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BACKGROUND: Clinical feedback is an important part of residency training, yet literature suggests this complex interaction is not completely understood. In particular, little is known about what resident versus attending physicians expect as feedback. This study investigates this gap in knowledge by examining differences in interactions that residents and attendings view as feedback. METHODS: Surveys containing sample clinical feedback scenarios were distributed to residents and attending physicians in emergency medicine and general surgery at a large academic medical center. Respondents were asked to decide whether useful feedback was provided in each scenario, and responses were compared between the two groups. Continuous features were summarized with medians, interquartile ranges (IQRs), and ranges; categorical features were summarized with frequency counts and percentages. Comparisons of features between residents and attendings were evaluated using Wilcoxon rank sum, chi-square, and Fisher exact tests. Statistical analyses were performed using version 9.4 of the SAS software package (SAS Institute, Inc.; Cary, NC). All tests were two-sided and p-values < 0.05 were considered statistically significant. RESULTS: Seventy-two individuals responded to the survey out of approximately 110 invitations sent (65%), including 35 (49%) residents and 37 (51%) attendings. Of 35 residents, 31 indicated their level of training, which included 13 (42%) PGY-1, 9 (29%) PGY-2, 6 (19%) PGY-3, and 3 (10%) PGY-4, respectively. Of 37 attendings, 34 indicated the number of years since completion of residency or last fellowship, at a median of 9 years (IQR 4-14; range 1-31). No significant difference was found in residents' and attendings' perceptions of what constituted feedback in the sample scenarios. CONCLUSIONS: While this study did not find a statistical difference in perception of feedback between residents and attendings, additional factors should be considered when investigating perceived feedback deficiencies. Further research is needed to better understand and improve the clinical feedback process.
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Actitud del Personal de Salud , Competencia Clínica , Retroalimentación Psicológica , Internado y Residencia/normas , Cuerpo Médico de Hospitales/normas , Femenino , Humanos , Masculino , Grupo de Atención al Paciente/normasRESUMEN
BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) implemented revisions to resident duty hour requirements (DHRs) in 2011 to improve patient safety and resident well-being. Perceptions of DHRs have been reported to vary by training stage and specialty among internal medicine and general surgery residents. The authors explored perceptions of DHRs among all residents at a large academic medical center. METHODS: The authors administered an anonymous cross-sectional survey about DHRs to residents enrolled in all ACGME-accredited core residency programs at their institution. Residents were categorized as medical and pediatric, surgery, or other. RESULTS: In total, 736 residents representing 24 core specialty residency programs were surveyed. The authors received responses from 495 residents (67%). A majority reported satisfaction (78%) with DHRs and believed DHRs positively affect their training (73%). Residents in surgical specialties and in advanced stages of training were significantly less likely to view DHRs favorably. Most respondents believed fatigue contributes to errors (89%) and DHRs reduce both fatigue (80%) and performance of clinical duties while fatigued (74%). A minority of respondents (37%) believed that DHRs decrease medical errors. This finding may reflect beliefs that handovers contribute more to errors than fatigue (41%). Negative perceived effects included diminished patient familiarity and continuity of care (62%) and diminished clinical educational experiences for residents (41%). CONCLUSIONS: A majority of residents reported satisfaction with the 2011 DHRs, although satisfaction was significantly less among residents in surgical specialties and those in advanced stages of training.
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Centros Médicos Académicos , Educación de Postgrado en Medicina/normas , Adhesión a Directriz/estadística & datos numéricos , Admisión y Programación de Personal/estadística & datos numéricos , Médicos , Carga de Trabajo/estadística & datos numéricos , Centros Médicos Académicos/estadística & datos numéricos , Acreditación/normas , Adulto , Actitud del Personal de Salud , Estudios Transversales , Fatiga , Femenino , Cirugía General/estadística & datos numéricos , Humanos , Internado y Residencia/estadística & datos numéricos , Masculino , Errores Médicos/estadística & datos numéricos , Persona de Mediana Edad , Minnesota , Pediatría/estadística & datos numéricos , Satisfacción Personal , Médicos/psicología , Especialización/estadística & datos numéricos , Tolerancia al Trabajo Programado , Carga de Trabajo/psicología , Adulto JovenRESUMEN
INTRODUCTION: Horizontal violence (HV) is defined as "persistent exposure to interpersonal aggression and mistreatment from colleagues." Our objective in this pilot, single-site study was to identify sources of HV toward emergency medicine (EM) residents, using the Negative Acts Questionnaire-Revised (NAQ-R). METHODS: In this investigation we used a descriptive cross-sectional survey design to categorize HV. All voluntary participants were residents in an Accreditation Council for Graduate Medical Education-approved, three-year academic EM residency. Data were collected via electronic survey and occurred six months into an academic year. We collected demographic information and responses to the NAQ-R in 2020. Horizontal violence is subdivided into three categories: work-related; person-related; and physical intimidation. Emergency medicine residents answered questions as they related to their interactions with residents and support staff, which included nursing. RESULTS: A total of 23 of 26 residents responded (89%). Participants were 56% women, 78% white, 11% Hispanic, and 89% heterosexual. Participant clinical year was 39% first-, 39% second-, and 22% third-year residents. Women reported a higher frequency of HV compared to men (1.3 vs 1.1, P =.01). By category, women indicated higher incidence of work-related violence from other residents (P = .05) and staff (P =.02). There was no difference in reported frequency of violence for interns compared to senior residents. CONCLUSION: Our pilot study demonstrated horizontal violence toward EM residents exists and is more prevalent in women.
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Medicina de Emergencia , Internado y Residencia , Estudios Transversales , Medicina de Emergencia/educación , Femenino , Humanos , Masculino , Proyectos Piloto , Factores de Riesgo , ViolenciaRESUMEN
BACKGROUND: Acute gastroenteritis is characterized by diarrhea, which may be accompanied by nausea, vomiting, fever, and abdominal pain. OBJECTIVE: To review the evidence on the assessment of dehydration, methods of rehydration, and the utility of antiemetics in the child presenting with acute gastroenteritis. DISCUSSION: The evidence suggests that the three most useful predictors of 5% or more dehydration are abnormal capillary refill, abnormal skin turgor, and abnormal respiratory pattern. Studies are conflicting on whether blood urea nitrogen (BUN) or BUN/creatinine ratio correlates with dehydration, but several studies found that low serum bicarbonate combined with certain clinical parameters predicts dehydration. In most studies, oral or nasogastric rehydration with an oral rehydration solution was equally efficacious as intravenous (i.v.) rehydration. Many experts discourage the routine use of antiemetics in young children. However, children receiving ondensetron are less likely to vomit, have greater oral intake, and are less likely to be treated by intravenous rehydration. Mean length of Emergency Department (ED) stay is also less, and very few serious side effects have been reported. CONCLUSIONS: In the ED, dehydration is evaluated by synthesizing the historical and physical examination, and obtaining laboratory data points in select patients. No single laboratory value has been found to be accurate in predicting the degree of dehydration and this is not routinely recommended. The evidence suggests that the majority of children with mild to moderate dehydration can be treated successfully with oral rehydration therapy. Ondansetron (orally or intravenously) may be effective in decreasing the rate of vomiting, improving the success rate of oral hydration, preventing the need for i.v. hydration, and preventing the need for hospital admission in those receiving i.v. hydration.
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Deshidratación/diagnóstico , Deshidratación/terapia , Fluidoterapia/métodos , Adolescente , Antieméticos/uso terapéutico , Niño , Preescolar , Deshidratación/complicaciones , Diarrea/complicaciones , Servicio de Urgencia en Hospital , Humanos , Lactante , Recién Nacido , Ondansetrón/uso terapéutico , Examen Físico , Índice de Severidad de la Enfermedad , Vómitos/complicaciones , Vómitos/tratamiento farmacológicoRESUMEN
BACKGROUND: Quality educators are a core component of successful residency training. A structured, consistent, validated evaluation of clinical educators is important to improve teaching aptitude, further faculty development, and improve patient care. STUDY OBJECTIVES: The authors sought to identify specific domains of instructional quality and to develop a composite instrument for assessing instructional quality. METHODS: The study setting is a 3-year residency program. Residents rated the quality of faculty member instruction using an 18-item survey twice over a 2-year period (2004-2005). Each survey item used a 9-point scale. Factor analysis employing a Varimax rotation identified domains of instructional performance. Cronbach's alpha was used to assess the internal consistency of the identified domains. RESULTS: There were 29 faculty members evaluated. Using 2004 data, five domains of instructional quality were identified that explained 92.5% of the variation in survey responses (χ(2) = 2.33, P = 0.11). These were: Competency and Professionalism (30% of variation), Commitment to Knowledge and Instruction (23%), Inclusion and Interaction (17%), Patient Focus (13%), and Openness to Ideas (9%). Competency and Professionalism included appropriate care, effective patient communication, use of new techniques, and ethical principles. Commitment to Knowledge and Instruction included research, mentoring, feedback, and availability. Inclusion and Interaction included procedural participation and bedside teaching. Patient Focus included compassion, effective care, and sensitivity to diverse populations. Openness to Ideas included enthusiasm and receptivity of new ideas. These five domains were consistent in the 2005 data (Cronbach's alpha 0.68-0.75). CONCLUSIONS: A five-domain instrument consistently accounted for variations in faculty teaching performance as rated by resident physicians. This instrument may be useful for standardized assessment of instructional quality.
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Medicina de Emergencia/educación , Docentes Médicos/normas , Internado y Residencia , Análisis Factorial , Humanos , Internado y Residencia/organización & administración , LiderazgoAsunto(s)
Infecciones/complicaciones , Infecciones/diagnóstico por imagen , Enfermedades Vaginales/diagnóstico por imagen , Enfermedades Vaginales/microbiología , Adolescente , Antibacterianos/uso terapéutico , Femenino , Humanos , Infecciones/tratamiento farmacológico , Dolor/microbiología , Ultrasonografía , Enfermedades Vaginales/tratamiento farmacológicoRESUMEN
The objective of this study was to evaluate the faculty and graduate training profiles of Pediatric Emergency Medicine (PEM) fellowship training programs. An electronic 10-point questionnaire was sent to 57 PEM fellowship directors, with a 70% response rate. Analysis of the individual certification of faculty members in PEM training programs demonstrated that the largest represented training types were general pediatricians and pediatricians with PEM sub-certification (29% and 62% representation, respectively). The remaining faculty types consistently showed < 5% overall involvement. Reported estimates on faculty delivery of clinical training, didactic training, and procedural skills demonstrated that pediatricians sub-board certified in PEM consistently administered the highest percentage of these skill sets (74%, 68%, and 68%, respectively). Emergency Medicine-trained physicians showed a relative increase of involvement in fellowship programs administered by Emergency Medicine departments and in those programs located within adult hospitals. Yet, this involvement still remained substantially lower than that of the pediatric-type faculty. Program directors of fellowships within pediatric hospitals and those administered by Pediatric programs demonstrated a preference for general pediatricians with sub-board certification in PEM to improve their faculty pools. Program directors of fellowship programs located in adult hospitals and those administered by departments of EM demonstrated no preference in training type. Lastly, program directors report that 95% of past graduates received their primary board certification through Pediatrics and only 5% received their primary board certification through Emergency Medicine. There are currently many more pediatric-trained physicians among PEM fellowship faculty and graduates. This survey has demonstrated that there has been a decline in EM-trained physicians involved in PEM fellowships since 2000.
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Medicina de Emergencia/educación , Docentes Médicos , Becas , Pediatría/educación , Recolección de Datos , Humanos , Internado y ResidenciaRESUMEN
BACKGROUND: Patient satisfaction surveys are vital to measuring a patient's experience of care. How scores of patients managed by emergency medicine (EM) residents change as residents progress through training is not known. OBJECTIVES: To evaluate whether EM residents' patient satisfaction scores improve as residency training progresses, similar to clinical skill improvement. METHODS: A retrospective cross-sectional study evaluated the correlation of patient satisfaction scores with EM resident year of training from 2015 through 2017. We evaluated for a change in score over time for the 4 "physician questions" and the "overall" score. RESULTS: We evaluated 1684 Press Ganey surveys linked to 40 EM resident physicians during the study period. The mean top box scores for the 4 physician questions (concern for comfort [P = .72], courtesy [P = .55], informative about treatment [P = .46], and listening [P = .91]) and overall assessment of emergency department care (P = .51) were not significantly improved over the course of resident. CONCLUSION: We did not observe a difference in EM residents' patient experience scores as their level of training progressed. Comprehensive patient experience training for residents might be needed.
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Jaundice (also known as hyperbilirubinemia) is a yellowish-greenish pigmentation of the sclera and skin caused by an increase in bilirubin production or a defect in bilirubin elimination. Management of hyperbilirubinemia is one of the most common reasons for readmission of a newborn. Prolonged unconjugated hyperbilirubinemia can result in acute bilirubin encephalopathy and eventually develop into chronic bilirubin encephalopathy (kernicterus). Kernicterus, the feared complication of hyperbilirubinemia, was considered almost extinct but has recently re-emerged despite virtual elimination of Rh disease. This review provides a systematic approach to the presentation, evaluation, and management of the jaundiced newborn.
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Bilirrubina , Servicio de Urgencia en Hospital , Ictericia Neonatal , Factores de Edad , Bilirrubina/sangre , Bilirrubina/metabolismo , Humanos , Recién Nacido , Ictericia Neonatal/sangre , Ictericia Neonatal/fisiopatología , Ictericia Neonatal/terapia , Fototerapia , RiesgoRESUMEN
Children often present with painful conditions that require painful interventions. Procedural sedation and analgesia refers to the pharmacologic technique of managing a child's pain and anxiety. Procedural sedation is a safe, effective, and humane way to facilitate appropriate medical care. It is important to distinguish the goals for the procedural sedation, pain relief or anxiolysis or both. Different medications and combinations of medications can be used to achieve the desired effect. It is also important to keep in mind the possible adverse reactions and side effects associated with each medication when choosing the sedation cocktail.
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Analgésicos/uso terapéutico , Ansiedad/prevención & control , Sedación Consciente/métodos , Servicio de Urgencia en Hospital , Hipnóticos y Sedantes/uso terapéutico , Dolor/tratamiento farmacológico , Ansiedad/etiología , Niño , Protección a la Infancia , Diagnóstico por Imagen/efectos adversos , Humanos , Monitoreo Fisiológico/instrumentación , Dolor/etiología , Planificación de Atención al Paciente , Guías de Práctica Clínica como Asunto , Terapéutica/efectos adversos , Estados UnidosRESUMEN
Blunt pediatric trauma is a major threat to the health and well-being of children. Nationwide, many practitioners care for children who face this issue. Some key principles related to the evaluation and management of these children are elucidated in this article.
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Traumatismos Abdominales/diagnóstico , Traumatismos Abdominales/terapia , Servicio de Urgencia en Hospital , Heridas no Penetrantes/diagnóstico , Heridas no Penetrantes/terapia , Traumatismos Abdominales/cirugía , Niño , Humanos , Examen Físico , Estados Unidos , Heridas no Penetrantes/cirugíaRESUMEN
In the past decade a large amount of attention has been focused on brain natriuretic peptide (BNP) testing in the evaluation of patients with acute dyspnea as well as the screening of patients for congestive heart failure (CHF). Because BNP is secreted by myocytes in response to ventricular stretch, it has long been thought that BNP could become a biochemical marker for CHF. Rapid assays have been developed and BNP testing has been studied in detection of CHF and predictive outcomes in a large variety of settings. We review the clinical evidence associated with the use of BNP testing in the acute care setting. We conclude with a discussion of clinical utility in the emergency department for the evaluation of patients presenting with acute dyspnea.
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Disnea/diagnóstico , Insuficiencia Cardíaca/diagnóstico , Péptido Natriurético Encefálico/sangre , Lesión Renal Aguda/diagnóstico , Biomarcadores/sangre , Urgencias Médicas , Humanos , Sistemas de Atención de Punto , Sensibilidad y Especificidad , Disfunción Ventricular Izquierda/diagnósticoRESUMEN
Since 1995, women have comprised more than 40% of all medical school graduates. However, representation at leadership levels in medicine remains considerably lower. Gender representation among the American Board of Medical Specialties (ABMS) boards of directors (BODs) has not previously been evaluated. Our objective was to determine the relative representation of women on ABMS BODs and compare it with the in-training and in-practice gender composition of the respective specialties. The composition of the ABMS BODs was obtained from websites in March 2016 for all Member Boards. Association of American Medical Colleges and American Medical Association data were utilized to identify current and future trends in gender composition. Although represented by a common board, neurology and psychiatry were evaluated separately because of their very different practices and gender demographic characteristics. A total of 25 specialties were evaluated. Of the 25 specialties analyzed, 12 BODs have proportional gender representation compared with their constituency. Seven specialties have a larger proportion of women serving on their boards compared with physicians in practice, and 6 specialties have a greater proportion of men populating their BODs. Based on the most recent trainee data (2013), women have increasing workforce representation in almost all specialties. Although women in both training and practice are approaching equal representation, there is variability in gender ratios across specialties. Directorship within ABMS BODs has a more equitable gender distribution than other areas of leadership in medicine. Further investigation is needed to determine the reasons behind this difference and to identify opportunities to engage women in leadership in medicine.
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Ejecutivos Médicos/estadística & datos numéricos , Médicos Mujeres/estadística & datos numéricos , Distribución por Sexo , Consejos de Especialidades , Femenino , Humanos , Internado y Residencia , Masculino , Medicina/estadística & datos numéricos , Estados UnidosAsunto(s)
Traumatismos del Tobillo/diagnóstico , Luxaciones Articulares/diagnóstico , Articulación Talocalcánea/lesiones , Traumatismos del Tobillo/diagnóstico por imagen , Humanos , Luxaciones Articulares/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Radiografía , Articulación Talocalcánea/diagnóstico por imagen , Voleibol/lesionesAsunto(s)
Ciclismo/lesiones , Traumatismos de la Rodilla/complicaciones , Fracturas de la Tibia/diagnóstico por imagen , Accidentes por Caídas , Adulto , Lesiones del Ligamento Cruzado Anterior , Humanos , Traumatismos de la Rodilla/diagnóstico , Traumatismos de la Rodilla/etiología , Imagen por Resonancia Magnética , Masculino , Radiografía , Rotura , Fracturas de la Tibia/complicaciones , Fracturas de la Tibia/etiología , Lesiones de Menisco TibialRESUMEN
A neonate presenting to the emergency department can present a challenge to even the most experienced clinician. This article has focused on four deceiving and potentially devastating neonatal diseases. 1. Neonatal herpes is a potentially devastating illness without pathognomonic signs or symptoms. Early recognition and therapy can reduce mortality markedly. Although no specific sign or symptom is diagnostic,the diagnosis should be strongly considered in the presence of HSV risk factors, atypical sepsis, unexplained acute hepatitis, or focal seizure activity. Acyclovir therapy should be initiated before viral dissemination or significant CNS replication occurs. 2. Pertussis is a disease in which infants are at greatest risk of death or severe complication. Neonatal pertussis often presents in an atypical manner, lacking the classic signs and symptoms such as the "whoop."More common signs and symptoms include cough, feeding difficulty,low-grade fever, emesis, increasing respiratory distress, apnea, cyanosis,and seizures. Management should include hospitalization, supportive care, and antibiotics. 3. Congenital heart defects, particularly ductal-dependent lesions, may have an initial asymptomatic period that culminates in a rapidly progressive and fatal course. A neonate with CHD presents with shock refractory to volume resuscitation or pressor support. Resuscitative efforts are ineffective unless PGE, is administered. 4. Inborn errors of metabolism often are unsuspected because of their protean and heterogeneous nature. Signs and symptoms are subtle,are nonspecific, and often mimic other, more common diseases.An elevated index of suspicion, along with application and correct interpretation of a select few laboratory tests, is the key to making a diagnosis. Therapy is relatively straightforward and focused on resuscitation followed by prevention of catabolism and correction of specifically identified abnormalities. Although these disorders are relatively uncommon, prompt diagnosis and therapy can lead to a decrease in morbidity and mortality. The key is to maintain a high index of suspicion.
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Medicina de Emergencia/métodos , Tratamiento de Urgencia/métodos , Enfermedades del Recién Nacido/diagnóstico , Enfermedades del Recién Nacido/terapia , Diagnóstico Diferencial , Electrocardiografía , Electroencefalografía , Técnica del Anticuerpo Fluorescente Directa , Cardiopatías Congénitas/diagnóstico , Cardiopatías Congénitas/epidemiología , Cardiopatías Congénitas/etiología , Cardiopatías Congénitas/terapia , Herpes Simple/diagnóstico , Herpes Simple/epidemiología , Herpes Simple/etiología , Herpes Simple/terapia , Humanos , Mortalidad Infantil , Recién Nacido , Enfermedades del Recién Nacido/epidemiología , Enfermedades del Recién Nacido/etiología , Cuidado Intensivo Neonatal/métodos , Errores Innatos del Metabolismo/diagnóstico , Errores Innatos del Metabolismo/epidemiología , Errores Innatos del Metabolismo/etiología , Errores Innatos del Metabolismo/terapia , Morbilidad , Tamizaje Neonatal , Oximetría , Reacción en Cadena de la Polimerasa , Resucitación/métodos , Factores de Riesgo , Factores de Tiempo , Estados Unidos/epidemiología , Tos Ferina/diagnóstico , Tos Ferina/epidemiología , Tos Ferina/etiología , Tos Ferina/terapiaRESUMEN
Malaria is frequently a deadly disease, particularly in tropical countries of the world where this protozoan infection is endemic. While physicians in tropical countries are familiar with the presentation, those who do not practice in endemic regions of the world may neglect to add tropical diseases to their differential diagnosis of fever. Epidemiologic data from the CDC show the number of cases of malaria being diagnosed in the United States in the last decade has risen sharply. With international travel continuing to rise, there is strong reason to consider malaria as a source of fever.