Impacts of United States Medical Licensing Examination Step 1 Scoring Change on Emergency Medicine Applicant Screening.

BACKGROUND: The U.S. Medical Licensing Examination (USMLE) Step 1 has been used as a screening tool for residency selection. In February 2020, Step 1 numerical scoring changed to pass/fail. OBJECTIVE: Our aim was to survey emergency medicine (EM) residency program attitudes towards the new Step 1 scoring change and to identify important applicant screening factors. METHODS: A 16-question survey was distributed through the Council of Residency Directors in Emergency Medicine listserv from November 11 through December 31, 2020. Given the Step 1 scoring change, the survey questioned the importance of EM rotation grades, composite standardized letters of evaluation (cSLOEs), and individual standardized letters of evaluation, using a Likert scale. Descriptive statistics of demographic characteristics and selection factors were performed along with a regression analysis. RESULTS: Of the 107 respondents, 48% were program directors, 28% were assistant or associate program directors, 14% were clerkship directors, and 10% were in other roles. Sixty (55.6%) disagreed with pass/fail Step 1 scoring change and, of those, 82% believed that numerical scoring was a good screening tool. The cSLOEs, EM rotation grades, and interview were the most important selection factors. Residencies with 50 or more residents had 5.25 odds (95% CI 1.25-22.1; p = 0.0018) of agreeing with pass/fail scoring and those who ranked cSLOEs as the most important selection factor had 4.90 odds (95% CI 1.125-21.37; p = 0.0343) of agreeing with pass/fail scoring. CONCLUSIONS: Most EM programs disagree with pass/fail scoring of Step 1 and will most likely use Step 2 score as a screening tool. The cSLOEs, EM rotation grades, and interview are considered the most important selection factors.

Teaching Rapid Assessment Skills in Triage for the Emergency Medicine Clerkship.

BACKGROUND: Rapidly assessing an undifferentiated patient and developing a gestalt for "sick vs. not sick" is a core component of emergency medicine (EM). Developing this skill requires clinical experience and pattern recognition, which can be difficult to attain during a typical EM clerkship. OBJECTIVE: We developed a novel approach to teaching medical students rapid assessment skills in the emergency department (ED) by implementing a teaching shift in triage. METHODS: Fourth-year medical students in our EM clerkship in fall 2019 were scheduled one shift in triage with a dedicated teaching attending. The students evaluated patients under direct supervision, discussed their immediate differential diagnosis, and proposed an initial workup. The attending gave real-time feedback using a standardized direct observation tool. Students completed an electronic pre and post survey (5-point Likert scale) to assess their comfort level in the following areas: performing a rapid triage assessment, determining "sick vs. not sick", performing a focused physical examination, developing a targeted differential diagnosis, and ordering an initial diagnostic workup. RESULTS: Twenty-one students participated in the triage shifts. There was a significant improvement in self-assessed comfort with performing a rapid triage assessment, mean pre 2.76 and post 4.43 (p < 0.0001). There were also significant improvements in the four other survey areas (p < 0.004 or less). CONCLUSIONS: A teaching shift in triage can increase medical students' self-assessed rapid assessment skills for patients in the ED. Benefits to the teaching attending included the opportunity to perform direct observation, give real-time feedback, and identify real-time teaching moments.

Active Cancer Patients Presenting to the Emergency Department with Acute Venous Thromboembolism: A Retrospective Cohort Study on Risks and Outcomes.

BACKGROUND: There is no prior study that has documented emergency department (ED) outcomes or stratified mortality risks of cancer patients presenting with an acute venous thromboembolism (VTE). OBJECTIVE: To evaluate ED treatment of these patients, to document their outcomes, and to identify risk factors associated with death. METHODS: A retrospective cohort study was performed on active cancer patients presenting with deep venous thrombosis or pulmonary embolism to two academic EDs between July 2012 and June 2016. Key outcomes included mortality, ED revisit, and admission within 30 days. The patient cohort was characterized; crosstabs and regression analysis were performed to assess relative risks (RRs) and mitigating factors associated with 30-day mortality. RESULTS: Of 355 patients, 9% died and 38% had one or more ED revisits or admissions. Recent immobility (RR 2.341, 95% CI 1.227-4.465), poor functional status (RR 2.090, 95% CI 1.028-4.248), recent admission (RR 2.441, 95% CI 1.276-4.669), and metastatic cancer (RR 4.669, 95% CI 1.456-14.979) were major risk factors for mortality. ED-provided anticoagulation reduced the overall mortality risk (RR 0.274, 95% CI 0.146-0.515) and mitigated the risk from recent immobility (RR 1.250, 95% CI 0.462-3.381), especially among patients with good or fair functional status. CONCLUSION: Immobility and cancer morbidity are key risk factors for mortality after an acute VTE, but ED-provided anticoagulation mitigates the risk of immobility among healthier patients. Eastern Cooperative Oncology Group performance status can help clinicians risk stratify these patients at presentation.

Clinical outcomes of ED patients with bandemia.

BACKGROUND: Although an elevated white blood cell count is a widely utilized measure for evidence of infection and an important criterion for evaluation of systemic inflammatory response syndrome, its component band count occupies a more contested position within clinical emergency medicine. Recent studies indicate that bandemia is highly predictive of a serious infection, suggesting that clinicians who do not appreciate the value of band counts may delay diagnosis or overlook severe infections. OBJECTIVES: Whereas previous studies focused on determining the quantitative value of the band count (ie, determining sensitivity, threshold for bandemia, etc.), this study directs attention to patient-centered outcomes, hypothesizing that the degree of bandemia predisposes patients to subsequent negative clinical outcomes associated with underappreciated severe infections. METHODS: This retrospective study of electronic medical records includes patients who initially presented to the emergency department (ED) with bandemia and were subsequently discharged from the ED. These patients were screened for repeat ED visits within 7 days and death within 30 days. RESULTS: In patients with severe bandemia who were discharged from the ED, there was a 20.9% revisit rate at 7 days and a 4.9% mortality rate at 30 days, placing severely bandemic patients at 5 times significantly greater mortality compared to nonbandemic patients (P = .032). CONCLUSION: Our review of patient outcomes suggests that the degree of bandemia, especially in the setting of concurrent tachycardia or fever, is associated with greater likelihood of negative clinical outcomes.

Medical student perceptions on the instruction of the emergency medicine oral case presentation.

BACKGROUND: The emergency medicine oral case presentation (EM OCP) is the clinician's communication tool to justify whether urgent intervention is required, to argue for ruling out emergent disease states, and to propose safe disposition plans in the context of triaging patients for medical care and prioritization of resources. The EM OCP provides the representation of the practice of emergency medicine, yet we do not know the current level of effectiveness of its instruction. OBJECTIVES: We aimed to document medical student perceptions and expectations of the instruction of the EM OCP. METHODS: We surveyed medical students from five institutions after their emergency medicine clerkship on their instruction of the EM OCP. Analysis included univariate descriptive statistics and chi-squared analyses for interactions. RESULTS: One hundred fifty-five medical students (82%) completed the survey. Most medical students reported the EM OCP to be unique compared to that of other disciplines (86%), integral to their clerkship evaluation (77%), and felt that additional teaching was required beyond their current medical school instruction (78%). A minority report being specifically taught the EM OCP (37%), that their instruction was consistent (29%), or that expectations of the EM OCP were clear (21%). Respondents felt that brief instruction during their orientation (65%) and reading with a portable summary card (45%) would improve their EM OCP skills, whereas other modalities would be less helpful. CONCLUSION: This study identifies a need for additional specific and consistent teaching of the EM OCP to medical students and their preference on how to receive this instruction.

Implementing a third-year emergency medicine medical student curriculum.

BACKGROUND: Emergency medicine (EM) is commonly introduced in the fourth year of medical school because of a perceived need to have more experienced students in the complex and dynamic environment of the emergency department. However, there is no evidence supporting the optimal time or duration for an EM rotation, and a number of institutions offer third-year rotations. OBJECTIVE: A recently published syllabus provides areas of knowledge, skills, and attitudes that third-year EM rotation directors can use to develop curricula. This article expands on that syllabus by providing a comprehensive curricular guide for the third-year medical student rotation with a focus on implementation. DISCUSSION: Included are consensus-derived learning objectives, discussion of educational methods, considerations for implementation, and information on feedback and evaluation as proposed by the Clerkship Directors in Emergency Medicine Third-Year Curriculum Work Group. External validation results, derived from a survey of third-year rotation directors, are provided in the form of a content validity index for each content area. CONCLUSIONS: This consensus-derived curricular guide can be used by faculty who are developing or revising a third-year EM medical student rotation and provide guidance for implementing this curriculum at their institution.

Impact of an automated patient outcome feedback system on emergency medicine resident patient follow-up: An interrupted time series analysis.

Objectives: Emergency medicine (EM) residents desire, but often lack, reliable feedback of patient outcomes following handoffs to other providers. This gap is a substantial barrier to calibrating their diagnostic decision making and learning. To address this educational priority, we developed and evaluated the Post-Handoff Reports of Outcomes (PHAROS) system-an automated system within our electronic health record (EHR) to deliver provider-specific patient outcome feedback. Methods: PHAROS includes: (1) individualized lists of patients seen and brief summaries of each case, (2) flags for important posthandoff events, and (3) links to charts to facilitate review. Starting June 2020, we coupled PHAROS with a resident educational session and individualized emails every 2 weeks outlining patients seen, number of posthandoff events, and instructions on how to access the PHAROS system. Results: From July 2017 through April 2022, we measured the proportion of handoffs followed by reaccessing patients' charts between 2 and 14 days posthandoff-a proxy for following up on the patient's outcomes. We performed an interrupted time series analysis on this outcome to determine if PHAROS was associated with a significant change in the trend of our outcome over time. Our secondary outcome was the number of times PHAROS was viewed each month. Our primary outcome had a significant increase in the slope over time (+0.13%/month, p = 0.03) after the introduction of the personalized reports and a nonsignificant change (-1.6%, p = 0.07) at the time of the intervention. The median (IQR) number of views of PHAROS per month was 33.2 (23.75-38.75). Conclusions: The PHAROS system was associated with a significant increase in the rate of posthandoff chart reaccess among EM residents over time. The PHAROS project demonstrated the feasibility of harnessing the capabilities of the EHR to create an automated system to support EM trainee feedback of patient outcomes-a key component of diagnostic calibration and learning.

Foreign Bodies of the Ear, Nose and Throat.

Foreign bodies to the ear, nose, and throat often can be managed in the emergency department, particularly if the patient offers a history consistent with foreign body and is calm and compliant with the examination and removal attempts. Tips for success include analgesia, adequate visualization, immobilization of the patient's head, dexterity and experience level of the provider, and minimizing attempts at removal. It is critical to recognize the risks involved with certain retained objects (button batteries or sharp objects) and when to call a consultant to help facilitate safe, successful removal of objects to the ear, nose, and throat.

Developing a third-year emergency medicine medical student curriculum: a syllabus of content.

Emergency medicine (EM) educators have published several curricular guides designed for medical student rotations and experiences. These guides primarily provided brief overviews of opportunities to incorporate EM into all 4 years of the medical student curriculum, with one specific to the fourth year. However, there are no published guidelines specific to third-year medical students rotating in EM. Given the differences between third-year and fourth-year students in terms of clinical experience, knowledge, and skills, the Clerkship Directors in Emergency Medicine (CDEM) established the Third-year EM Medical Student Curriculum Work Group to create a third-year curriculum. The work group began this process by developing consensus-based recommendations for the content of a third-year medical student EM rotation, which are presented in this syllabus.

Inaccuracy of the global assessment score in the emergency medicine standard letter of recommendation.

OBJECTIVES: The standard letter of recommendation (SLOR) is used by most emergency medicine (EM) faculty to submit evaluations for medical students applying for EM residency programs. In the global assessment score (GAS) section, there is a crucial summative question that asks letter writers to estimate the applicant's rank order list (ROL) position in their own program. The primary aim of the study was to determine if these estimated global assessment tiers agreed with the actual ROL, using the criteria recommended by the Council of Emergency Medicine Residency Directors (CORD). METHODS: Data from SLORs written by EM faculty from five California institutions were retrospectively collected from the 2008-2009 residency application year. Descriptive and comparative statistical analyses were performed using the documented GAS tiers and actual ROL positions. RESULTS: A total of 105 SLORs were reviewed from the five participating institutions. Three SLORs were excluded and 102 were analyzed. Only 27 (26%) SLORs documented a GAS tier that accurately predicted the applicant's actual ROL position. The GAS tier overestimated the applicant's position on the ROL in 67 (66%) SLORs, whereas it underestimated the position in eight (8%) SLORs. Accuracy was poor regardless of the number of letter writers on the SLOR (p = 0.890), the writer's administrative title (p = 0.326), whether the student was a home or visiting student (p = 0.801), or if the student had prior EM rotation experience (p = 0.793). CONCLUSIONS: Standard letter of recommendation writers are inaccurate in estimating the ROL position of the applicant using the GAS tier criteria. The GAS tiers were accurate only 26% of the time. Because of the valuable role that the SLOR plays in determining an applicant's competitiveness in the National Resident Matching Program (NRMP) in EM, future discussion should focus on improving the consistency and accuracy of the GAS section. Furthermore, there needs to be a national dialogue to reassess the utility of the criterion-based GAS within the SLOR.