Executive summary of the SAEM 2022 consensus conference to address racism in emergency medicine clinical research, training, and leadership.

INTRODUCTION: Racism has not only contributed to disparities in health care outcomes, but also has negatively impacted the recruitment, retention, and promotion of historically excluded groups in academic medicine. The 2022 Society for Academic Emergency Medicine (SAEM) consensus conference, "Diversity, Equity, and Inclusion: Developing a Research Agenda for Addressing Racism in Emergency Medicine," convened a diverse group of researchers, educators, administrative leaders, and health care providers to help address the impact of racism in three domains in academic emergency medicine: clinical research, education and training, and academic leadership. The main goals of the consensus process were to identify current knowledge gaps and create a research agenda within each domain using an iterative consensus-building methodology. METHODS: The planning committee identified three fundamental domains to develop a research agenda and created workgroups who completed a literature search to identify gaps in knowledge. After a consensus building process, potential questions were presented at the in-person consensus conference. Ninety SAEM members representing faculty and trainees participated in breakout groups in each domain to generate consensus recommendations for priority research. RESULTS: For clinical research, three research gaps with six questions (n) were identified: remedies for bias and systematic racism (3), biases and heuristics in clinical care (2), and racism in study design (1). For education and training, three research gaps with seven questions were identified: curriculum and assessment (2), recruitment (1), and learning environment (4). For academic leadership, three research gaps with five questions were identified: understanding the current diversity, equity, and inclusion (DEI) landscape and culture (1), analyzing programs that improve DEI and identifying factors that lead to improved diversity (3), and quantifying the value of professional stewardship activities (1). CONCLUSION: This article reports the results of the consensus conference with the goal of influencing emergency care research, education, and policy and facilitating collaborations, grant funding, and publications in these domains.

Perceptions of Emergency Care by Sexual and Gender Minorities in Colorado: Barriers, Quality, and Factors Affecting Identity Disclosure.

INTRODUCTION: Expanding on data concerning emergency department (ED) use and avoidance by the sexual minority (those who identify as lesbian, gay, bisexual, queer, other [LGTBQ+]) and gender minority (those who identify as transgender, gender nonconforming, other) community may inform future ED LGTBQ+ training and clinical practice. Investigation objectives included characterizing rates of emergency care avoidance, identifying barriers to emergency care, and assessing emergency care quality and cultural competency for sexual and gender minorities. METHODS: In this population-based, cross-sectional needs assessment, sexual minority, gender minority, and/or cisgender heterosexual-identified participants were selected based on participants' subscription to newsletters or social media accounts for One Colorado, an LGBTQ+ advocacy organization. Each participant completed a single digital survey that collected qualitative and quantitative data about ED perception, use, and demographics. RESULTS: A total of 477 LGBTQ+ or heterosexual-identified individuals (mean age = 44.3 (standard deviation [SD] = 16.7)) participated in the study. Lifetime emergency care avoidance rates for gender minorities were markedly increased (odds ratio [OR] 3.8, 95% confidence interval [CI], 2.2 - 6.6; P <.001), while avoidance rates for sexual minorities were similar to those of cisgender heterosexual respondents (17% vs 14%; P <.001). Gender minorities were more likely than sexual minorities to both avoid emergency care due to fear of discrimination (43% vs 15%; P =.002) and to have experienced discrimination during their last ED visit (OR 11, [95% CI, 5-24]; P <.001). No significant differences were observed between participants in care avoidance due to financial reasons or prior negative experiences. No cited ED factors that influenced identity disclosure decisions were distinctly predictive. CONCLUSION: Gender minorities are more likely than sexual minorities and heterosexual cisgender individuals to report ED avoidance and discrimination at last ED visit. Future work characterizing deficits in LGBTQ+ ED care might reduce these avoidance and discrimination rates, enhancing the level of patient care provided to this population.

Advancing Diversity and Inclusion: An Organized Approach Through a Medical Specialty Academy.

BACKGROUND: The benefits of a diverse workforce in medicine have been previously described. While the population of the United States has become increasingly diverse, this has not occurred in the physician workforce. In academic medicine, underrepresented in medicine (URiM) faculty are less likely to be promoted or retained in academic institutions. Studies suggest that mentorship and engagement increase the likelihood of development, retention, and promotion. However, it is not clear what form of mentorship creates these changes. The Academy for Diversity and Inclusion in Emergency Medicine (ADIEM), an academy within the Society for Academic Emergency Medicine, is a group focused on advancing diversity and inclusion as well as promoting the development of its URiM students, residents, and faculty. The Academy serves many of the functions of a mentoring program. We assessed whether active involvement in ADIEM led to increased publications, promotion, or leadership advancement in the areas of diversity, equity, and inclusion. METHODS: We performed a survey of ADIEM members to determine if career development and productivity, defined as written scholarly products, presentations, and mentorship in the area of diversity, equity, and inclusion was enhanced by the establishment of the academy. To determine whether there were significant changes in academic accomplishments after the formation of ADIEM, two groups, ADIEM leaders and ADIEM nonleader members, were examined. RESULTS: Thirteen ADIEM leaders and 14 ADIEM nonleader members completed the survey. Academic productivity in the area of diversity, equity, and inclusion increased significantly among ADIEM leaders when compared to ADIEM nonleader members after the founding of ADIEM. In particular, in the ADIEM leader group, there were significant increases in manuscript publications (1.31 ± 1.6 to 5.5 ± 7.96, p = 0.12), didactic presentations (3.85 ± 7.36 to 23.46 ± 44.52, p < 0.01), grand rounds presentations (0.83 ± 1.75 to 8.6 ± 10.71, p < 0.05), and student/resident mentees (6.46 ± 9.36 to 25 ± 30.41, p = 0.02). CONCLUSION: The formation of a specialized academy within a national medical society has advanced academic accomplishments in diversity, equity, and inclusion in emergency medicine among ADIEM leadership. Involvement of URiM and lesbian, gay, bisexual, and transgender faculty in the academy fostered faculty development, mentoring, and educational scholarship.

Toward Structural Competency in Emergency Medical Education.

As the emergency department (ED) is the "front door" of the hospital and the primary site by which most patients access the health care system, issues of inequity are especially salient for emergency medicine (EM) practice. Improving the health of ED patients, especially those who are stigmatized and disenfranchised, depends on having emergency physicians that are cognizant and attentive to their needs in and out of the medical encounter. EM resident education has traditionally incorporated a "cultural competency" model to equip residents with tools to combat individual bias and stigma. Although this framework has been influential in drawing attention to health inequities, it has also been criticized for its potential to efface differences within groups (such as socioeconomic differences), overstate cultural or racial differences, and unintentionally reinforce stereotypes or blaming of patients for their ill health or difficult circumstances. In contrast, emerging frameworks of structural competency call for physicians to recognize the ways in which health outcomes are influenced by complex, interrelated structural forces (e.g., poverty, racism, gender discrimination, immigration policy) and to attend to these causes of poor health. We present here the framework of structural competency, extending it to the unique ED setting. We provide tangible illustrations of the ways in which this framework is relevant to the ED setting and can be incorporated in EM education.

Applicant Reactions to the AAMC Standardized Video Interview During the 2018 Application Cycle.

PURPOSE: This study examined applicant reactions to the Association of American Medical Colleges Standardized Video Interview (SVI) during its first year of operational use in emergency medicine (EM) residency program selection to identify strategies to improve applicants' SVI experience and attitudes. METHOD: Individuals who self-classified as EM applicants applying in the Electronic Residency Application Service 2018 cycle and who completed the SVI in summer 2017 were invited to participate in 2 surveys. Survey 1, which focused on procedural issues, was administered immediately after SVI completion. Survey 2, which focused on applicants' SVI experience, was administered in fall 2017, after SVI scores were released. RESULTS: The response rates for surveys 1 and 2 were 82.3% (2,906/3,532) and 58.7% (2,074/3,532), respectively. Applicant reactions varied by aspect of the SVI studied and their SVI total scores. Most applicants were satisfied with most procedural aspects of the SVI, but most applicants were not satisfied with the SVI overall or with their total SVI scores. About 20% to 30% of applicants had neutral opinions about most aspects of the SVI. Negative reactions to the SVI were stronger for applicants who scored lower on the SVI. CONCLUSIONS: Applicants had generally negative reactions to the SVI. Most were skeptical of its ability to assess the target competencies and its potential to add value to the selection process. Applicant acceptance and appreciation of the SVI will be critical to the SVI's acceptance by the graduate medical education community.

Why Residents Quit: National Rates of and Reasons for Attrition Among Emergency Medicine Physicians in Training.

INTRODUCTION: Recruiting and retaining residents who will complete their emergency medicine (EM) training is vital, not only because residency positions are a limited and costly resource, but also to prevent the significant disruptions, increased workload, and low morale that may arise when a resident prematurely leaves a program. We investigated national rates of EM resident attrition and examined the reasons and factors associated with their attrition. METHODS: In this retrospective, observational study we used national data from the American Medical Association National Graduate Medical Education Census for all residents who entered Accreditation Council for Graduate Medical Education-accredited EM programs between academic years 2006-2007 and 2015-2016. Our main outcome was the annual national rate of EM resident attrition. Secondary outcomes included the main reason for attrition as well as resident factors associated with attrition. RESULTS: Compared to the other 10 largest specialties, EM had the lowest rate of attrition (0.8%, 95% confidence interval [CI] [0.7-0.9]), or approximately 51.6 (95% CI [44.7-58.5]) residents per year. In the attrition population, 44.2% of the residents were women, a significantly higher proportion when compared to the proportion of female EM residents overall (38.8%, p=0.011). A greater proportion of Hispanic/Latino (1.8%) residents also left their programs when compared to their White (0.9%) counterparts (p<0.001). In examining reasons for attrition as reported by the program director, female residents were significantly more likely than male residents to leave due to "health/family reasons" (21.5% vs 9.6%, p=0.019). CONCLUSION: While the overall rate of attrition among EM residents is low, women and some under-represented minorities in medicine had a higher than expected rate of attrition. Future studies that qualitatively investigate the factors contributing to greater attrition among female and some ethnic minority residents are necessary to inform efforts promoting inclusion and diversity within the specialty.

Assessment of toxicology knowledge in the fourth-year medical students: Three years of data.

BACKGROUND: Pharmacology and toxicology are core content knowledge for physicians. Medical students should demonstrate understanding of general pharmacology and basic treatment of poisoning. The objective of this study was to measure the knowledge of the 4th-year medical students (MS4) on these topics over 3 years. METHODS: A multiple-choice exam (15 questions) was administered to MS4 students in spring of 2010, 2011, and 2012. Questions were developed by medical toxicologists to evaluate basic knowledge in three areas: pharmacologic effects (PE), treatment of poisoning (TOP), and pharmacokinetics (PK). The students were grouped by intended specialties into pharmacologic intense (anesthesia, emergency medicine, internal medicine, pediatrics, and psychiatry), less pharmacologic intense specialties (dermatology, OB/GYN, ophthalmology, pathology, physical medicine and rehabilitation, radiology, and surgery) and by completion of a pharmacology or toxicology elective. Mean group scores were compared using ANOVA. RESULTS: Totally 332 of 401 (83%) students completed the survey. Mean scores were stable over the three years, higher for students completing a toxicology rotation and for students entering a pharmacologically intense specialty. CONCLUSION: The external validity is limited to a single medical school with incomplete participation and content was limited by the survey length. Consistent results over the three-year period and correlation of performance with completing a toxicology rotation and intent to enter a pharmacology intensive specialty suggest this survey may correlate with toxicology knowledge. Implementation of required core courses focused on toxicology may improve core content knowledge in fourth year medical students.

Teaching the Emergency Department Patient Experience: Needs Assessment from the CORD-EM Task Force.

INTRODUCTION: Since the creation of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction (PS) scores, patient experience (PE) has become a metric that can profoundly affect the fiscal balance of hospital systems, reputation of entire departments and welfare of individual physicians. While government and hospital mandates demonstrate the prominence of PE as a quality measure, no such mandate exists for its education. The objective of this study was to determine the education and evaluation landscape for PE in categorical emergency medicine (EM) residencies. METHODS: This was a prospective survey analysis of the Council of Emergency Medicine Residency Directors (CORD) membership. Program directors (PDs), assistant PDs and core faculty who are part of the CORD listserv were sent an email link to a brief, anonymous electronic survey. Respondents were asked their position in the residency, the name of their department, and questions regarding the presence and types of PS evaluative data and PE education they provide. RESULTS: We obtained 168 responses from 139 individual residencies, representing 72% of all categorical EM residencies. This survey found that only 27% of responding residencies provide PS data to their residents. Of those programs, 61% offer simulation scores, 39% provide third-party attending data on cases with resident participation, 37% provide third-party acquired data specifically about residents and 37% provide internally acquired quantitative data. Only 35% of residencies reported having any organized PE curricula. Of the programs that provide an organized PE curriculum, most offer multiple modalities; 96% provide didactic lectures, 49% small group sessions, 47% simulation sessions and 27% specifically use standardized patient encounters in their simulation sessions. CONCLUSION: The majority of categorical EM residencies do not provide either PS data or any organized PE curriculum. Those that do use a heterogeneous set of data collection modalities and educational techniques. American Osteopathic Association and Accreditation Council for Graduate Medical Education residencies show no significant differences in their resident PS data provision or formal curricula. Further work is needed to improve education given the high stakes of PS scores in the emergency physician's career.

Transition of Care Practices from Emergency Department to Inpatient: Survey Data and Development of Algorithm.

INTRODUCTION: We aimed to assess the current scope of handoff education and practice among resident physicians in academic centers and to propose a standardized handoff algorithm for the transition of care from the emergency department (ED) to an inpatient setting. METHODS: This was a cross-sectional survey targeted at the program directors, associate or assistant program directors, and faculty members of emergency medicine (EM) residency programs in the United States (U.S.). The web-based survey was distributed to potential subjects through a listserv. A panel of experts used a modified Delphi approach to develop a standardized algorithm for ED to inpatient handoff. RESULTS: 121 of 172 programs responded to the survey for an overall response rate of 70.3%. Our survey showed that most EM programs in the U.S. have some form of handoff training, and the majority of them occur either during orientation or in the clinical setting. The handoff structure from ED to inpatient is not well standardized, and in those places with a formalized handoff system, over 70% of residents do not uniformly follow it. Approximately half of responding programs felt that their current handoff system was safe and effective. About half of the programs did not formally assess the handoff proficiency of trainees. Handoffs most commonly take place over the phone, though respondents disagree about the ideal place for a handoff to occur, with nearly equivalent responses between programs favoring the bedside over the phone or face-to-face on a computer. Approximately two-thirds of responding programs reported that their residents were competent in performing ED to inpatient handoffs. Based on this survey and on the review of the literature, we developed a five-step algorithm for the transition of care from the ED to the inpatient setting. CONCLUSION: Our results identified the current trends of education and practice in transitions of care, from the ED to the inpatient setting in U.S. academic medical centers. An algorithm, which guides this process, is proposed to address the current gap in the standardized approach to ED to inpatient handoffs that were identified in the survey's assessment of needs.

The Impact of the 2008 Council of Emergency Residency Directors (CORD) Panel on Emergency Medicine Resident Diversity.

BACKGROUND: In 2008, the Council of Emergency Medicine Residency Directors (CORD) developed a set of recruitment strategies designed to increase the number of under-represented minorities (URMs) in Emergency Medicine (EM) residency. OBJECTIVES: We conducted a survey of United States (US) EM residency program directors to: describe the racial and ethnic composition of residents; ascertain whether each program had instituted CORD recruitment strategies; and identify program characteristics associated with recruitment of a high proportion of URM residents. METHODS: The survey was distributed to accredited, nonmilitary US EM residency programs during 2013. Programs were dichotomized into high URM and low URM by the percentage of URM residents. High- and low-URM programs were compared with respect to size, geography, percentage of URM faculty, importance assigned to common applicant selection criteria, and CORD recruitment strategies utilized. Odds ratios and 95% confidence limits were calculated. RESULTS: Of 154 residency programs, 72% responded. The median percentage of URM residents per program was 9%. Only 46% of EM programs engaged in at least two recruitment strategies. Factors associated with higher resident diversity (high-URM) included: diversity of EM faculty (high-URM) (odds ratio [OR] 5.3; 95% confidence interval [CI] 2.1-13.0); applicant's URM status considered important (OR 4.9; 95% CI 2.1-11.9); engaging in pipeline activities (OR 4.8; 95% CI 1.4-15.7); and extracurricular activities considered important (OR 2.6; 95% CI 1.2-6.0). CONCLUSION: Less than half of EM programs have instituted two or more recruitment strategies from the 2008 CORD diversity panel. EM faculty diversity, active pipeline programs, and attention paid to applicants' URM status and extracurricular activities were associated with higher resident diversity.

Publishing Venues for Education Scholarship: A Needs Assessment.

OBJECTIVES: Education research is a developing field. It is unknown if there are adequate venues for scholarship distribution. The objectives of this study were to identify types of education scholarship produced, where this type of scholarship is published, barriers to achieving publication for education scholarship, and perceptions of adequacy of publication venues. METHODS: Study participants were emergency medicine (EM) education and academic leaders who completed an online survey consisting of multiple-choice, completion, and 10-point Likert scale items. RESULTS: A total of 45 of 59 (76.3%) subjects completed the survey. A total of 33 of 45 (73.3%) respondents had published education scholarship. Most (29/44, 65.9%) felt that there were inadequate venues for publishing education scholarship. Of those who publish education scholarship, most (30/33; 90.9%) publish either less than one or one to two peer-reviewed products per year, but collaborate with others more frequently (less than one per year, 7/33, 21.2%; one or two per year, 17/33, 51.5%; three or four per year, 7/33, 21.2%; five or more per year, 2/33, 6.1%). The most frequently published scholarship were curricular innovations and original research, with mean ratings of 5.61 and 5.21, respectively, on a 10-point Likert scale. Peer-reviewed print journal was the most frequently utilized venue, with a mean rating of 6.21. Other venues (mean rating) include peer-reviewed online journal (4.0), MedEd Portal (3.58), free open-access education (3.47), newsletter (3.0), and curricular toolbox (2.55). The most common rejection reason was "not suitable for this journal/venue," with a mean rating of 5.33. Other reasons include research methodology (4.07), small sample size (4.17), single-site study (4.28), and misunderstanding of project purpose (4.10). Respondents believed that additional education supplements in journals would be most helpful in increasing successful publication, with a mean rating of 8.31. Other helpful items included a central online repository of venues that publish education scholarship, online training in education research design/methodology, and an online networking site of education researchers to promote collaboration, with mean ratings of 6.88, 6.75, and 6.28, respectively. CONCLUSION: The majority of our sampling of EM education and academic leaders publish education scholarship. There is a perceived lack of venues for this work. Multiple barriers as well as potential strategies for success have been identified. This information may inform interventions to support the dissemination of education scholarship.

Handoff Practices in Emergency Medicine: Are We Making Progress?

OBJECTIVES: Transitions of care present a risk for communication error and may adversely affect patient care. This study addresses the scope of current handoff practices amongst U.S. emergency medicine (EM) residents. In addition, it evaluates current educational and evaluation practices related to handoffs. Given the ever-increasing emphasis on transitions of care in medicine, we sought to determine if interval changes in resident transition of care education, assessment, and proficiency have occurred. METHODS: This was a cross-sectional survey study guided by the Kern model for medical curriculum development. The Council of Residency Directors Listserv provided access to 175 programs. The survey focused on elucidating current practices of handoffs from emergency physicians (EPs) to EPs, including handoff location and duration, use of any assistive tools, and handoff documentation in the emergency department (ED) patient's medical record. Multiple-choice questions were the primary vehicle for the response process. A four-point Likert-type scale was used in questions regarding perceived satisfaction and competency. Respondents were not required to answer all questions. Responses were compared to results from a similar 2011 study for interval changes. RESULTS: A total of 127 of 175 programs responded to the survey, making the overall response rate 72.6%. Over half of respondents (72 of 125, 57.6%) indicated that their ED uses a standardized handoff protocol, which is a significant increase from 43.2% in 2011 (p = 0.018). Of the programs that do have a standardized system, a majority (72 of 113, 63.7%) of resident physicians use it regularly. Significant increases were noted in the number of programs offering formal training during orientation (73.2% from 59.2%; p = 0.015), decreases in the number of programs offering no training (2.4% from 10.2%; p = 0.013), and no assessment of proficiency (51.5% from 69.8%; p = 0.006). No significant interval changes were noted in handoffs being documented in the patient's medical record (57.4%), the percentage of computer/electronic signouts, or the level of dissatisfaction with handoff tools (54.1%). Less than two-thirds of respondents (80 of 126, 63.5%) indicated that their residents were "competent" or "extremely competent" in delivering and receiving handoffs. CONCLUSIONS: An insufficient level of handoff training is currently mandated or available for EM residents, and their handoff skills appear to be developed mostly informally throughout residency training with varying results. Programs that have created a standardized protocol are not ensuring that the protocol is actually being employed in the clinical arena. Handoff proficiency most often goes unevaluated, although it is improved from 2011.

Increasing Resident Diversity in an Emergency Medicine Residency Program: A Pilot Intervention With Three Principal Strategies.

PROBLEM: Much work remains to be done to align the diversity of the health care workforce with the changing racial and ethnic backgrounds of patients, especially in the field of emergency medicine. APPROACH: In academic year (AY) 2012-2013, to increase the number of underrepresented minority (URM) candidates who were interviewed and matched, the Denver Health Residency in Emergency Medicine program (DHREM) initiated a focused pilot intervention with three principal strategies: (1) a scholarship-based externship program, (2) a funded second-look event, and (3) increased involvement and visibility of URM faculty in the interview and recruitment process. OUTCOMES: One year after implementation of the pilot intervention, the percentage of URMs among all applicants invited to interview at the DHREM doubled (7.1% [20/282] in AY 2011-2012, 7.0% [24/344] in AY 2012-2013, and 14.8% [58/393] in AY 2013-2014) (95% confidence interval [CI] = 5-10, 4-11, and 11-19, respectively). Of all DHREM interviewees in AY 2013-2014, 17.6% (49/279) (95% CI = 12-23) were URMs, nearly a threefold increase from AY 2012-2013 (6.2% [14/226], 95% CI = 3-10). In AY 2013-2014, 23.5% (4/17) (95% CI = 7-50) of all new DHREM residents were URMs, compared with 5.9% (1/17) in AY 2011-2012 and 5.6% (1/18) in AY 2012-2013 (95% CI = 0-29 and 0-27, respectively). NEXT STEPS: Additional studies are needed to determine whether these results are sustainable and generalizable to other residency programs in emergency medicine and other specialties.

Ready for Discharge? A Survey of Discharge Transition-of-Care Education and Evaluation in Emergency Medicine Residency Programs.

This study aimed to assess current education and practices of emergency medicine (EM) residents as perceived by EM program directors to determine if there are deficits in resident discharge handoff training. This survey study was guided by the Kern model for medical curriculum development. A six-member Council of EM Residency Directors (CORD) Transitions of Care task force of EM physicians performed these steps and constructed a survey. The survey was distributed to program residency directors via the CORD listserve and/or direct contact. There were 119 responses to the survey, which were collected using an online survey tool. Over 71% of the 167 American College of Graduate Medical Education (ACGME) accredited EM residency programs were represented. Of those responding, 42.9% of programs reported formal training regarding discharges during initial orientation and 5.9% reported structured curriculum outside of orientation. A majority (73.9%) of programs reported that EM residents were not routinely evaluated on their discharge proficiency. Despite the ACGME requirements requiring formal handoff curriculum and evaluation, many programs do not provide formal curriculum on the discharge transition of care or evaluate EM residents on their discharge proficiency.

What do patients want? Survey of patient desires for education in an urban university hospital.

INTRODUCTION: This study examines the emergency department (ED) waiting room (WR) population's knowledge about the ED process and hospital function and explores the types of educational materials that might appeal to patients and their companions in an ED waiting room. Our goal was to identify potential high-impact opportunities for patient education. METHODS: A 32-question survey about demographics, usage of primary care physicians (PCP), understanding of the ED and triage process, desire to know about delays, health education and understanding of teaching hospitals was offered to all qualified individuals. RESULTS: Five hundred and forty-four surveys were returned. Fifty-five percent reported having a PCP, of which 53% (29% of all WR patients) called a PCP prior to coming to the ED. It was found that 51.2% can define triage; 51% as an acuity assessment and 17% as a vital signs check. Sixty-nine percent knew why patients were seen according to triage priority. Seventy-two percent wanted to know about delays, yet only 25% wanted to know others' wait times. People wanted updates every 41 minutes and only three percent wanted a physician to do this. Forty-one percent wanted information on how the ED functions, 60% via handouts and 43% via video. Information on updates and common medical emergencies is significantly more important than material on common illnesses, finding a PCP, or ED function (p<0.05). Median estimated time for medical workup ranged from 35 minutes for radiographs, to one hour for lab results, computed tomography, specialist consult, and admission. Sixty-nine percent knew the definition of a teaching hospital and of those, 87% knew they were at a teaching hospital. Subgroup analysis between racial groups showed significantly reduced knowledge of the definitions of triage and teaching hospitals and significantly increased desire for information on ED function in minority groups (p<0.05). CONCLUSION: The major findings in this study were that many visitors would like handouts about ED function and medical emergencies over other topics. Additionally, the knowledge of functions such as triage and teaching hospitals were 70% and 69%, respectively. This was reduced in non-Caucasian ethnicities, while there was an increased desire for information on ED function relative to Caucasians. This research suggests increasing updates and educational materials in the waiting room could impact the waiting room and overall hospital experience.

Recurrent priapism from therapeutic quetiapine.

Priapism is rarely related to use of non-erectile related medications. The objective was to educate about the multiple possible causes of priapism and to provide treatment recommendations for the different types of priapism. We present the case of a 43-year-old African American male with a history of schizoaffective disorder who presented to our emergency department multiple times over a three year period with priapism, each episode related to the ingestion of quetiapine. Following penile aspiration and intercavernosal injection of phenylephrine, this patient had resolution of his priapism. This case demonstrates an unusual case of recurrent priapism.

Impact of a teaching service on emergency department throughput.

INTRODUCTION: There are 161 emergency medicine residency programs in the United States, many of which have medical students rotating through the emergency department (ED). Medical students are typically supervised by senior residents or attendings while working a regular shift. Many believe that having students see and present patients prolongs length of stay (LOS), as care can be delayed. Our institution implemented a unique method of educating medical students while in the ED with the creation of a teaching service, whose primary goal is education in the setting of clinical care. The objective of this study was to explore the effect of the teaching service on efficiency by describing LOS and number of patients seen on shifts with and without a teaching service. METHODS: This was a retrospective chart review performed over a 12-month period of visits to an urban academic ED. We collected data on all patients placed in a room between 14:00 and 19:59, as these were the hours that the teaching shift worked in the department. We categorized shifts as 1) a teaching service with students (TWS); 2) a teaching service without students (TWOS); and 3) no teaching service (NTS). LOS and median number of patients seen on days with a teaching service, both with and without students (TWS and TWOS), was compared to LOS on days without a teaching service (NTS). RESULTS: The median LOS on shifts with a dedicated teaching service without students (TWOS) was 206 minutes, while the median LOS on shifts with a teaching service with students (TWS) was 220 minutes. In comparison, the median LOS on shifts when no teaching service was present (NTS) was 202.5 minutes. The median number of patients seen on shifts with the teaching service with students (TWS) was 44, identical to the number seen on shifts when the teaching service was present without students (TWOS). When the teaching service was absent (NTS), the median number of patients seen was 40. CONCLUSION: A teaching service in the ED is a novel educational model for medical student and resident instruction that increases total ED patient throughput and has only a modest effect on increased median length of stay for patients.

Comparing diagnostic performance and the utility of clinical vignette-based assessment under testing conditions designed to encourage either automatic or analytic thought.

PURPOSE: Although decades of research have yielded considerable insight into physicians' clinical reasoning processes, assessing these processes remains challenging; thus, the authors sought to compare diagnostic performance and the utility of clinical vignette-based assessment under testing conditions designed to encourage either automatic or analytic thought. METHOD: This 2011-2012 multicenter randomized study of 393 clinicians (medical students, postgraduate trainees, and faculty) measured diagnostic accuracy on clinical vignettes under two conditions: one encouraged participants to give their first impression (FI), and the other led participants through a directed search (DS) for the correct diagnosis. The authors compared accuracy, feasibility, reliability, and relation to United States Medical Licensing Exam (USMLE) scores under each condition. RESULTS: A 2 (instructional condition) × 2 (vignette complexity) × 3 (experience level) analysis of variance revealed no difference in accuracy as a function of instructional condition (F[1,379] = 2.44, P = .12), but demonstrated the expected main effects of vignette complexity (F[1,379] = 965.2, P < .001) and experience (F[2,379] = 39.6, P < .001). Pearson correlations revealed greater associations between assessment scores and USMLE performance in the FI condition than in the DS condition (P < .001). Spearman-Brown calculations consistently indicated that alpha ≥ 0.75 could be achieved more efficiently under the FI condition relative to the DS condition. CONCLUSIONS: Instructions to trust one's first impres-sions result in similar performance when compared with instructions to consider clinical information in a systematic fashion, but have greater utility when used for the purposes of assessment.