Medical Students' Use of Different Coping Strategies and Relationship With Academic Performance in Preclinical and Clinical Years.

Phenomenon: Medical students' coping abilities are important for academic success and emotional health. The authors explored differences in students' use of active, problem-solving strategies and emotional, inwardly directed approaches; the change in coping strategies used during medical school; and coping strategy impact on performance. APPROACH: One hundred eighty-three students completed the Ways of Coping Scale at matriculation and end of the 2nd and 3rd years. Frequency of each of 8 ways of coping, changes in coping strategy use over time, and relationship of coping method with preclinical and clinical scores were calculated. FINDINGS: Students varied widely in use of coping mechanisms. Over time, students shifted to using emotional strategies more frequently while decreasing their use of active strategies. Coping strategies were unrelated to preclinical academic performance (R2 = .09, adjusted R2 = .04, ns) but were related to clinical performance (R2 = .23, adjusted R2 = .18, p < .0001), with active coping associated with higher performance and emotional methods associated with lower performance. Insights: Students decreased use of active coping strategies and increased use of emotional coping strategies over time, but emotional strategies were associated with poorer clinical academic performance. These shifts in coping methods may be detrimental to student performance and learning. Improving students' ability to cope should be an educational priority.

Understanding the Struggles to Be a Medical Provider: View Through Medical Student Essays.

BACKGROUND: The clinical learning environment helps to shape the professional identity of medical students. This process begins from existing personal identity and is influenced by various factors, including clinical experiences and clinical learning environment. OBJECTIVE: The purpose of this study was to examine medical students' reflections as a way to identify and better characterize the modern struggles that medical students face, in order to inform the development of professional identity. METHODS: Students rotating in their emergency medicine clerkship wrote reflections on dilemmas that highlighted common struggles of becoming a doctor. Qualitative analysis was performed to determine common themes from the essays. The research team coded 173 reflections and identified themes and major domains. RESULTS: The first domain was Patient-Provider Conflict, including challenging patient (34%), difficult communication (25%), competing priorities between patients' interest and trainees need to learn (19%), and bias (13%). The second domain was Provider-Specific Issues, such as the "gray zone," in which there is not a clear standard of practice (29%), end-of-life care (14%), emotional struggle (6%), and fear of litigation (5%). The final domain was Systems Issues, such as cost of care (12%) and role of the emergency department (6%). CONCLUSIONS: The reflections point to a wide variety of challenges that students confront in practice that will contribute to how they develop into physicians.

Medical student perceptions of an initial collaborative immersion experience.

Recent reviews of interprofessional education (IPE) highlight the need for innovative curricula focused on longitudinal clinical learning. We describe the development and early outcomes of the initial clinical experience (ICE), a longitudinal practice-based course for first-year medical students. While IPE courses focus on student-to-student interaction, ICE focuses on introducing students to interprofessional collaboration. Students attend 14 sessions at one of 18 different clinical sites. They work directly with different health professionals from among 17 possible professions, including nurses, pharmacists, social workers, and respiratory, occupational, and physical therapists. Between 2015 and 2016, 167 students completed the course, and 81 completed the end-of-course evaluation. Students agreed or strongly agreed that ICE meaningfully contributed to their understanding of healthcare teams and different professional roles (86%), improved their understanding of healthcare systems (84%), improved their ability to communicate with healthcare professionals (61%), and improved their ability to work on interprofessional teams (65%). Select themes from narrative comments suggest that clinical immersion improves understanding of professional roles, helps students understand their own future roles in healthcare teams, and increases awareness of and respect for other professionals, with the potential to change future practice. ICE may be a template for other schools wishing to expand their current educational offerings, by engaging learners in more authentic, longitudinal clinical experiences with practicing healthcare professionals.

Retention Curves for Pediatric and Neonatal Intubation Skills After Simulation-Based Training.

OBJECTIVES: We evaluated the retention of pediatric and neonatal intubation performance abilities of clinicians trained on a simulated or live tissue model at 3 intervals after initial training to assess competency degradation related to either training modality or retention interval. METHODS: We implemented a quasi-experimental design with purposive sampling to assess performance differences between 171 subjects randomly assigned to 1 of 3 intervals after initial training: 6 weeks, 18 weeks, or 52 weeks. Training followed the American Heart Association Pediatric Advanced Life Support and Neonatal Resuscitation Program protocols with hands-on practice using 1 of 2 models (live feline or simulated feline). Assessment data were captured using validated instruments and analyzed using analysis of variance with repeated measures (statistical significance set at P < 0.05). RESULTS: Cognitive retention scores decreased significantly (P = 0.000) from posttraining cognitive scores. There were no significant differences between posttraining and retention scores for pediatric and neonatal performances. Both affect and self-efficacy retention scores decreased significantly (P = 0.000) from posttraining scores at 18 and 52 weeks, but remained constant at 6 weeks. Retention scores for all dimensions showed a significant difference between subjects with varying amounts of experience performing pediatric and neonatal intubation, such that those with more experience scored higher those with less (P < 0.003). CONCLUSIONS: Retention performance outcomes decreased sufficiently from posttraining scores to suggest that training refreshment could serve to maintain posttraining competency in the ability to perform pediatric and neonatal intubation. Retraining intervals may be best aligned with provider experience levels. Future research focusing on the effect of variable interval refresher training on retention in pediatric and neonatal intubation is merited.

Essentials of PEM Fellowship Part 2: The Profession in Entrustable Professional Activities.

This article is the second in a 7-part series that aims to comprehensively describe the current state and future directions of pediatric emergency medicine (PEM) fellowship training from the essential requirements to considerations for successfully administering and managing a program to the careers that may be anticipated upon program completion. This article describes the development of PEM entrustable professional activities (EPAs) and the relationship of these EPAs with existing taxonomies of assessment and learning within PEM fellowship. It summarizes the field in concepts that can be taught and assessed, packaging the PEM subspecialty into EPAs.

Performance-based comparison of neonatal intubation training outcomes: simulator and live animal.

The purpose of this article was to establish psychometric validity evidence for competency assessment instruments and to evaluate the impact of 2 forms of training on the abilities of clinicians to perform neonatal intubation. To inform the development of assessment instruments, we conducted comprehensive task analyses including each performance domain associated with neonatal intubation. Expert review confirmed content validity. Construct validity was established using the instruments to differentiate between the intubation performance abilities of practitioners (N = 294) with variable experience (novice through expert). Training outcomes were evaluated using a quasi-experimental design to evaluate performance differences between 294 subjects randomly assigned to 1 of 2 training groups. The training intervention followed American Heart Association Pediatric Advanced Life Support and Neonatal Resuscitation Program protocols with hands-on practice using either (1) live feline or (2) simulated feline models. Performance assessment data were captured before and directly following the training. All data were analyzed using analysis of variance with repeated measures and statistical significance set at P < .05. Content validity, reliability, and consistency evidence were established for each assessment instrument. Construct validity for each assessment instrument was supported by significantly higher scores for subjects with greater levels of experience, as compared with those with less experience (P = .000). Overall, subjects performed significantly better in each assessment domain, following the training intervention (P = .000). After controlling for experience level, there were no significant differences among the cognitive, performance, and self-efficacy outcomes between clinicians trained with live animal model or simulator model. Analysis of retention scores showed that simulator trained subjects had significantly higher performance scores after 18 weeks (P = .01) and 52 weeks (P = .001) and cognitive scores after 52 weeks (P = .001). The results of this study demonstrate the feasibility of using valid, reliable assessment instruments to assess clinician competency and self-efficacy in the performance of neonatal intubation. We demonstrated the relative equivalency of live animal and simulation-based models as tools to support acquisition of neonatal intubation skills. Retention of performance abilities was greater for subjects trained using the simulator, likely because it afforded greater opportunity for repeated practice. Outcomes in each assessment area were influenced by the previous intubation experience of participants. This suggests that neonatal intubation training programs could be tailored to the level of provider experience to make efficient use of time and educational resources. Future research focusing on the uses of assessment in the applied clinical environment, as well as identification of optimal training cycles for performance retention, is merited.

Lumbar Punctures at an Academic Level 4 NICU: Indications for a New Curriculum.

ISSUE: Pediatric residents commonly perform lumbar punctures during their clinical training. The objective of this study was to assess residents' rate of nontraumatic lumbar punctures, examine the adequacy of samples, and implement proper documentation of the procedure in an academic Level 4 Neonatal Intensive Care Unit. We hypothesize that traumatic taps are common and that documentation of the procedure is poor. EVIDENCE: A retrospective chart review was done of infants admitted to the neonatal intensive care unit from January 2011 to November 2011 who underwent a lumbar puncture. Procedure notes were evaluated for completion of proper documentation, the lab specimen was assessed for red blood cell count less than 1,000 cells/mm(3), and individuals were assessed for their ability to obtain a cerebrospinal fluid sample to send to the lab for analysis (i.e., sample of adequate volume and not clotted) and the total number of attempts to obtain a sample. A total of 184 charts were reviewed. Procedure notes were incomplete (58%) and lacked pertinent details. Eight percent of samples obtained had no record of the procedure being preformed. There was inadequate sample acquisition in 23% of the lumbar punctures. More than three attempts were noted in 14% of lumbar punctures performed. Many specimens contained very high red blood cell counts. Seventy-five percent of lumbar punctures with full documentation (n = 60), resulted in cerebrospinal fluid with more than 1,000 red blood cells/mm(3) and 55% of underdocumented lumbar punctures resulted in cerebrospinal fluid with more than 1,000 red blood cells/mm(3) (n = 71). IMPLICATIONS: We found that poorly documented lumbar punctures are common and the ability of residents to obtain satisfactory cerebrospinal fluid is low. The inability of residents to consistently perform nontraumatic lumbar punctures is likely a common phenomenon. New educational methods and evaluation criteria must be developed to address this gap in resident education.

Understanding ethical dilemmas in the emergency department: views from medical students' essays.

BACKGROUND: For medical students, the emergency department (ED) often presents ethical problems not encountered in other settings. In many medical schools there is little ethics training during the clinical years. The benefits of reflective essay writing in ethics and professionalism education are well established. OBJECTIVES: The purpose of this study was to determine and categorize the types of ethical dilemmas and scenarios encountered by medical students in the ED through reflective essays. METHODS: During a 4(th)-year emergency medicine rotation, all medical students wrote brief essays on an ethical situation encountered in the ED, and participated in an hour debriefing session about these essays. Qualitative analysis was performed to determine common themes from the essays. The frequency of themes was calculated. RESULTS: The research team coded 173 essays. The most common ethical themes were autonomy (41%), social justice (32.4%), nonmaleficence (31.8%), beneficence (26.6%), fidelity (12%), and respect (8.7%). Many of the essays contained multiple ethical principles that were often in conflict with each other. In one essay, a student grappled with the decision to intubate a patient despite a preexisting do-not-resuscitate order. This patient encounter was coded with autonomy, beneficence, and nonmaleficence. Common scenarios included ethical concerns when caring for critical patients, treatment of pain, homeless or alcoholic patients, access to care, resource utilization, and appropriateness of care. CONCLUSION: Medical students encounter patients with numerous ethically based issues. Frequently, they note conflicts between ethical principles. Such essays constitute an important resource for faculty, resident, and student ethics training.

Injectable lidocaine provides similar analgesia compared to transdermal lidocaine/tetracaine patch for the incision and drainage of skin abscesses: a randomized, controlled trial.

BACKGROUND: Local anesthesia used for incision and drainage of abscesses is known to be painful. STUDY OBJECTIVE: We studied the analgesia provided by a lidocaine/tetracaine patch compared to injectable lidocaine during incision and drainage (I&D) of skin abscesses. METHODS: This was a prospective, double-blind, randomized, controlled trial carried out in the Emergency Department (ED) of an adult tertiary referral center. Adult patients with a skin abscess in need of I&D were randomized to one of two groups. One group received a lidocaine/tetracaine patch and injectable normal saline for anesthesia. The second group received a placebo patch and injectable 1% lidocaine. A visual analog pain scale was used to record the patient's pain level prior to treatment, during the procedure, and after I&D. RESULTS: There were 20 patients enrolled in the study, including 12 randomized to the lidocaine/tetracaine patch and 8 to the injectable lidocaine. Pain scores preprocedure were similar in the two groups. Pain scores during I&D and postprocedure were compared between groups using a paired t-test. Patients receiving injectable lidocaine experienced pain that was similar (50.1 ± 5.9 mm; 95% confidence interval [CI] 45.2-55.1) to those receiving the transdermal lidocaine/tetracaine patch (60.1 mm ± 11.0; 95% CI = 55.2-68.1), p = 0.04, with a power of 80% to detect a difference of 20 mm at p ≤ 0.05; although this was statistically significant, it was not clinically significant. There was also no statistical difference between the two groups in the postprocedure pain scores (p = 0.65). CONCLUSION: Local injection of lidocaine provided clinically similar analgesia compared to the lidocaine/tetracaine patch during I&D of skin abscesses in the ED. Pain at presentation and after the procedure was similar in both groups. Emergency physicians should continue to use a local injected anesthetic for I&D of skin abscesses until a less painful alternative is identified.

Location of the appendix in the gravid patient.

BACKGROUND: Several studies have attempted to support or dispel the teaching of appendix movement away from the right lower quadrant (RLQ) during pregnancy with contradictory results. OBJECTIVE: This study investigated the location of the appendix in the gravid patient in an emergency department (ED) setting using computed tomography (CT). METHODS: This was a retrospective chart review of consecutive gravid patients presenting to the ED for trauma who required abdominal CT. The patient population was obtained using the Vidant Medical Center Trauma Registry from January 1, 2000 to December 31, 2006. The abdomen was divided into nine regions using the mid-clavicular lines, superior anterior iliac spine, and umbilicus. A single Board-certified radiologist determined the region location of the appendix. RESULTS: Forty-five patients were identified and 35 were studied. Ten patients were excluded due to appendix not identified, unknown gestational age, or inability to review the CT study. In 21 of 22 third-trimester pregnancies, the appendix was not found in the right lower region (RLR), which corresponded to the RLQ. All 11 patients in the second trimester did not have the appendix in the RLR. Two patients were identified in the first trimester and neither appendix was found in the RLR. CONCLUSIONS: The appendix in the gravid patient was not found in the RLR with increasing frequency as pregnancy progressed.

Are interns prepared? A summary of current transition to residency preparation courses content.

Background: The transition from medical student to emergency medicine resident is a critical point in training. Medical students start residency with different levels of understanding and some are not meeting the emergency medicine (EM) Level 1 milestones. Residency preparation courses (RPCs) were created to fill this gap and prepare medical students for residency. Objectives: The objective was to review content from current RPC curricula to determine the content that should be included in an EM-specific transition to residency preparation course. Methods: We collected curricula from RPC course directors at different institutions and reviewed and coded the topics into categories: (1) didactics, (2) procedures, and (3) unique topics (defined as nontraditional topics that did not fit squarely into didactics or procedures). Results: We obtained content from 13 different RPC curricula. Length of the courses ranged from one to 8 weeks with the mean being three weeks. Most courses were taught within a larger medical school course and were not specific to EM (62%). The most frequently taught didactic topics were airway interventions (85%), critical care (69%), and chest pain/shortness of breath (62%). Most programs included a simulation component (92%) and the most common procedures included airway interventions (69%); lines-central, arterial, and Cordis (69%); lumbar puncture (62%); and ultrasound (62%). Many of the courses had unique or special features taught within the curriculum. The most frequently taught unique content were sessions on self-awareness and self-regulation (85%) and advanced communication (69%). Conclusions: After multiple RPC curricula content was reviewed, a set of basic curriculum has been determined and supported by the content analysis. By including a standardized curriculum within RPC's, this will help better prepare medical students and create a standard for medical students entering EM residency and may allow intern orientations to focus on higher level skills.

"Cold feet": A qualitative study of medical students who seriously considered emergency medicine but chose another specialty.

Introduction: Emergency medicine (EM) has historically been among the most competitive specialties in the United States. However, in 2022 and 2023, 219 of 2921 and 554 of 3010 respective National Resident Matching Program positions were initially unfilled. Medical students' selection of a medical specialty is a complex process. To better understand recent trends in the EM residency match, this qualitative study explored through one-on-one interviews the rationale of senior medical students who seriously considered EM but ultimately pursued another specialty. Methods: A convenience sample of senior medical students from across the United States was recruited via multiple mechanisms after the 2023 match. Participant characteristics were collected via an online survey. Qualitative data were generated through a series of one-on-one semistructured interviews and thematic analysis of the data was performed using a constant comparative approach. Results: Sixteen senior medical students from 12 different institutions participated in the study. Thematic saturation was reached after 12 interviews but data from all 16 interviews were included for qualitative analyses. Five major themes emerged as important in students' consideration but ultimate rejection of EM as a career: (1) innate features of EM attracted or dissuaded students, (2) widespread awareness of a recent workforce report, (3) burnout in EM, (4) their perception of EM's standing in the health care landscape, and (5) early EM experience and exposure. Conclusions: This qualitative study identified five major themes in the career decisions of senior medical students who seriously considered EM but chose another specialty. These findings may help inform the perceptions of students and guide future EM recruitment efforts.

The Effectiveness of Continuous Glucose Monitoring Devices in Managing Uncontrolled Diabetes Mellitus: A Retrospective Study.

This retrospective study aimed to assess the effectiveness of continuous glucose monitoring (CGM) devices in managing uncontrolled diabetes mellitus (DM). The study cohort comprised 25 patients with uncontrolled diabetes who received treatment at an internal medicine resident clinic. The objective was to evaluate the impact of transitioning from self-monitoring of blood glucose (SMBG) to CGM devices on glycemic control, as measured by changes in hemoglobin A1c (HbA1c) levels, average blood glucose levels, hypoglycemic events, time spent within the target blood sugar range, and glucose variability. The findings indicated significant improvements in glycemic control with the adoption of CGM devices, highlighting their potential benefits for optimizing diabetes management. The study is particularly interesting because it was done in an internal medicine continuity clinic with the main participation of the internal medicine residents under the supervision of an endocrinologist. It was not done as the majority of the other studies used CGM in specialized endocrinology clinics.

A Multilevel Model for Evaluating Interprofessional Learning.

Medical schools should engage in best practices for evaluating preclinical interprofessional collaborative programs. This innovation models a multilevel program evaluation of Interprofessional Clinical Experience (ICE), a required course for all first-year medical students. Data from student course evaluations and preceptor surveys determined that the course was effective at teaching interprofessional practices. Competency assessments showed nearly all students achieved the expected level. On the Readiness for Interprofessional Learning Scale, students increased their self-reported attitudes around interprofessional practices. Improvements to the ICE course will continue based on student and preceptor feedback from this multilevel program evaluation.

Medical student experiences of applying into emergency medicine during the COVID-19 pandemic: A multi-institutional survey of emergency medicine-bound medical students.

Background: The COVID-19 pandemic added new and great uncertainty to the typical approach to applying into emergency medicine (EM) for medical students. There are little data on students' lived experience of applying during this time period. We performed a multi-institutional survey of EM-bound students' experiences with preparing to apply into EM during the pandemic. Methods: This was a cross-sectional survey design study of fourth-year students preparing to apply into EM during the 2020-2021 academic year. All self-identified EM-bound students at four participating institutions were recruited by email in June 2020 to participate in a 13-item, 5-point Likert-scale survey. Univariate descriptive statistics, response rate, and nonresponse bias were calculated. Results: Sixty-seven of 125 eligible students responded for an overall response rate of 53.6%. Nonresponse bias for specific survey items ranged from 0.01 to 0.12. Students rated the importance of securing an EM rotation at their home institution the highest of any item (mean ± SD = 4.81 ± 0.68). Students indicated higher satisfaction with advice from their department of EM (mean ± SD = 4.28 ± 0.75) than from their school of medicine (mean ± SD = 3.52 ± 0.89). Students indicated higher confidence in their home EM rotations' ability to assure adequate personal protective equipment (PPE; mean ± SD = 3.91 ± 0.83) than an away rotation (mean ± SD = 2.82, 1.09). Students reported feeling between moderately and quite stressed about applying into EM this year (mean ± SD = 3.49 ± 1.01), but reported the financial stress the lowest of any item (mean ± SD = 1.46 ± 0.84). Students rated it highly important that away rotations prioritize students from institutions without an EM residency (mean ± SD = 4.51 ± 0.93). Conclusion: Medical students applying into EM during the COVID-19 pandemic felt confident in their EM advisors' recommendations and their home institution's PPE provision. Students with EM residency programs at their schools recognized the importance of away rotations being prioritized for students from schools without EM residency programs. Strong EM advising is important to students.

Erratum: This Article Corrects: "Behind the Curtain: The Nurse's Voice in Assessment of Residents in the Emergency Department".

[This corrects the article on p. 23 in vol. 20, PMID: 30643597.].

Increasing Education Research Productivity: A Network Analysis.

INTRODUCTION: Forming effective networks is important for personal productivity and career development. Although critical for success, these networks are not well understood. The objective of this study was to usze a social network analysis tool to demonstrate the growth of institutional publication networks for education researchers and show how a single institution has expanded its publication network over time. METHODS: Publications from a single institution's medical education research group (MERG) were pulled since its inception in 2010 to 2019 using Web of Science to collect publication information. Using VOSViewer software, we formed and plotted a network sociogram comparing the first five years to the most recent 4.25 years to compare the institutions of authors from peer reviewed manuscripts published by this group. RESULTS: We found 104 peer-reviewed research articles, editorials, abstracts, and reviews for the MERG authors between 2010 and 2019 involving 134 unique institutions. During 2010-2014, there were 26 publications involving 56 institutions. From 2015-2019, there were 78 publications involving 116 unique institutions. CONCLUSION: This brief report correlates successful research productivity in medical education with the presence of increased inter-institutional collaborations as demonstrated by network sociograms. Programs to intentionally expand collaborative networks may prove to be an important element of facilitating successful careers in medical education scholarship.

Behind the Curtain: The Nurse's Voice in Assessment of Residents in the Emergency Department.

Introduction: Feedback provides valuable input for improving physician performance. Conventionally, feedback is obtained from attending physicians; however, residents work in close contact with other members of the care team, especially nurses. Nurses may have more opportunity to directly observe trainees. In addition, they may value different behaviors and provide unique feedback. The objective of this study was to examine the nurse's perspective of resident performance in the emergency department. Methods: This was a retrospective, mixed-methods study of nursing assessments of residents using a five-point scale from 1 (unsatisfactory) to 5 (outstanding) and providing comments. Analysis included descriptive statistics of the quantitative assessments and content analysis of the nursing comments by a group of attendings, residents, and nurses. Results: Nurses assessed residents as above expectation or outstanding, especially for the categories of "How would you rate this resident's attitude?" (65%) and "Is this resident a team player?" (64%). Content analysis of the comments yielded nine themes including being kind, communication with nurses, being a team player, work ethic and efficiency, and respect for other team members. Of the comments made, 50% provided positive feedback, and the majority of comments (80%) were determined to be actionable. Conclusion: Our data indicate that nurses provide feedback on residents' kindness, efficiency and communication. These two aspects of interacting in the healthcare setting may not be highlighted in conventional, attending provider feedback, yet they are clearly noted by the nurse's voice.