Foundations of Emergency Medicine: Impact of a Standardized, Open-access, Core Content Curriculum on In-Training Exam Scores.

Introduction: Learners frequently benefit from modalities such as small-group, case-based teaching and interactive didactic experiences rather than passive learning methods. These contemporary techniques are features of Foundations of Emergency Medicine (FoEM) curricula, and particularly the Foundations I (F1) course, which targets first-year resident (PGY-1) learners. The American Board of Emergency Medicine administers the in-training exam (ITE) that provides an annual assessment of EM-specific medical knowledge. We sought to assess the effect of F1 implementation on ITE scores. Methods: We retrospectively analyzed data from interns at four EM residency programs accredited by the Accreditation Council for Graduate Medical Education. We collected data in 2021. Participating sites were geographically diverse and included three- and four-year training formats. We collected data from interns two years before (control group) and two years after (intervention group) implementation of F1 at each site. Year of F1 implementation ranged from 2015-2018 at participating sites. We abstracted data using a standard form including program, ITE raw score, year of ITE administration, US Medical Licensing Exam Step 1 score, Step 2 Clinical Knowledge (CK) score, and gender. We performed univariable and multivariable linear regression to explore differences between intervention and control groups. Results: We collected data for 180 PGY-1s. Step 1 and Step 2 CK scores were significant predictors of ITE in univariable analyses (both with P < 0.001). After accounting for Step 1 and Step 2 CK scores, we did not find F1 implementation to be a significant predictor of ITE score, P = 0.83. Conclusion: Implementation of F1 curricula did not show significant changes in performance on the ITE after controlling for important variables.

Development, Implementation, and Evaluation of an Open Access, Level-Specific, Core Content Curriculum for Emergency Medicine Residents.

BACKGROUND: Leaders in graduate medical education must provide robust clinical and didactic experiences to prepare residents for independent practice. Programs traditionally create didactic experiences individually, requiring tremendous resources with variable content exposure and quality. OBJECTIVE: We sought to create and implement a free, open access, learner-centric, level-specific, emergency medicine (EM) residency curriculum. METHODS: We developed Foundations of Emergency Medicine (FoEM) Foundations I and II courses using Kern's model of curriculum development. Fundamental topics were identified through content guidelines from the American Board of Emergency Medicine. We incorporated learner-centric strategies into 2 flipped classroom, case-based courses targeting postgraduate year (PGY) 1 and PGY-2 residents. The curriculum was made freely available online in 2016. Faculty and resident users were surveyed annually for feedback, which informed iterative refinement of the curriculum. RESULTS: Between 2016 and 2020, registration for FoEM expanded from 2 sites with 36 learners to 154 sites and 4453 learners. In 2019, 98 of 102 (96%) site leaders and 1618 of 2996 (54%) learners completed the evaluative survey. One hundred percent of responding leaders and 93% of learners were "satisfied" or "very satisfied" with FoEM content. Faculty and residents valued FoEM's usability, large volume of content, quality, adaptability, organization, resident-faculty interaction, and resident-as-teacher opportunities. Challenges to implementation included resident attendance, conference structure, technology limitations, and faculty engagement. CONCLUSIONS: We developed and implemented a learner-centric, level-specific, national EM curriculum that has been widely adopted in the United States.

Radiology Education Among Emergency Medicine Residencies: A National Needs Assessment.

INTRODUCTION: Radiology training is an important component of emergency medicine (EM) education, but its delivery has been variable. Program directors have reported a lack of radiology skills in incoming interns. A needs assessment is a crucial first step toward improving radiology education among EM residencies. Our objective was to explore the current state of radiology education in EM residency programs. METHODS: This was a cross-sectional survey study of all Accreditation Council for Graduate Medical Education-accredited EM programs in the United States. Program leadership completed an online survey consisting of multiple choice, Likert scale, and free-response items. We calculated and reported descriptive statistics. RESULTS: Of eligible EM programs, 142/252 (56%) completed the survey including 105 postgraduate year (PGY) 1-3 and 36 PGY 1-4 programs. One respondent opted out of answering demographic questions. 23/141 (16%) were from the Western region, 29/141 (21%) were from the North Central region, 14/141 (10%) were from the South-Central region, 28/141 (20%) were from the Southeast region, and 47/141 (33%) were from the Northeast region. A total of 88/142 (62%) of responding programs did not have formal radiology instruction. Of the education that is provided, 127/142 (89%) provide it via didactics/lectures and 115/142 (81%) rely on instruction during clinical shifts. Only 51/142 (36%) provide asynchronous opportunities, and 23/142 (16%) have a dedicated radiology rotation. The majority of respondents reported spending 0-2 hours per month on radiology instruction (108/142; 76%); 95/141 (67%) reported that EM faculty "often" or "always" provide radiology instruction; 134/142 (95%), felt that it was "extremely" or "very important" for ED providers to be able to independently interpret radiograph results; and 129/142 (90.84%) either "sometimes" or "always" rely on their independent radiograph interpretations to make clinical decisions. The radiology studies identified as most important to be able to independently interpret were radiographs obtained for lines/tubes, chest radiographs, and radiographs obtained for musculoskeletal-related complaints. CONCLUSION: A minority of EM residency programs have formal instruction in radiology despite the majority of responding program leadership believing that these are important skills. The most important curricular areas were identified. These results may inform the development of formal radiology curricula in EM graduate medical education.

Emergency Medicine Residents With Higher Levels of Debt Are Less Likely to Choose Academic Jobs, but There Is a Difference by Gender.

OBJECTIVES: We sought to answer the following question: Does educational debt burden affect decisions by emergency medicine residents about whether to pursue academic versus community medicine jobs directly after residency? METHODS: In this observational study, graduating residents across eight emergency medicine residencies were surveyed concurrent with their in-training examinations over 2 years to assess levels of educational debt and demographic information. Job types chosen by residents upon graduation were obtained from their respective program directors. The impact of debt on type of job chosen was assessed through multivariate logistic regression with demographic controls and program fixed effects, with additional analysis of observed differences by gender. RESULTS: Information was collected on 159 residents from 14 graduating classes across eight programs representing six different states. Residents with higher levels of debt had lower odds of choosing an academic fellowship or faculty position upon graduation (odds ratio [OR] = 0.77, confidence interval [CI] = 0.60 to 0.98). On further analysis, higher debt predicted lower odds of choosing an academic position for men (OR = 0.59, CI = 0.41 to 0.82), but not for women (OR = 1.05, CI = 0.63 to 1.76). CONCLUSIONS: When male emergency medicine residents have higher levels of debt, they are significantly less likely to pursue an academic fellowship or faculty position after residency. This may not be the case for female residents. Results may reflect differences in the factors that affect men and women's decisions about jobs after residency, which merits further study.

An Emergency Medicine Virtual Clerkship: Made for COVID, Here to Stay.

INTRODUCTION: Safety concerns surrounding the coronavirus 2019 pandemic led to the prohibition of student rotations outside their home institutions. This resulted in emergency medicine (EM)-bound students having less specialty experience and exposure to outside programs and practice environments, and fewer opportunities to gain additional Standardized Letters of Evaluation, a cornerstone of the EM residency application. We filled this void by implementing a virtual clerkship. METHODS: We created a two-week virtual, fourth-year visiting clerkship focused on advanced medical knowledge topics, social determinants of health, professional development, and professional identity formation. Students completed asynchronous assignments and participated in small group-facilitated didactic sessions. We evaluated the virtual clerkship with pre- and post-medical knowledge tests and evaluative surveys. RESULTS: We hosted 26 senior medical students over two administrations of the same two-week virtual clerkship. Students had a statistically significant improvement on the medical knowledge post-tests compared to pre-tests (71.7% [21.5/30] to 76.3% [22.9/30]). Students reported being exposed to social determinants of health concepts they had not previously been exposed to. Students appreciated the interactive nature of the sessions; networking with other students, residents, and faculty; introduction to novel content regarding social determinants of health; and exposure to future career opportunities. Screen time, technological issues, and mismatch between volume of content and time allotted were identified as potential challenges and areas for improvement. CONCLUSION: We demonstrate that a virtual EM visiting clerkship is feasible to implement, supports knowledge acquisition, and is perceived as valuable by participants. The benefits seen and challenges faced in the development and implementation of our clerkship can serve to inform future virtual clerkships, which we feel is a complement to traditional visiting clerkships even though in-person clerkships have been re-established.

The Implementation of a National Multifaceted Emergency Medicine Resident Wellness Curriculum Is Not Associated With Changes in Burnout.

BACKGROUND: The Accreditation Council for Graduate Medical Education Common Program Requirements effective 2017 state that programs and sponsoring institutions have the same responsibility to address well-being as they do other aspects of resident competence. OBJECTIVES: The authors sought to determine if the implementation of a multifaceted wellness curriculum improved resident burnout as measured by the Maslach Burnout Inventory (MBI). METHODS: We performed a multicenter educational interventional trial at 10 emergency medicine (EM) residencies. In February 2017, we administered the MBI at all sites. A year-long wellness curriculum was then introduced at five intervention sites while five control sites agreed not to introduce new wellness initiatives during the study period. The MBI was readministered in August 2017 and February 2018. RESULTS: Of 523 potential respondents, 437 (83.5%) completed at least one MBI assessment. When burnout was assessed as a continuous variable, there was a statistically significant difference in the depersonalization component favoring the control sites at the baseline and final survey administrations. There was also a higher mean personal accomplishment score at the control sites at the second survey administration. However, when assessed as a dichotomous variable, there were no differences in global burnout between the groups at any survey administration and burnout scores did not change over time for either control or intervention sites. CONCLUSIONS: In this national study of EM residents, MBI scores remained stable over time and the introduction of a multifaceted wellness curriculum was not associated with changes in global burnout scores.

A Virtual Book Club for Professional Development in Emergency Medicine.

INTRODUCTION: Professional development is an important component of graduate medical education, but it is unclear how to best deliver this instruction. Book clubs have been used outside of medicine as a professional development tool. We sought to create and evaluate a virtual professional development book club for emergency medicine interns. METHODS: We designed and implemented a virtual professional development book club during intern orientation. Afterward, participants completed an evaluative survey consisting of Likert and free-response items. Descriptive statistics were reported. We analyzed free-response data using a thematic approach. RESULTS: Of 15 interns who participated in the book club, 12 (80%) completed the evaluative survey. Most (10/12; 83.3%) agreed or strongly agreed that the book club showed them the importance of professional development as a component of residency training and helped them reflect on their own professional (11/12; 91.7%) and personal development (11/12; 91.7%). Participants felt the book club contributed to bonding with their peers (9/12; 75%) and engagement with the residency program (9/12; 75%). Our qualitative analysis revealed five major themes regarding how the book club contributed to professional and personal development: alignment with developmental stage; deliberate practice; self-reflection; strategies to address challenges; and communication skills. CONCLUSION: A virtual book club was feasible to implement. Participants identified multiple ways the book club positively contributed to their professional development. These results may inform the development of other book clubs in graduate medical education.

Late Pregnancy and Postpartum Emergencies.

The period just after delivery is a high-risk period for women with associated morbidity and even mortality. There are large variations in complication rates across various groups in the United States. This article covers complications commonly encountered in the emergency department in late pregnancy and the early postpartum period. It specifically addresses postpartum depression, peripartum cardiomyopathy, and the late pregnant or postpartum patient presenting with headache or neurologic complaints. Emergency physicians should be well versed in common and life-threatening postpartum pathologies.

Postdelivery Emergencies.

This article covers a high-risk time in a woman's life, the period just after delivery of her baby. There are large variations in complication rates across various groups in the United States. Many women seek care in the emergency department for routine and more serious postpartum pathologies. Emergency physicians should be well versed in common and life-threatening complications of delivery. The specific pathologies discussed in this article include lactation in the emergency department, postpartum hemorrhage, amniotic fluid embolism, endometritis, and mastitis.

Injuries Associated With Standing Electric Scooter Use.

Importance: Since September 2017, standing electric scooters have proliferated rapidly as an inexpensive, easy mode of transportation. Although there are regulations for safe riding established by both electric scooter companies and local governments, public common use practices and the incidence and types of injuries associated with these standing electric scooters are unknown. Objective: To characterize injuries associated with standing electric scooter use, the clinical outcomes of injured patients, and common use practices in the first US metropolitan area to experience adoption of this technology. Design, Setting, and Participants: This study of a case series used retrospective cohort medical record review of all patients presenting with injuries associated with standing electric scooter use between September 1, 2017, and August 31, 2018, at 2 urban emergency departments associated with an academic medical center in Southern California. All electric scooter riders at selected public intersections in the community surrounding the 2 hospitals were also observed during a 7-hour observation period in September 2018. Main Outcomes and Measures: Incidence and characteristics of injuries and observation of riders' common use practices. Results: Two hundred forty-nine patients (145 [58.2%] male; mean [SD] age, 33.7 [15.3] years) presented to the emergency department with injuries associated with standing electric scooter use during the study period. Two hundred twenty-eight (91.6%) were injured as riders and 21 (8.4%) as nonriders. Twenty-seven patients were younger than 18 years (10.8%). Ten riders (4.4%) were documented as having worn a helmet, and 12 patients (4.8%) had either a blood alcohol level greater than 0.05% or were perceived to be intoxicated by a physician. Frequent injuries included fractures (79 [31.7%]), head injury (100 [40.2%]), and contusions, sprains, and lacerations without fracture or head injury (69 [27.7%]). The majority of patients (234 [94.0%]) were discharged home from the emergency department; of the 15 admitted patients, 2 had severe injuries and were admitted to the intensive care unit. Among 193 observed electric scooter riders in the local community in September 2018, 182 (94.3%) were not wearing a helmet. Conclusions and Relevance: Injuries associated with standing electric scooter use are a new phenomenon and vary in severity. In this study, helmet use was low and a significant subset of injuries occurred in patients younger than 18 years, the minimum age permitted by private scooter company regulations. These findings may inform public policy regarding standing electric scooter use.

Academic Life in Emergency Medicine Blog and Podcast Watch: Toxicologic Emergencies.

The Academic Life in Emergency Medicine (ALiEM) Approved Instructional Resources (AIR) Series was created in 2014 to address a lack of both curation of online educational content and a nationally available curriculum that meets individualized interactive instruction. Using an expert-based, crowdsourced approach, the AIR series identifies trustworthy, high-quality, educational blog and podcast content. Here, we summarize the content rated as high quality per our a priori criteria as evaluated by eight attending physicians.

A Novel Tool for Assessment of Emergency Medicine Resident Skill in Determining Diagnosis and Management for Emergent Electrocardiograms: A Multicenter Study.

BACKGROUND: Reading emergent electrocardiograms (ECGs) is one of the emergency physician's most crucial tasks, yet no well-validated tool exists to measure resident competence in this skill. OBJECTIVES: To assess validity of a novel tool measuring emergency medicine resident competency for interpreting, and responding to, critical ECGs. In addition, we aim to observe trends in this skill for resident physicians at different levels of training. METHODS: This is a multi-center, prospective study of postgraduate year (PGY) 1-4 residents at five emergency medicine (EM) residency programs in the United States. An assessment tool was created that asks the physician to identify either the ECG diagnosis or the best immediate management. RESULTS: One hundred thirteen EM residents from five EM residency programs submitted completed assessment surveys, including 43 PGY-1s, 33 PGY-2s, and 37 PGY-3/4s. PGY-3/4s averaged 74.6% correct (95% confidence interval [CI] 70.9-78.4) and performed significantly better than PGY-1s, who averaged 63.2% correct (95% CI 58.0-68.3). PGY-2s averaged 69.0% (95% CI 62.2-73.7). Year-to-year differences were more pronounced in management than in diagnosis. CONCLUSIONS: Residency training in EM seems to be associated with improved ability to interpret "critical" ECGs as measured by our assessment tool. This lends validity evidence for the tool by correlating with a previously observed association between residency training and improved ECG interpretation. Resident skill in ECG interpretation remains less than ideal. Creation of this sort of tool may allow programs to assess resident performance as well as evaluate interventions designed to improve competency.

Faculty Prediction of In-Training Examination Scores of Emergency Medicine Residents: A Multicenter Study.

BACKGROUND: The Emergency Medicine In-Training Examination (EMITE) is one of the few validated instruments for medical knowledge assessment of emergency medicine (EM) residents. The EMITE is administered only once annually, with results available just 2 months before the end of the academic year. An earlier predictor of EMITE scores would be helpful for educators to institute timely remediation plans. A previous single-site study found that only 69% of faculty predictions of EMITE scores were accurate. OBJECTIVE: The goal of this article was to measure the accuracy with which EM faculty at five residency programs could predict EMITE scores for resident physicians. METHODS: We asked EM faculty at five different residency programs to predict the 2014 EMITE scores for all their respective resident physicians. The primary outcome was prediction accuracy, defined as the proportion of predictions within 6% of the actual scores. The secondary outcome was prediction precision, defined as the mean deviation of predictions from the actual scores. We assessed faculty background variables for correlation with the two outcomes. RESULTS: One hundred and eleven faculty participated in the study (response rate 68.9%). Mean prediction accuracy for all faculty was 60.0%. Mean prediction precision was 6.3%. Participants were slightly more accurate at predicting scores of noninterns compared to interns. No faculty background variable correlated with the primary or secondary outcomes. Eight participants predicted scores with high accuracy (>80%). CONCLUSIONS: In this multicenter study, EM faculty possessed only moderate accuracy at predicting resident EMITE scores. A very small subset of faculty members is highly accurate.

Altered mental status in a young, healthy female.

A young previously healthy patient presented with fever and altered mental status. Her evaluation would eventually reveal a profound hyponatremia in the setting of a viral meningoencephalitis. This case report reviews the evaluation of hyponatremia and treatment options for syndrome of inappropriate antidiuretic hormone hypersecretion, her ultimate diagnosis.