Applying the master adaptive learner framework to just-in-time training of procedures.

Background: Just-in-time training (JITT) occurs in the clinical context when learners need immediate guidance for procedures due to a lack of proficiency or the need for knowledge refreshment. The master adaptive learner (MAL) framework presents a comprehensive model of transforming learners into adaptive experts, proficient not only in their current tasks but also in the ongoing development of lifelong skills. With the evolving landscape of procedural competence in emergency medicine (EM), trainees must develop the capacity to acquire and master new techniques consistently. This concept paper will discuss using JITT to support the development of MALs in the emergency department. Methods: In May 2023, an expert panel from the Society for Academic Emergency Medicine (SAEM) Medical Educator's Boot Camp delivered a comprehensive half-day preconference session entitled "Be the Best Teacher" at the society's annual meeting. A subgroup within this panel focused on applying the MAL framework to JITT. This subgroup collaboratively developed a practical guide that underwent iterative review and refinement. Results: The MAL-JITT framework integrates the learner's past experiences with the educator's proficiency, allowing the educational experience to address the unique requirements of each case. We outline a structured five-step process for applying JITT, utilizing the lumbar puncture procedure as an example of integrating the MAL stages of planning, learning, assessing, and adjusting. This innovative approach facilitates prompt procedural competence and cultivates a positive learning environment that fosters acquiring adaptable learning skills with enduring benefits throughout the learner's career trajectory. Conclusions: JITT for procedures holds the potential to cultivate a dynamic learning environment conducive to nurturing the development of MALs in EM.

A national pilot study on simulation-based upstander training for emergency medicine clinicians.

Objective: This study assesses the effectiveness of clinical simulation-based training in boosting self-perceived confidence for using upstander communication skills to confront racism, discrimination, and microaggressions (RDM). Methods: We conducted an observational cohort study with emergency medicine professionals at the 2023 Scientific Assembly of the American Academy of Emergency Medicine in New Orleans, Louisiana. The study featured a clinical simulation-based training on upstander communications skills session followed by small- and large-group debriefs. Participants completed pre- and post-training questionnaires assessing demographics and confidence in health equity competencies. This survey was used in a previous study with emergency medicine residents. Data were analyzed using an independent Student's t-test, with a significance threshold of 0.05. Results: Thirty-two individuals participated in the simulation-based training, and 24 completed surveys, with a 75% response rate. Most participants were non-Hispanic (24, 85.7%) and women (18, 64%), with racial demographics mostly White (8, 28.6%), Black or African American (8, 28.6%), and Asian (6, 21.4%). After the workshop, there was a notable increase in self-perceived ability and confidence in identifying RDM (from 7 ± 3.2 to 8.6 ± 1.6, p < 0.003), using upstander communication tools (from 6.1 ± 3.5 to 8.5 ± 1, p < 0.0001), and the likelihood of intervening in RDM situations (from 7.1 ± 3.3 to 8.8 ± 1.1, p < 0.0002). Conclusions: The clinical simulation-based training significantly improved participants' confidence and self-perceived ability to address RDM in simulated clinical environments. This training method is a promising tool for teaching health equity topics in clinical medicine.

"I don't want to be the squeaky wheel": Addressing bias as a leader in emergency medicine.

BACKGROUND: Implicit bias poses a barrier to inclusivity in the health care workforce and is detrimental to patient care. While previous studies have investigated knowledge and training gaps related to implicit bias, emergency medicine (EM) leaders' self-awareness and perspectives on bias have not been studied. Using art to prompt reflections on implicit bias, this qualitative study explores (1) the attitudes of leaders in EM toward implicit bias and (2) individual or structural barriers to navigating and addressing bias in the workplace. METHODS: Investigators facilitated an hour-long workshop in May 2022 for those with leadership positions in the Society for Academic Emergency Medicine (SAEM), a leading national EM organization, including 62 attending physicians, eight residents/fellows, and four medical students. The workshop utilized arts-based methods to generate a psychologically supportive space to lead conversations around implicit bias in EM. The session included time for individual reflection, where participants used an electronic platform to respond anonymously to questions regarding susceptibility, fears, barriers, and experiences surrounding bias. Two independent coders compiled, coded, and reviewed the responses using an exploratory constructivist approach. RESULTS: A total of 125 responses were analyzed. Four major themes emerged: (1) acceptance that bias exists; (2) individual barriers, including fear of negative reactions, often due to power dynamics between respondents and other members of the ED; (3) institutional barriers, such as insufficient funding and unprotected time committed to addressing bias; and (4) ambiguity about defining and prioritizing bias. CONCLUSIONS: This qualitative analysis of reflections from an arts-based workshop highlights perceived fears and barriers that may impact EM physicians' motivation and comfort in addressing bias. These results may help guide interventions to address individual and structural barriers to mitigating bias in the workplace.

An Exploration of the Interplay Between Well-being and Quality and Safety.

PURPOSE: Quality improvement and patient safety (QIPS) and clinician well-being work are interconnected and impact each other. Well-being is of increased importance in the current state of workforce shortages and high levels of burnout. The Canadian Association of Emergency Physicians (CAEP) Academic Symposium sought to understand the interplay between QIPS and clinician well-being and to provide practical recommendations to clinicians and institutions on ensuring that clinician well-being is integrated into QIPS efforts. METHODS: A team of emergency physicians with expertise in well-being and QIPS performed a literature review, drafted goals and recommendations, and presented at the CAEP Academic Symposium in 2023 for feedback. Goals and recommendations were then further refined. RESULTS: Three goals and recommendations were developed as follows: QIPS leaders and practitioners must (1) understand the potential intersection of well-being and QIPS, (2) consider a well-being lens for all QIPS work, and (3) incorporate QIPS methodology in efforts to improve clinician well-being. CONCLUSION: QIPS and clinician well-being are often closely linked. By incorporating these recommendations, QIPS strategies can enhance clinician well-being.

RéSUMé: OBJECTIF: Le travail d'amélioration de la qualité et de la sécurité des patients (QIPS) et le bien-être des cliniciens sont interreliés et ont des répercussions les uns sur les autres. Le bien-être est d'une importance croissante dans l'état actuel des pénuries de main-d'œuvre et des niveaux élevés d'épuisement professionnel. Le symposium universitaire de l'Association canadienne des médecins d'urgence (ACMU) visait à comprendre l'interaction entre le SPQI et le bien-être des cliniciens et à fournir des recommandations pratiques aux cliniciens et aux établissements pour assurer le bien-être des cliniciens. . .Le programme QIPS est intégré aux efforts du QIPS. MéTHODES: Une équipe de médecins urgentistes ayant une expertise en bien-être et QIPS a effectué une revue de la littérature, rédigé des objectifs et des recommandations, et présenté au symposium académique de l'ACMU en 2023 pour obtenir une rétroaction. Les objectifs et les recommandations ont ensuite été affinés. RéSULTATS: Trois objectifs et recommandations ont été élaborés : les dirigeants et les praticiens du SPQI doivent (1) comprendre l'intersection potentielle du bien-être et du SPQI, (2) envisager une optique du bien-être pour tous les travaux du SPQI, et (3) intégrer la méthodologie QIPS dans les efforts visant à améliorer le bien-être des cliniciens. CONCLUSIONS: Le SPQI et le bien-être des cliniciens sont souvent étroitement liés. En intégrant ces recommandations, les stratégies QIPS peuvent améliorer le bien-être des cliniciens.

Measuring and Predicting Faculty Consensus Rankings of Standardized Letters of Evaluation.

Background Standardized letters of evaluation (SLOE) are becoming more widely incorporated into the residency application process to make the letter of recommendation, an already critical component in a residency application packet, more objective. However, it is not currently known if the reviewers of these letters share consensus regarding the strength of an applicant determined by their SLOE. Objective We measured the level of faculty agreement regarding applicant competitiveness as determined by SLOEs and the ability of 2 algorithms to predict faculty consensus rankings. Methods Using data from the 2021-2022 Match cycle from the Council of Residency Directors in Emergency Medicine SLOE Database as a blueprint, authors created 50 fictional SLOEs representative of the national data. Seven faculty then rated these SLOEs in order of applicant competitiveness, defined as suggested rank position. Consensus was evaluated using cutoffs established a priori, and 2 prediction models, a point-based system and a linear regression model, were tested to determine their ability to predict consensus rankings. Results There was strong faculty consensus regarding the interpretation of SLOEs. Within narrow windows of agreement, faculty demonstrated similar ranking patterns with 83% and 93% agreement for "close" and "loose" agreement, respectively. Predictive models yielded a strong correlation with the consensus ranking (point-based system r=0.97, linear regression r=0.97). Conclusions Faculty displayed strong consensus regarding the competitiveness of applicants via SLOEs, adding further support to the use of SLOEs for selection and advising. Two models predicted consensus competitiveness rankings with a high degree of accuracy.

Brain versus bot: Distinguishing letters of recommendation authored by humans compared with artificial intelligence.

Objectives: Letters of recommendation (LORs) are essential within academic medicine, affecting a number of important decisions regarding advancement, yet these letters take significant amounts of time and labor to prepare. The use of generative artificial intelligence (AI) tools, such as ChatGPT, are gaining popularity for a variety of academic writing tasks and offer an innovative solution to relieve the burden of letter writing. It is yet to be determined if ChatGPT could aid in crafting LORs, particularly in high-stakes contexts like faculty promotion. To determine the feasibility of this process and whether there is a significant difference between AI and human-authored letters, we conducted a study aimed at determining whether academic physicians can distinguish between the two. Methods: A quasi-experimental study was conducted using a single-blind design. Academic physicians with experience in reviewing LORs were presented with LORs for promotion to associate professor, written by either humans or AI. Participants reviewed LORs and identified the authorship. Statistical analysis was performed to determine accuracy in distinguishing between human and AI-authored LORs. Additionally, the perceived quality and persuasiveness of the LORs were compared based on suspected and actual authorship. Results: A total of 32 participants completed letter review. The mean accuracy of distinguishing between human- versus AI-authored LORs was 59.4%. The reviewer's certainty and time spent deliberating did not significantly impact accuracy. LORs suspected to be human-authored were rated more favorably in terms of quality and persuasiveness. A difference in gender-biased language was observed in our letters: human-authored letters contained significantly more female-associated words, while the majority of AI-authored letters tended to use more male-associated words. Conclusions: Participants were unable to reliably differentiate between human- and AI-authored LORs for promotion. AI may be able to generate LORs and relieve the burden of letter writing for academicians. New strategies, policies, and guidelines are needed to balance the benefits of AI while preserving integrity and fairness in academic promotion decisions.

A Virtual National Diversity Mentoring Initiative to Promote Inclusion in Emergency Medicine.

INTRODUCTION: Trainees underrepresented in medicine (URiM) face additional challenges seeking community in predominantly white academic spaces, as they juggle the effects of institutional, interpersonal, and internalized racism while undergoing medical training. To offer support and a space to share these unique experiences, mentorship for URiM trainees is essential. However, URiM trainees have limited access to mentorship from URiM faculty. To address this gap, we developed a national virtual mentoring program that paired URiM trainees interested in emergency medicine (EM) with experienced mentors. METHODS: We describe the implementation of a virtual Diversity Mentoring Initiative (DMI) geared toward supporting URiM trainees interested in EM. The program development involved 1) partnering of national EM organizations to obtain funding; (2) identifying a comprehensive platform to facilitate participant communication, artificial intelligence-enabled matching, and ongoing data collection; 3) focusing on targeted recruitment of URiM trainees; and (4) fostering regular leadership meeting cadence to customize the platform and optimize the mentorship experience. CONCLUSION: We found that by using a virtual platform, the DMI enhanced the efficiency of mentor-mentee pairing, tailored matches based on participants' interests and the bandwidth of mentors, and successfully established cross-institutional connections to support the mentorship needs of URiM trainees.

Influence of COVID-19 on Stress at Work During the First Wave of the Pandemic Among Emergency Health Care Workers.

OBJECTIVES: For more than 2 years, coronavirus disease (COVID-19) has forced worldwide health care systems to adapt their daily practice. These adaptations add to the already stressful demands of providing timely medical care in an overcrowded health care system. Specifically, the COVID-19 pandemic added stress to an already overwhelmed emergency and critical care health care workers (HCWs) on the front lines during the first wave of the pandemic.This study assessed comparative subjective and objective stress among frontline HCWs using a visual analog scale and biometric data, specifically heart rate variability (HRV). METHODS: This is a prospective, observational study using surveys and heart rate monitoring among HCWs who work in 3 frontline health care units (emergency department, mobile intensive care unit, and intensive care unit) in the University Hospital of Clermont-Ferrand, France. Two sessions were performed: 1 during the first wave of the pandemic (April 10 to May 10, 2020) and 1 after the first wave of the pandemic (June 10 to July 15, 2020).The primary outcome is the difference in stress levels between the 2 time points. Secondary objectives were the impact of overcrowding, sociodemographics, and other variables on stress levels. We also assessed the correlation between subjective and objective stress levels. RESULTS: Among 199 HCWs, 98 participated in biometric monitoring, 84 had biometric and survey data, and 12 with only biometric data. Subjective stress was higher during the second time point compared to the first (4.39 ± 2.11 vs 3.16 ± 2.34, P = 0.23). There were higher objective stress levels with a decrease in HRV between the first and the second time points. Furthermore, we found higher patient volumes as a source of stress during the second time point. We did not find any significant correlation between subjective and objective stress levels. CONCLUSION: HCWs had higher stress levels between the 2 waves of the pandemic. Overcrowding in the emergency department is associated with higher stress levels. We did not find any correlation between subjective and objective stress among intensive care and emergency HCWs during the first wave of the pandemic.

Trends of Academic Faculty Identifying as Hispanic at US Medical Schools, 1990-2021.

Background: According to recent census data, Hispanic and Latino populations comprise the largest minority group in the United States. Despite ongoing efforts for improved diversity, equity, and inclusion, Hispanics remain underrepresented in medicine (UIM). In addition to well-established benefits to patient care and health systems, physician diversity and increased representation in academic faculty positively impact the recruitment of trainees from UIM backgrounds. Disproportionate representation (as compared to increases of certain underrepresented groups in the US population) has direct implications for recruitment of UIM trainees to residency programs. Objective: To examine the number of full-time US medical school faculty physicians who self-identify as Hispanic in light of the increasing Hispanic population in the United States. Methods: We analyzed data from the Association of American Medical Colleges from 1990 to 2021, looking at those academic faculty who were classified as Hispanic, Latino, of Spanish Origin, or of Multiple Race-Hispanic. We used descriptive statistics and visualizations to illustrate the level of representation of Hispanic faculty by sex, rank, and clinical specialty over time. Results: Overall, the proportion of faculty studied who identified as Hispanic increased from 3.1% (1990) to 6.01% (2021). Moreover, while the proportion of female Hispanic academic faculty increased, there remains a lag between females versus males. Conclusions: Our analysis shows that the number of full-time US medical school faculty who self-identify as Hispanic has not increased, though the population of Hispanics in the United States has increased.

Ethnic and Racial Differences in Ratings in the Medical Student Standardized Letters of Evaluation (SLOE).

Background: The Standardized Letter of Evaluation (SLOE) stratifies the assessment of emergency medicine (EM) bound medical applicants. However, bias in SLOE, particularly regarding race and ethnicity, is an underexplored area. Objective: This study aims to assess whether underrepresented in medicine (UIM) and non-UIM applicants are rated differently in SLOE components. Methods: This was a cross-section study of EM-bound applicants across 3 geographically distinct US training programs during the 2019-2020 application cycle. Using descriptive and regression analyses, we examine the differences between UIM applicants and non-UIM applicants for each of the SLOE components: 7 qualifications of an EM physician (7QEM), global assessment (GA) rating, and projected rank list (RL) position. Results: Out of a combined total of 3759, 2002 (53.3%) unique EM-bound applicants were included. UIM applicants had lower ratings for each of the 7QEM questions, GA, and RL positions. Compared to non-UIM applicants, only some of the 7QEM components: "Work ethic and ability to assume responsibility," "Ability to work in a team, and "Ability to communicate a caring nature," were associated with their SLOE. "Commitment to EM" correlated more with GA for UIM than for non-UIM applicants. Conclusions: This study shows a difference in SLOE rating, with UIM applicants receiving lower ratings than non-UIM applicants.

Physician Pipeline and Pathway Programs: An Evidence-based Guide to Best Practices for Diversity, Equity, and Inclusion from the Council of Residency Directors in Emergency Medicine.

Improving the diversity and representation in the medical workforce requires intentional and deliberate efforts to improve the pipeline and pathway for underrepresented in medicine (UIM) applicants. Diversity enhances educational experiences and improves patient care and outcomes. Through a critical review of the literature, in this article we offer evidence-based guidelines for physician pipeline and pathway programs (PP). Recommendations are provided regarding considerations on the types of programs and surrounding implementation to ensure a sound infrastructure and framework. We believe this guide will be valuable for all leaders and faculty members seeking to grow the UIM applicant pool in our efforts to advance diversity, equity, and inclusion within medicine.

Factors driving burnout and professional fulfillment among emergency medicine residents: A national wellness survey by the Society for Academic Emergency Medicine.

Objectives: This study aimed to identify rates of and contributors to burnout and professional fulfillment among emergency medicine (EM) resident physicians. Methods: This was a cross-sectional, national survey of resident members of the Society for Academic Emergency Medicine (SAEM). Primary outcomes were burnout and professional fulfillment measured using a previously validated instrument with additional domains pertaining to the academic environment. The survey included question domains examining organizational factors (e.g., academic work environment, satisfaction with training, electronic health records, values alignment, and control over schedule) and individual factors (e.g., self-compassion, meaningfulness of clinical work, impact of work on health and personal relationships, perceived appreciation, thoughts of attrition, and expectations of the field of EM). Logistic regression was performed to determine the relationships between the primary outcomes and each domain. Results: The survey was sent electronically to 2641 SAEM resident members. A total of 275 residents completed the survey with a response rate of 10.4%. A total of 151 (55%) respondents were male, and 210 (76%) were White. A total of 132 (48%) residents reported burnout, and 75 (28%) reported professional fulfillment. All organizational and individual factors were significantly associated with both primary outcomes. EM residents reported that meaningfulness of clinical work had the most significant positive association with professional fulfillment (adjusted odds ratio [OR] 2.2 [95% confidence interval {CI} 1.8-2.7]) and negative association with burnout (adjusted OR 0.46 [95% CI 0.37-0.56]). Thoughts of attrition from academics and accurate expectations of EM were also associated with both primary outcomes, with adjusted ORs (95% CIs) of 0.40 (0.21-0.72) and 5.6 (1.9-23.8) for professional fulfillment and 4.1 (2.5-7.1) and 0.19 (0.08-0.40) for burnout, respectively. Conclusions: This study found a high prevalence of burnout and a low prevalence of professional fulfillment among EM residents. Multiple factors were significantly associated with each occupational phenomenon, with meaningfulness of clinical work demonstrating the strongest relationships with burnout and professional fulfillment.

Sex and race visual representation in emergency medicine textbooks and the hidden curriculum.

Introduction: In addition to formal training, informal training often occurs through a hidden curriculum. As the hidden curriculum shapes the knowledge and values held by learners, we must consider its role in implicit bias. One example is through the selection of images used in formal instruction. This study aimed to examine the representation of sex and race among images in two textbooks in emergency medicine (EM). Methods: We performed a cross-sectional study of the sex and race representation of figures in Rosen's Emergency Medicine: Concepts and Clinical Practice 9th Edition and Tintinalli's Emergency Medicine: A Comprehensive Study Guide 9th Edition. Two reviewers screened all images for inclusion, with disagreements resolved by a third reviewer. Images were excluded if they did not include visualized skin. Two reviewers independently reviewed each image and assessed the sex, race, and roles in the image. A third reviewer resolved any disagreements. Results: A total of 959 images (Rosen's n = 377; Tintinalli's n = 582) met inclusion criteria. Race was estimated in 877 cases (91.3%). Of those, White individuals comprised 77.6% (95% confidence interval [CI] 75.0%-80.2%). Sex was estimated in 362 cases (37.7%). Of those images, males comprised 70.2% (95% CI 65.4%-74.9%), and females comprised 29.8% (95% CI 25.1%-34.6%). Conclusion: There is a male sex and White race predominance in visual representation among two EM textbooks. We propose a call to action for the mindful selection of images in formal education to represent diversity, equity, and inclusion and close the gap between the formal and hidden curriculum.

Holistic Review, Mitigating Bias, and Other Strategies in Residency Recruitment for Diversity, Equity, and Inclusion: An Evidence-based Guide to Best Practices from the Council of Residency Directors in Emergency Medicine.

Advancement of diversity, equity, and inclusion (DEI) in emergency medicine can only occur with intentional recruitment of residency applicants underrepresented in medicine (UIM). Shared experiences from undergraduate and graduate medical education highlight considerations and practices that can contribute to improved diversity in the resident pool, such as holistic review and mitigating bias in the recruitment process. This review, written by members of the Council of Residency Directors in Emergency Medicine (CORD) Best Practices Subcommittee, offers best practice recommendations for the recruitment of UIM applicants. Recommendations address pre-interview readiness, interview approach, and post-interview strategies that residency leadership may use to implement holistic review and mitigate bias for recruitment of a diverse class.

Gender differences in emergency medicine standardized letters of evaluation.

Objectives: The Standardized Letter of Evaluation (SLOE) is a vital portion of any medical student's emergency medicine (EM) residency application. Prior literature suggests gender bias in EM SLOE comparative ranking, but there is limited understanding of the impact of gender on other SLOE components. The study objective was to evaluate the presence of gender differences in the 7 Qualifications for EM (7QEM), Global Assessment (GA), and anticipated Rank List (RL) position. A secondary objective was to evaluate the gender differences in 7QEM scores and their link to GA and anticipated RL position. Methods: We performed a cross-sectional study using SLOEs from a subset of United States applicants to three EM residency programs during the 2019-2020 application cycle. We collected self-reported demographics, 7QEM scores, GA, and anticipated RL position. We utilized linear regression analyses and repeated measures ANOVA to evaluate if the relationship between the 7QEM scores, GA score, and anticipated RL position was different for men and women. Results: 2103 unique applicants were included (38.6% women, 61.4% men), with 4952 SLOEs meeting inclusion criteria. The average QEM (2.51 vs. 2.39; p < 0.001), GA (2.68 vs. 2.48; p < 0.001), and RL (2.68 vs. 2.47; p < 0.001) scores were statistically higher for women than men. When exploring the relationship between the 7QEM and GA, Ability to communicate a caring nature to patients was not found to be a statistically significant predictor for men, but it was for women. When exploring the relationship between 7QEM and RL, Commitment to EM was not a significant predictor for men, but it was for women. Conclusions: Women scored higher than men on the 7QEM, GA, and anticipated RL position on SLOEs. The 7QEM scores factored differently for men and women.

Faculty Recruitment, Retention, and Representation in Leadership: An Evidence-Based Guide to Best Practices for Diversity, Equity, and Inclusion from the Council of Residency Directors in Emergency Medicine.

Improving the recruitment, retention, and leadership advancement of faculty who are under-represented in medicine is a priority at many academic institutions to ensure excellence in patient care, research, and health equity. Here we provide a critical review of the literature and offer evidence-based guidelines for faculty recruitment, retention, and representation in leadership. Recommendations for recruitment include targeted recruitment to expand the candidate pool with diverse candidates, holistic review of applications, and incentivizing stakeholders for success with diversity efforts. Retention efforts should establish a culture of inclusivity, promote faculty development, and evaluate for biases in the promotion and tenure process. We believe this guide will be valuable for all leaders and faculty members seeking to advance diversity, equity, and inclusion in their institutions.