The National Clinical Assessment Tool for Medical Students in the Emergency Department (NCAT-EM).

INTRODUCTION: Clinical assessment of medical students in emergency medicine (EM) clerkships is a highly variable process that presents unique challenges and opportunities. Currently, clerkship directors use institution-specific tools with unproven validity and reliability that may or may not address competencies valued most highly in the EM setting. Standardization of assessment practices and development of a common, valid, specialty-specific tool would benefit EM educators and students. METHODS: A two-day national consensus conference was held in March 2016 in the Clerkship Directors in Emergency Medicine (CDEM) track at the Council of Residency Directors in Emergency Medicine (CORD) Academic Assembly in Nashville, TN. The goal of this conference was to standardize assessment practices and to create a national clinical assessment tool for use in EM clerkships across the country. Conference leaders synthesized the literature, articulated major themes and questions pertinent to clinical assessment of students in EM, clarified the issues, and outlined the consensus-building process prior to consensus-building activities. RESULTS: The first day of the conference was dedicated to developing consensus on these key themes in clinical assessment. The second day of the conference was dedicated to discussing and voting on proposed domains to be included in the national clinical assessment tool. A modified Delphi process was initiated after the conference to reconcile questions and items that did not reach an a priori level of consensus. CONCLUSION: The final tool, the National Clinical Assessment Tool for Medical Students in Emergency Medicine (NCAT-EM) is presented here.

Pain treatment and relief among patients with primary headache subtypes in the ED.

OBJECTIVE: The aim of this study is to determine if emergency physicians treat headache subtypes differently and if this difference affects pain relief. METHODS: This was a prospective observational, institutional review board-approved study of adults undergoing treatment for a primary headache. Before the treatment and 60 minutes after, patients completed a 100-mm Visual Analog Scale (VAS) describing their pain. Patients also completed a headache diagnosis worksheet that differentiated headache type based on International Headache Society criteria. Treatments were recorded. Data were analyzed using descriptive statistics, 95% confidence intervals, analysis of variance, and chi(2) tests as appropriate. RESULTS: A total of 184 patients were enrolled: 83 (45.1%) with migraine, 61 (33.2%) with migrainous, and 40 (21.7%) with tension-type headaches. There was no difference in the presenting VAS score or treatments of the 3 headache subtypes. The migraine group was most likely to receive any pain medication (78.31%), and the tension group the least likely to receive any pain medication (62.50%). A 50% decrease in VAS was achieved by only 32.5% of the patients. Sumatriptan, followed by droperidol, provided the greatest decrease in VAS scores. Oral and parenteral narcotics provided equivalent pain relief, with nonsteroidal anti-inflammatory drugs (NSAIDs) providing the least pain relief. CONCLUSION: There was no difference in the treatments used or pain relief achieved between migraine, migrainous, and tension-type headaches. The differentiation of primary headache subtypes does not appear to be important to their treatment in the acute setting of the emergency department.

Patient and physician perceptions as risk factors for oligoanalgesia: a prospective observational study of the relief of pain in the emergency department.

OBJECTIVES: Previous studies have reported that pain is undertreated in the emergency department (ED), but few physician-dependent risk factors have been identified. In this study, the authors determine whether pain treatment and relief in ED patients are negatively associated with the physician's perception of whether the patient was exaggerating symptoms, and with the patient and physician's perceptions of the interaction between them, as well as whether demographic characteristics were associated with these perceptions. METHODS: This was a prospective observational study of patients who were undergoing treatment for painful disorders in the ED. Before treatment for pain, patients were asked to complete a 100-mm visual analog scale (VAS) describing their pain. Demographic information and pain treatments administered were recorded. Patients completed a second pain VAS before discharge from the ED. Patients were then asked to complete three queries describing their perception of their interaction with the physician. After the patient had left the department, the patient's physician was asked to complete a query describing his or her perception of the interaction and to complete a VAS describing how likely it was that the patient was exaggerating symptoms to obtain pain medicines for nonmedical purposes. RESULTS: There were 1,695 patients enrolled in the study; 32 patients were excluded because of missing or incomplete data, leaving 1,663 for analysis. Of these patients, 71.9% received a pain medication while in the ED. There was no association between the physician's VAS for perceived exaggeration of symptoms, the queries describing physician-patient interactions, and patient ethnicity and whether patients received pain treatment in the ED. There was a negative correlation between the physician's VAS for perceived exaggeration of symptoms and the change in the patient's pre- and posttreatment pain VAS scores. The physician's VAS score for perceived exaggeration of symptoms was higher among Native American patients than among other ethnic groups (p < or = 0.001). The patient and physician queries rating their interaction show a decreased absolute reduction of VAS pain scores (p > or = 0.001) and a reduction in the number of patients having at least a 50% reduction in their pain VAS score when interactions were rated "bad" and "very bad" (p < or = 0.001). CONCLUSIONS: The physician's perception of whether a patient was exaggerating symptoms was associated with the patient's ethnic background and with both the physician's and patient's perception of their interaction. These perceptions were negatively associated with the achievement of pain relief and the change in the patient's pain VAS scores, but not with whether a patient was treated with a pain medication.