculum to medical students prior to their introduction to the wards, so we sought to determine the effects that a pre-clinical Emergency Medicine Interest Group (EMIG) Milestones Elective would have on preparing the students interested in Emergency Medicine (EM) as a specialty to meet the level 1 milestones prior to their intern year. METHODS: The elective hosted 15 events throughout the academic year, and pre- and post-curriculum surveys were administered. Thirteen first- and second-year medical students at our institution who completed the elective self-reported their perception of preparedness for each level 1 milestone in the 19 sub-competencies. A repeated measures design was used through identical pre- and post-curriculum surveys to determine any changes in self-reported preparedness for meeting level 1 milestones after completing the elective using Wilcoxon Signed Ranks Test. RESULTS: There was a significant increase in the median scoring from 1 to 2 (p=0.027) in overall self-reported preparedness for meeting the level 1 milestones included in the elective, as well as significant increases in subcategories across competencies 1-4 outlined by the ACGME. There was no significant increase in preparedness for professionalism or interpersonal communication competencies. There was no significant increase in interest in EM as a result of the elective. CONCLUSION: Implementing a milestones-based curriculum during the pre-clinical years shows improved self-reported preparedness of students interested in pursuing EM for meeting level 1 milestones prior to residency. Additionally, a specialty-based elective such as this one offered through EMIG may further increase interest in the field during pre-clinical years.
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INTRODUCTION: When discharging a patient from the emergency department (ED), it is crucial to make sure that they understand their disposition and aftercare instructions. However, numerous factors make it difficult to ensure that patients understand their next steps. Our objective was to determine whether patient understanding of ED discharge and aftercare instructions could be improved through instructional videos in addition to standard written discharge instructions. METHODS: This was a prospective pre- and post-intervention study conducted at a single-center, academic tertiary care ED. Patients presenting with the five selective chief complaints (closed head injury, vaginal bleeding, laceration care, splint care, and upper respiratory infection) were given questionnaires after their discharge instructions to test comprehension. Once video discharge instructions were implemented, patients received standard discharge instructions in addition to video discharge instructions and were given the same questionnaire. A total of 120 patients were enrolled in each group. RESULTS: There were significantly better survey scores after video discharge instructions (VDI) vs standard discharge instructions (SDI) for the closed head injury (27% SDI vs 46% VDI, P = 0.003); upper respiratory infection (28% SDI vs 64% VDI; P < 0.0001); and vaginal bleeding in early pregnancy groups (20% SDI vs 60% VDI, P < 0.0001). There were no significant differences in survey scores between the splint care (53% SDI vs 66% VDI; P = 0.08) and suture care groups (29% SDI vs 31% VDI; P = 0.40). CONCLUSION: Video discharge instructions supplementing standard written instructions can help improve patient comprehension and information retention. This better understanding of aftercare instructions is essential to patient follow-up and has been shown to improve patient outcomes.
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Assistência ao Convalescente , Serviço Hospitalar de Emergência/organização & administração , Alta do Paciente , Gravação em Vídeo , Feminino , Humanos , Masculino , Educação de Pacientes como Assunto , Estudos Prospectivos , Inquéritos e QuestionáriosRESUMO
As part of the Accreditation Council for Graduate Medical Education requirements, residents must participate in structured didactic activities. Traditional didactics include lectures, grand rounds, simulations, case discussions, and other forms of in-person synchronous learning. The COVID-19 pandemic has made in-person activities less feasible, as many programs have been forced to transition to remote didactics. Educators must still achieve the goals and objectives of their didactic curriculum despite the new limitations on instructional strategies. There are several strategies that may be useful for organizing and creating a remote residency didactic curriculum. Educators must master new technology, be flexible and creative, and set rules of engagement for instructors and learners. Establishing best practices for remote didactics will result in successful, remote, synchronous didactics; reduce the impact of transitioning to a remote learning environment; and keep educators and learners safe as shelter-at-home orders remain in place.
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We introduced the AliveCor KardiaMobile electrocardiogram (ECG), a Food and Drug Administration (FDA)-approved, iPad-enabled medical device, into the preclerkship curriculum to demonstrate the clinical relevance of cardiac electrophysiology with active learning. An evaluation showed that medical students considered the KardiaMobile ECG active learning activity to be a valuable educational tool for teaching cardiac physiology.
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Educação de Graduação em Medicina , Estudantes de Medicina , Currículo , Eletrocardiografia , Humanos , Aprendizagem Baseada em Problemas , Faculdades de Medicina , EnsinoRESUMO
BACKGROUND: When being treated at a university-based hospital, a patient may encounter multiple levels of physicians, including trainees during a single emergency visit. Patients want to know the roles of their providers, but their understanding of the medical education hierarchy is poor. OBJECTIVES: Our study explored patient understanding of commonly used physician and trainee titles as well as the factors that contribute to patient understanding in our emergency department patient population. Additionally, we evaluated a new badge buddy system that identifies medical personnel impacts patient's perceptions of providers. We examined how the increasing prevalence of medicine in media may change patient perceptions of the medical hierarchy. METHODS: Patients pending discharge from the emergency room was assessed through a knowledge-based and opinion-based questionnaire. Questions quantified the percentage of patients who understood titles of their team. RESULTS: Of 423 patients who completed the study, 88% (N = 365) felt it was very important to know the level of training of their doctor when being treated in the emergency department. Seventy-four percent (N = 303) believed they knew the role of their care providers but the mean knowledge score was 4.7 of 8, suggesting a poor understanding of the medical training hierarchy. Younger patients and those who felt that knowing the level of training of their doctor was very important noticed the badge buddies more frequently (80.9%, P = .020 and 81%, P < .001). CONCLUSIONS: Our study found that patients had a poor understanding of the medical training hierarchy, but felt that it is important to know the level of training of their staff. The implementation of a badge buddy served this purpose for most patients, but was less effective for older patients. Further research may be needed to evaluate if a different intervention, such as a detailed video or teach-back techniques explaining the levels of medical training, would be more effective for a larger population of patients.
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BACKGROUND: Medical student mistreatment has detrimental effects on student well-being and poses a patient safety risk, yet 40% of medical school graduates report being mistreated during their training. Unfortunately, this statistic has not changed significantly since 2013. The 'hidden curriculum' contributes to the pervasiveness of mistreatment in medical schools in the USA. The #MDsToo curriculum was developed to mitigate the effects of the hidden curriculum by sensitising faculty members and residents to mistreatment. METHODS: During the curriculum, participants are introduced to the KIND (knowledge-sharing, inclusive, non-discriminatory, developmentally appropriate) framework for modelling positive teacher-learner interactions and detecting mistreatment. Using KIND, faculty members and residents identify and categorise mistreatment in eight video cases depicting mistreatment, and reflect on their own experiences with mistreatment. RESULTS: Two hundred and forty-eight participants responded to a course survey. Most had experienced mistreatment. After the training, almost half stated that there were situations in the past that they did not recognize as mistreatment that they would now classify as mistreatment, and most stated that they were likely to report mistreatment now. CONCLUSION: The #MDsToo curriculum may provide an effective design for mistreatment prevention training. Next steps include multi-institutional implementation and longitudinal outcome studies.
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Currículo , Estudantes de Medicina , Docentes , Humanos , Faculdades de Medicina , Inquéritos e QuestionáriosRESUMO
BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) requires that residency programs in emergency medicine plan at least 5 hours of didactic experiences per week. Instructional methods should include small-group techniques, problem-based learning, or computer-based instruction. Despite recommendations from the ACGME, many programs' conference didactics continue to include primarily lecture-based instruction. METHODS: The authors describe instructional methods that promote active learning and may be superior to traditional lecture-based education. RESULTS: These methods include varying instructional methods, case-based learning, team-based learning and the flipped classroom, audience response systems, simulation, "wars," oral boards, escape rooms and scavenger hunts, expert panel discussions, debates, clinical pathologic cases, and leaderboards. The authors discuss how these methods can be implemented to make emergency medicine didactic conferences more varied and interactive for learners. CONCLUSIONS: While there is minimal research on the efficacy of these methods in graduate medical education, many have shown to improvement engagement of learners and to be effective in undergraduate medical education. Further research will be needed to determine if long-term learning outcomes can be improved with these strategies.
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BACKGROUND: The standardized letter of evaluation (SLOE) in emergency medicine (EM) is one of the most important items in a student's application to EM residency and replaces narrative letters of recommendation. The SLOE ranks students into quantile categories in comparison to their peers for overall performance during an EM clerkship and for their expected rank list position. Gender differences exist in several assessment methods in undergraduate and graduate medical education. No authors have recently studied whether there are differences in the global assessment of men and women on the SLOE. OBJECTIVES: The objective of this study was to determine if there is an effect of student gender on the outcome of a SLOE. METHODS: This was a retrospective observational study examining SLOEs from applications to a large urban, academic EM residency program from 2015 to 2016. Composite scores (CSs), comparative rank scores (CRSs), and rank list position scores (RLPSs) on the SLOE were compared for female and male applicants using Mann-Whitney U-test. RESULTS: From a total 1,408 applications, 1,038 applicants met inclusion criteria (74%). We analyzed 2,092 SLOEs from these applications. Female applicants were found to have slightly lower and thus better CRSs, RLPSs, and CSs than men. The mean CRS for women was 2.27 and 2.45 for men (p < 0.001); RLPS for women was 2.32 and 2.52 for men (p < 0.001) and CS was 4.59 for women and 4.97 for men (p < 0.001). CONCLUSIONS: Female applicants have somewhat better performance on the EM SLOE than their male counterparts.
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BACKGROUND: The standardized letter of evaluation (SLOE) was developed to make letters of recommendation in emergency medicine (EM) more objective and discerning. Typically, students obtain one SLOE from a home EM rotation and at least one more SLOE from an away clerkship. It is unclear if students perform better on their home or away EM rotations. OBJECTIVE: The purpose of this study was to determine if students perform better on the group SLOE at their home institution compared to an away institution. METHODS: The authors performed a retrospective application review of all allopathic applicants to an urban, academic EM residency program. The authors calculated a composite score (CS) for each group SLOE, using the global assessment scores for comparative rank and rank list position. A lower CS indicates better performance. The authors compared mean CS for students' first home rotations with first away rotations. For students in the study who had a third (second away or second home site) SLOE available, the authors compared mean CS on the students' first SLOEs with mean CS on the students' third SLOEs. RESULTS: A total of 624 records were included in the primary analysis. There was a small, but significant difference between mean CS for students' home rotations when compared to away rotations (4.67 vs. 4.85, p = 0.024). Students performed better on their home rotations. Students who had three SLOEs available performed worse on their third rotation (first = 4.40, second = 4.63, third = 4.77, p = 0.012 for first vs. third). For all available SLOEs, more than 50% of students fell into the top 10% or top one-third categories. CONCLUSION: Students perform slightly better on their home EM rotations. Students' mean SLOE CS is slightly worse for a third rotation when compared to a first rotation.