Training and Practice Settings of Physicians Dual-Certified in Emergency and Sports Medicine.

ABSTRACT: Survey study of training and practice paradigms and job satisfaction of dual-boarded emergency medicine (EM) and sports medicine (SM) physicians. The REDCap survey was sent to 193 American Board of EM members who hold a Certificate of Added Qualification in SM. A total of 124 EM/SM physicians responded (67.5% male). More than 70% completed three-year residencies while only 28.5% had an EM/SM residency faculty. One-quarter delayed fellowship after residency 6.45 years on average. Regarding their first job after fellowship, 27.6% practiced only EM, 54.5% practiced both EM and SM, and 12.2% practiced only SM. Regarding their current job, 29.1% practice only EM. 47.3% practice both EM and SM, and 20.9% practice only SM. Only 13.9% and 9.9% indicated they are unhappy with their first job and current job, respectively. There is significant variability in practice settings for EM/SM physicians with the overwhelming majority being happy with their career choices.

Recommended Musculoskeletal and Sports Medicine Model Curriculum for Emergency Medicine Residency Training.

ABSTRACT: Musculoskeletal and sports medicine conditions are common in the emergency department (ED). Emergency physicians may not be receiving adequate education to achieve clinical competency in musculoskeletal medicine during residency training. This article aims to provide a standardized musculoskeletal and sports medicine curriculum for emergency medicine training. Broad curriculum goals include proficiency in evaluating and managing patients presenting to the ED with acute and chronic musculoskeletal complaints and other medical conditions related to or affected by physical exertion, sports participation, or environmental exposure. Specific objectives focus on knowledge of these disorders, physical examination skills, procedural skills including musculoskeletal ultrasound, appropriate consultation and referral, and patient education for these conditions. Educational methods will consist of didactics; online self-directed learning modules; simulation; and supervised clinical experiences in the ED, primary care sports medicine clinics, and orthopedic clinics if available. Curriculum implementation is expected to vary across programs due to differences in residency program structure and resources.

Current gaps in emergency medicine core content education for oncologic emergencies: A targeted needs assessment.

Objective: The core content of emergency medicine (EM) residency training includes the management of oncologic emergencies; however, documented knowledge gaps continue to exist in this subtopic. This study represents a targeted needs assessment as indicated by Step 2 of Kern's curriculum design to determine the specific training gaps to be addressed within the oncologic EM curriculum. Methods: A multi-institutional cross-sectional survey of oncologists (surgical and medical) and emergency physicians (attendings and residents) was conducted during 2023 at five institutions. The voluntary survey consisted of general and specialty-specific questions exploring gaps in oncologic emergency-specific training/education topics. Descriptive statistics reported responses as frequencies and percentages. Results: Of the 833 surveys sent across the five sites, 302 (36.3%) were accessed by link; of these, 271 (89.7%) surveys were completed. There were no differences in the responses between early and later respondents and no differences in the characteristics of respondents between sites. A vast majority of the oncologist and EM groups (91.2% and 83.0%, respectively) reported a belief that emergency physicians would benefit from additional oncologic emergency training. Our survey identified 16 important topics for inclusion in an oncologic EM curriculum, including five topics not present on the 2022 Model of Clinical Practice of Emergency Medicine. Conclusions: Based on this needs assessment, an oncologic EM curriculum should include the topics listed under oncologic emergencies in the 2022 Model of the Clinical Practice of Emergency Medicine along with our respondent-identified topics of radiation therapy adverse effects, stem cell transplant complications, and the management of cancer-specific postsurgical complications, pain, and common diseases in patients with cancer.

Plantaris rupture: a mimic of deep venous thrombosis.

BACKGROUND: The differential diagnosis of non-traumatic lower extremity pain and swelling runs the gamut from simple musculoskeletal injury to a possibly life-threatening deep venous thrombosis (DVT). Although evaluation and management are often guided by physical examination and history, a diagnostic study is often required. Institutional factors surrounding diagnostic imaging often lead physicians to empirically treat these patients for DVT with a plan for definitive diagnosis at a later time. OBJECTIVES: We discuss plantaris tendon rupture, the ability of the clinician to differentiate DVT from musculoskeletal injury, and the risks of anticoagulation in the setting of an undifferentiated, painful, swollen lower extremity. CASE REPORT: We report the case of a 57-year-old transgendered woman who presented with left lower extremity pain and swelling and was found to have a rare cause of tennis leg: plantaris tendon rupture. CONCLUSIONS: Frequently, clinical examination and history are insufficient to distinguish DVT from musculoskeletal injury. In these instances, anticoagulation carries a risk of compartment syndrome and hemorrhage with uncertain benefit to the patient. A definitive diagnosis should be sought before initiation of anticoagulation of the swollen, painful lower extremity.

Does the Medical Student Performance Evaluation Change the Decision to Invite Residency Applicants?

INTRODUCTION: Although emergency medicine (EM) residency program directors (PD) have multiple sources to evaluate each applicant, some programs await the release of the medical student performance evaluation (MSPE) to extend interview offers. While prior studies have demonstrated that MSPE content is variable and selectively positive, no prior work has evaluated the impact of the MSPE on the likelihood to invite (LTI) applicants for a residency interview. This study aimed to evaluate how information in the MSPE impacted LTI, with the hypothesis that changes in LTI would be relatively rare based on MSPE review alone. METHODS: We conducted a prospective, observational study analyzing applications to three EM residency programs during the 2019-2020 match cycle. Reviewers assessed applications and rated the LTI on a five-point Likert scale where LTI was defined as follows: 1 = definitely no; 2 = probably no; 3 = unsure; 4 = probably yes; and 5 = definitely yes. The LTI was recorded before and after MSPE review. A change in LTI was considered meaningful when it changed the overall trajectory of the applicant's likelihood to receive an invitation to interview. RESULTS: We reviewed a total of 877 applications with the LTI changing ≥1 point on the Likert scale 160 (18.2%) times. The LTI was meaningfully impacted in a minority of applications - 48 total (5.5 %, p< 0.01) - with only 1 (0.11%) application changing from 1 or 2 (definitely/probably no) to 4 or 5 (probably/definitely yes) and 34 (3.8%) changing from 3 (unsure) to 4 or 5 (probably/definitely yes). Thirteen (1.5%) applications changed from 4 or 5 (probably/definitely yes) to 3 (unsure or probably/definitely no). CONCLUSION: Review of the MSPE resulted in a meaningful change in LTI in only 5.5% of applications. Given the time required for program leadership to review all parts of the variably formatted MSPEs, this finding supports a more efficient application review, where the PD's focus is on succinct and objective aspects of the application, such as the Standardized Letter of Evaluation.

Deep venous thromboembolism in a triathlete.

BACKGROUND: Demanding athletic events can contribute multiple risk factors to the development of deep venous thrombosis (DVT) in athletes. OBJECTIVES: To discuss risk factors for the development of DVT in athletes participating in athletic events. CASE REPORT: We present the case of a young female athlete who had a DVT, complicated by pulmonary embolism, after participating in a half-Ironman triathlon. CONCLUSION: Our patient developed a DVT complicated by pulmonary embolism as a result of many factors relating to participation in a triathlon. Demanding athletic events can contribute different risk factors to the development of DVT in athletes. The diagnosis of DVT should be considered in any athlete presenting with leg pain, especially after a strenuous athletic event.

Knee and Leg Injuries.

Knee and leg injuries are extremely common presentations to the emergency department. Understanding the anatomy of the knee, particularly the vasculature and ligamentous structures, can help emergency physicians (EPs) diagnose and manage these injuries. Use of musculoskeletal ultrasonography can further aid EPs through the diagnostic process. Proper use of knee immobilizers can also improve long-term patient outcomes.

Knowledge Translation and Barriers to Imaging Optimization in the Emergency Department: A Research Agenda.

Researchers have attempted to optimize imaging utilization by describing which clinical variables are more predictive of acute disease and, conversely, what combination of variables can obviate the need for imaging. These results are then used to develop evidence-based clinical pathways, clinical decision instruments, and clinical practice guidelines. Despite the validation of these results in subsequent studies, with some demonstrating improved outcomes, their actual use is often limited. This article outlines a research agenda to promote the dissemination and implementation (also known as knowledge translation) of evidence-based interventions for emergency department (ED) imaging, i.e., clinical pathways, clinical decision instruments, and clinical practice guidelines. We convened a multidisciplinary group of stakeholders and held online and telephone discussions over a 6-month period culminating in an in-person meeting at the 2015 Academic Emergency Medicine consensus conference. We identified the following four overarching research questions: 1) what determinants (barriers and facilitators) influence emergency physicians' use of evidence-based interventions when ordering imaging in the ED; 2) what implementation strategies at the institutional level can improve the use of evidence-based interventions for ED imaging; 3) what interventions at the health care policy level can facilitate the adoption of evidence-based interventions for ED imaging; and 4) how can health information technology, including electronic health records, clinical decision support, and health information exchanges, be used to increase awareness, use, and adherence to evidence-based interventions for ED imaging? Advancing research that addresses these questions will provide valuable information as to how we can use evidence-based interventions to optimize imaging utilization and ultimately improve patient care.

Responding to the refusal of care in the emergency department.

The emergency department (ED) serves as the primary gateway for acute care and the source of health care of last resort. Emergency physicians are commonly expected to rapidly assess and treat patients with a variety of life-threatening conditions. However, patients do refuse recommended therapy, even when the consequences are significant morbidity and even mortality. This raises the ethical dilemma of how emergency physicians and ED staff can rapidly determine whether patient refusal of treatment recommendations is based on intact decision-making capacity and how to respond in an appropriate manner when the declining of necessary care by the patient is lacking a basis in informed judgment. This article presents a case that illustrates the ethical tensions raised by the refusal of life-sustaining care in the ED and how such situations can be approached in an ethically appropriate manner.

Gender- and sex-specific sports-related injury research in emergency medicine: a consensus on future research direction and focused application.

Title IX, the commercialization of sports, the social change in sports participation, and the response to the obesity epidemic have contributed to the rapid proliferation of participation in both competitive organized sports and nontraditional athletic events. As a consequence, emergency physicians are regularly involved in the acute diagnosis, management, disposition, and counseling of a broad range of sports-related pathology. Three important and highly publicized mechanisms of injury in sports relevant to emergency medicine (EM) include concussion, heat illness, and sudden cardiac death. In conjunction with the 2014 Academic Emergency Medicine consensus conference "Gender-specific Research in Emergency Care: Investigate, Understand, and Translate How Gender Affects Patient Outcomes," a consensus group consisting of experts in EM, emergency neurology, sports medicine, and public health convened to deliberate and develop research questions that could ultimately advance the field of sports medicine and allow for meaningful application in the emergency department (ED) clinical setting. Sex differences in injury risk, diagnosis, ED treatment, and counseling are identified in each of these themes. This article presents the consensus-based priority research agenda.

A survey of handoff practices in emergency medicine.

This study aimed to assess practices in emergency department (ED) handoffs as perceived by emergency medicine (EM) residency program directors and other senior-level faculty and to determine if there are deficits in resident handoff training. This cross-sectional survey study was guided by the Kern model for medical curriculum development. A 12-member Council of Emergency Medicine Residency Directors (CORD) Transitions in Care task force of EM physicians performed these steps and constructed a survey. The survey was distributed to the CORD listserv. There were 147 responses to the anonymous survey, which were collected using an online tool. At least 41% of the 158 American College of Graduate Medical Education EM residency programs were represented. More than half (56.6%) of responding EM physicians reported that their ED did not use a standardized handoff. There also exists a dearth of formal handoff training and handoff proficiency assessments for EM residents.

Focusing a gender lens on emergency medicine research: 2012 update.

The influence of sex and gender on patient care is just being recognized in emergency medicine (EM). Providers are realizing the need to improve outcomes for both men and women by incorporating sex- and gender-specific science into clinical practice, while EM researchers are now beginning to study novel sex- and gender-specific perspectives in the areas of acute care research. This article serves as an update on the sex differences in a variety of acute clinical care topics within the field of EM and showcases opportunities for improving patient care outcomes and expanding research to advance the science of gender-specific emergency care.

An algorithm for transition of care in the emergency department.

OBJECTIVES: The objective of this study is to present an algorithm for improving the safety and effectiveness of transitions of care (ToC) in the emergency department (ED). METHODS: This project was undertaken by the Council of Emergency Medicine Residency Directors (CORD) Transitions of Care Task Force and guided by the six-step Kern model for curriculum development. A targeted needs assessment in survey form was designed using a modified Delphi method among the CORD ToC Task Force. The survey was designed for four subgroups within the ED: emergency medicine (EM) residency program directors, EM academic chairpersons, EM residents, and EM nurses. Members from nationally recognized EM organizations assisted in the development of each respective survey, including the Academic Affairs Committee of the American College of Emergency Physicians, the leadership of the Emergency Medicine Residents' Association (EMRA), and the leadership of Emergency Nurses Association (ENA). The surveys contained questions about current handoff practices and asked participants to rate the importance of key logistical and informational parameters within a ToC. Survey validity was achieved through content validity, item analysis, format familiarity, and electronic scoring. The surveys of program directors and academic chairpersons were distributed through the CORD listserv, the resident survey was distributed via EMRA correspondents, and the nurse survey was distributed through the ENA listserv. Following survey collection, the ToC Task Force convened and used the data to assess handoff practices and deficiencies. The Task Force developed recommendations for a ToC algorithm that was then piloted by medical educators in their institutions. These educators shared their experiences with senior department members in a phone interview. This informant feedback was used to address deficiencies in the algorithm and finalize the recommendations from the CORD Task Force. RESULTS: The surveys for program directors (n = 147), academic chairpersons (n = 99), residents (n = 194), and nurses (n = 902) were electronically scored. Handoff education in the form of structured workshops or classes was typically not offered, with only 10.9% of residents and 9.0% of nurses reporting that they received such training. The majority (93.9%) of EM academic chairpersons stated that assessments of handoff proficiency were not conducted within their programs. Computerized handoff was the most popular assistive tool among all surveyed groups. Handoff parameters that were rated as "important" and "extremely important" included uninterrupted time and space to perform the handoff, identification of "high-risk" handoffs, and the opportunity for questions and clarification from the handoff recipient. The developed handoff algorithm consisted of five steps: 1) setting the stage, 2) assembling the team, 3) identification of high-risk patients, 4) shift sign-out, and 5) closing the loop. CONCLUSIONS: The authors present specific guidelines for an algorithm-based approach to transitioning care within the ED. This algorithm is based on surveys of perceived deficiencies and emphasizes informational and logistical parameters within a ToC. Standardizing the process of the ToC may allow for future research on the link between effective ToC and patient outcomes.

The emerging role of simulation education to achieve patient safety: translating deliberate practice and debriefing to save lives.

Simulation-based educational processes are emerging as key tools for assessing and improving patient safety. Multidisciplinary or interprofessional simulation training can be used to optimize crew resource management and safe communication principles. There is good evidence that simulation training improves self-confidence, knowledge, and individual and team performance on manikins. Emerging evidence supports that procedural simulation, deliberate practice, and debriefing can also improve operational performance in clinical settings and can result in safer patient and population/system outcomes in selected settings. This article highlights emerging evidence that shows how simulation-based interventions and education contribute to safer, more efficient systems of care that save lives.

Knee and leg injuries.

The knee plays a significant role in ambulation and the activities of daily living. During the course of these activities and its role in weight bearing, the knee is susceptible to a variety of different forces and the emergency physician should be familiar with the diagnosis and treatment of the injuries that result. In addition to following basic trauma protocols, thorough neurovascular and musculoskeletal examinations should be performed and supplemented with appropriate imaging. Emergency physicians should also consider recent developments in knee anatomy and function when evaluating the patient with an acutely injured knee.

Simulation center accreditation and programmatic benchmarks: a review for emergency medicine.

Simulation-based education has grown significantly over the past 10 years. As a result, more professional organizations are developing or implementing accreditation processes to help define minimum standards and best practices in simulation-based training. However, the benefits and potential pitfalls of sponsoring and implementing such programs have yet to be fully evaluated across specialties. The board of directors of the Society for Academic Emergency Medicine (SAEM) requested an evaluation of the potential to create an emergency medicine (EM)-based Simulation Consultation and Accreditation Service. In response to this request, the Simulation Accreditation and Consultation Work Group, a subgroup of the Committee on Technology in Medical Education (now Simulation Academy), was created. The work group was charged with: 1) reviewing current benchmarks and standards set by existing simulation accreditation programs; 2) analyzing current EM simulation program structures, including leadership, administrative, and financial components; and 3) proposing a potential model for EM-based simulation accreditation. This article outlines currently existing and proposed accreditation models and identifies components that support best practices. It then goes on to describe three general programmatic models to better understand how simulation training can be operationalized in EM. Finally, the work group uses this collective information to propose how an accreditation process, in concert with the SAEM Simulation Consultation Service, can enhance and advance EM simulation training.

Teaching and assessing procedural skills using simulation: metrics and methodology.

Simulation allows educators to develop learner-focused training and outcomes-based assessments. However, the effectiveness and validity of simulation-based training in emergency medicine (EM) requires further investigation. Teaching and testing technical skills require methods and assessment instruments that are somewhat different than those used for cognitive or team skills. Drawing from work published by other medical disciplines as well as educational, behavioral, and human factors research, the authors developed six research themes: measurement of procedural skills; development of performance standards; assessment and validation of training methods, simulator models, and assessment tools; optimization of training methods; transfer of skills learned on simulator models to patients; and prevention of skill decay over time. The article reviews relevant and established educational research methodologies and identifies gaps in our knowledge of how physicians learn procedures. The authors present questions requiring further research that, once answered, will advance understanding of simulation-based procedural training and assessment in EM.

EPs do not accept the strategy of "lumbar puncture first" in subarachnoid hemorrhage.

It has been proposed that the workup of suspected subarachnoid hemorrhage should begin with lumbar puncture (LP) rather than computed tomography (CT) scan. We investigated whether EPs would in fact advocate this strategy in an index hypothetical case and in variations of the index case. An eight-question survey was distributed to EM physicians attending national continuing medical education meetings. Questions included whether the responders would advocate "LP first" in the following scenarios: (1) the index case in which the patient's symptoms had been present for more than 12 hours, other diagnoses were very unlikely, the patient was fully insured, and CT scan was available immediately; (2) a case in which the patient is not insured; (3) a case in which the respondent is the patient; and (4) a case in which there is a delay in obtaining a CT scan. Two hundred forty-one of 275 surveys were completed for a response rate of 88%. Given the index scenario, only 22.8% of the respondents would advise patients to have an LP first versus 17.9% if they themselves were the patient (P=.11). Compared with the index scenario, 34.0% of respondents would advise LP first if their patient did not have insurance (P<.0001); a majority, 57.1%, would advise LP first if the CT were delayed (P<.0001). The "LP first" strategy for workup of subarachnoid hemorrhage was rejected by most EM physicians except when the CT scan would entail delay. Compared with the index case, an added number of physicians would advocate this strategy if the patient was uninsured. The ethical implication of advocating a strategy because of financial concerns and that most physicians would not favor for themselves or their patients merits attention.