Relationship Between Institutional Standardized Letter of Evaluation Global Assessment Ranking Practices, Interviewing Practices, and Medical Student Outcomes.

BACKGROUND: Emergency medicine (EM) program directors rely largely on the standardized letter of evaluation (SLOE) to help determine which applicants to interview in the face of an increasing number of applications. To further characterize the SLOE's role in the EM application process, particularly the global assessment (GA) ranking and its effect on interviewing practices and medical student outcomes, the leaders of EM programs were surveyed regarding their experiences in both generating and utilizing the SLOE. METHODS: Individuals on the Council of Emergency Medicine Residency Directors (CORD) and Clerkship Directors in Emergency Medicine (CDEM) Academy listservs were anonymously surveyed from March 21-30, 2015, with 18 questions in multiple-choice and fill-in-the-blank formats. RESULTS: There were 99 respondents. Only 39 respondents (39%) reported adhering strictly to SLOE guidelines by evenly placing their students into thirds (top, middle, lower) on the SLOE GA. Most respondents interviewed individuals ranked in the lower third. Programs adhering strictly to ranking guidelines were more likely to interview students in the lower third than those adhering loosely or not at all. There was no relationship between a program's self-reported adherence to the SLOE ranking guidelines and the number of unmatched students in EM during the 2014 and 2015 academic years. CONCLUSION: Many SLOE writers do not strictly adhere to CORD's SLOE writing guidelines when using the GA ranking, due to the fear of adversely impacting an applicant's ability to successfully match into EM. This calls into question the validity of the SLOE as it is currently used. However, this study suggests that adhering to recommended SLOE ranking guidelines is unlikely to substantially increase the risk that students will fail to match. If more evaluators were to adhere to the guidelines, the SLOE could become the valid evaluation instrument that graduate medical education has long been pursuing.

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.

Emergency medicine clerkship curriculum: an update and revision.

In 2006, the latest version of a national curriculum for the fourth-year emergency medicine (EM) clerkship was published. Over the past several years, that curriculum has been implemented across multiple clerkships. The previous curriculum was found to be too long and detailed to cover in 4 weeks. As well, updates to the Liaison Committee on Medical Education (LCME)'s form and function document, which guides the structure of a clerkship, have occurred. Combining experience, updated guidelines, and the collective wisdom of members of the national organization of the Clerkship Directors in Emergency Medicine (CDEM), an update and revision of the fourth-year EM clerkship educational syllabi has been developed.

An emergency department-based vaccination program: overcoming the barriers for adults at high risk for vaccine-preventable diseases.

BACKGROUND: More than 10% of the population visit emergency departments (ED) every year. Many of these patients are not up-to-date on routine vaccinations that could prevent future illnesses. The ED could significantly impact these vaccination trends. OBJECTIVES: This study was a feasibility study to determine whether patients would be amenable to an ED-based program that provided appropriate immunizations when they were at high risk for these diseases. In addition, the authors sought to identify barriers that predict high-risk patients who did not receive immunizations before ED presentation and to identify barriers that predict those high-risk unvaccinated patients who are unwilling to receive vaccinations when offered in the ED. METHODS: This study was a prospective cross-sectional study of all patients arriving in the ED at one inner-city trauma center between 10 am and 10 pm over the course of a three-week intervention period. The subjects completed a survey that included information about their risk of influenza (flu) and pneumococcal disease, their immunization history, and their perceptions of their need for immunization. Demographic information collected included insurance status, age, gender, and primary language. All high-risk patients who were not current with their immunizations were offered vaccination. The primary outcome was improvement in vaccination coverage based on an ED surveillance and treatment system for vaccinations. The secondary outcomes were barriers to successful vaccination before ED presentation and barriers to acceptance of vaccination in the ED. Results were compared using chi-square test and confidence interval analysis. Characteristics of barriers to immunization were determined using a logistic regression model. A p-value < 0.05 was considered significant. RESULTS: A total of 674 subjects were entered into the study. Vaccination of subjects at high risk for flu increased significantly from 16% before to 83% after ED evaluation and treatment, and vaccination of subjects at high risk for pneumococcal disease increased significantly from 18% before to 84% after ED evaluation and treatment. Significant barriers to vaccination before ED presentation were lack of insurance (odds ratio [OR] = 0.31 for flu, 0.22 for pneumococcal disease), age younger than 50 years (OR = 0.18 for flu, 0.24 for pneumococcal disease), and no perceived need for vaccination (OR = 0.07 for flu). The sole significant barrier to vaccine administration in the ED was perceived need for vaccination (OR = 0.32 for flu). CONCLUSIONS: An ED-based vaccination program is both feasible and successful. Other than a shortage of vaccine, the only ED barrier to vaccination (perceived need) might be overcome with patient education.