Effect of Interpolated Questions on Podcast Knowledge Acquisition and Retention: A Double-Blind, Multicenter, Randomized Controlled Trial.

STUDY OBJECTIVE: We determine whether interpolated questions in a podcast improve knowledge acquisition and retention. METHODS: This double-blinded controlled trial randomized trainees from 6 emergency medicine programs to listen to 1 of 2 versions of a podcast, produced de novo on the history of hypertension. The versions were identical except that 1 included 5 interpolated questions to highlight educational points (intervention). There were 2 postpodcast assessments, 1 within 48 hours of listening (immediate posttest) and a second 2 to 3 weeks later (retention test), consisting of the same 15 multiple-choice questions, 5 directly related to the interpolated questions and 10 unrelated. The primary outcome was the difference in intergroup mean assessment scores at each point. A sample size was calculated a priori to identify a significant interarm difference. RESULTS: One hundred thirty-seven emergency medicine trainees were randomized to listen to a podcast, 69 without interpolated questions (control) and 68 with them (intervention). Although no significant difference was detected at the immediate posttest, trainees randomized to the interpolated arm had a significantly higher mean score on the retention test, with a 5.6% absolute difference (95% confidence interval 0.2% to 10.9%). For the material covered by the interpolated questions, the intervention arm had significantly higher mean scores on both the immediate posttest and retention tests, with absolute differences of 8.7% (95% confidence interval 1.6% to 15.8%) and 10.1% (95% confidence interval 2.8% to 17.4%), respectively. There was no significant intergroup difference for noninterpolated questions. CONCLUSION: Podcasts containing interpolated questions improved knowledge retention at 2 to 3 weeks, driven by the retention of material covered by the interpolated questions. Although the gains may be modest, educational podcasters may improve knowledge retention by using interpolating questions.

Epidemiologic Risk Factors for In Situ and Invasive Breast Cancers Among Postmenopausal Women in the National Institutes of Health-AARP Diet and Health Study.

Comparing risk factor associations between invasive breast cancers and possible precursors may further our understanding of factors related to initiation versus progression. Accordingly, among 190,325 postmenopausal participants in the National Institutes of Health-AARP Diet and Health Study (1995-2011), we compared the association between risk factors and incident ductal carcinoma in situ (DCIS; n = 1,453) with that of risk factors and invasive ductal carcinomas (n = 7,525); in addition, we compared the association between risk factors and lobular carcinoma in situ (LCIS; n = 186) with that of risk factors and invasive lobular carcinomas (n = 1,191). Hazard ratios and 95% confidence intervals were estimated from multivariable Cox proportional hazards regression models. We used case-only multivariable logistic regression to test for heterogeneity in associations. Younger age at menopause was associated with a higher risk of DCIS but lower risks of LCIS and invasive ductal carcinomas (P for heterogeneity < 0.01). Prior breast biopsy was more strongly associated with the risk of LCIS than the risk of DCIS (P for heterogeneity = 0.04). Increased risks associated with use of menopausal hormone therapy were stronger for LCIS than DCIS (P for heterogeneity = 0.03) and invasive lobular carcinomas (P for heterogeneity < 0.01). Associations were similar for race, age at menarche, age at first birth, family history, alcohol consumption, and smoking status, which suggests that most risk factor associations are similar for in situ and invasive cancers and may influence early stages of tumorigenesis. The differential associations observed for various factors may provide important clues for understanding the etiology of certain breast cancers.

Psychological safety and perceived organizational support in emergency medicine residencies.

Background: The clinical learning environment (CLE) is a key focus of the Accreditation Council of Graduate Medical Education. It impacts knowledge acquisition and professional development. A previous single-center study evaluated the psychological safety and perceived organizational support of the CLE across different specialties. Building on this work, we explored and evaluated psychological safety and perceived organizational support across multiple heterogeneous emergency medicine (EM) residencies to identify trends and factors affecting perceptions of the CLE. Methods: Using the Psychological Safety Scale (PSS) and Survey of Perceived Organizational Support (SPOS), residents from seven U.S. EM residencies were surveyed using REDCap software from September through November 2021, with 300 potential respondents. As an adjunct to these surveys, three open-ended questions were included regarding features of their learning environments. Results: A total of 137 out of 300 residents completed the survey. The overall response rate was 45.7%. There was a variable response rate across programs (26.0%-96.7%). Pooled results demonstrate an overall positive perception of CLEs, based on positive mean responses (i.e., "Members of my department are able to bring up problems and tough issue" had a mean of 4.2 on a 5-point Likert scale). Open responses identified teaching, collegiality, and support from program leadership as supportive features of the CLE. Confrontational interdisciplinary communication, a sense of being devalued, and off-service rotations were identified as threats or areas for improvement to the CLE. Conclusions: PSS and SPOS scores were generally positive in this multi-institution study, consistent with the prior single-institution study indicating that EM is often considered psychologically safe and supportive. EM training programs can consider using the PSS/SPOS to audit their own programs to identify areas for improvement and foster supportive features already in place.

A Collaborative Approach to Mentored Peer Reviews Sponsored by the Council of Residency Directors in Emergency Medicine.

Introduction: Historically, there have been no systematic programs for teaching peer review, leaving trainees to learn by trial and error. Recently, a number of publications have advocated for programs where experienced reviewers mentor trainees to more efficiently acquire this knowledge. Objective: Our goal was to develop an introductory learning experience that intentionally fosters peer-review skills. Methods: The Council of Residency Directors in Emergency Medicine (CORD) offered education fellowship directors the opportunity to mentor their fellows by reviewing submitted manuscript(s) supplemented by educational material provided by their journal. Reviews were collaboratively created. The decision letter that was sent to manuscript authors was also sent to the mentees; it included all reviewers' and editor's comments, as feedback. In 2022, fellows received a post-experience survey regarding prior experiences and their perspectives of the mentored peer-review experience. Results: From 2020-2022, participation grew from 14 to 30 education fellowships, providing 76 manuscript peer reviews. The 2022 survey-response rate of 87% (20/23) revealed that fellows were inexperienced in education scholarship prior to participation: 30% had authored an education paper, and 10% had performed peer review of an education manuscript. Overall, participants were enthusiastic about the program and anxious to participate the following year. In addition, participants identified a number of benefits of the mentored experience including improved understanding of the scholarship process; informing fellows' scholarly pursuits; improved conceptualization of concepts learned elsewhere in training; and learning through exposure to scholarship. Conclusion: This program's early findings suggest that collaboration between academic societies and interested graduate medical education faculty has the potential to formalize the process of learning peer review, benefitting all involved stakeholders.

Development and Validation of a Scoring Rubric for Editorial Evaluation of Peer-review Quality: A Pilot Study.

Introduction: Despite the importance of peer review to publications, there is no generally accepted approach for editorial evaluation of a peer review's value to a journal editor's decision-making. The graduate medical education editors of the Western Journal of Emergency Medicine Special Issue in Educational Research & Practice (Special Issue) developed and studied the holistic editor's scoring rubric (HESR) with the objective of assessing the quality of a review and an emphasis on the degree to which it informs a holistic appreciation for the submission under consideration. Methods: Using peer-review guidelines from several journals, the Special Issue's editors formulated the rubric as descriptions of peer reviews of varying degree of quality from the ideal to the unacceptable. Once a review was assessed by each editor using the rubric, the score was submitted to a third party for blinding purposes. We compared the performance of the new rubric to a previously used semantic differential scale instrument. Kane's validity framework guided the evaluation of the new scoring rubric around three basic assumptions: improved distribution of scores; relative consistency rather than absolute inter-rater reliability across editors; and statistical evidence that editors valued peer reviews that contributed most to their decision-making. Results: Ninety peer reviews were the subject of this study, all were assessed by two editors. Compared to the highly skewed distribution of the prior rating scale, the distribution of the new scoring rubric was bell shaped and demonstrated full use of the rubric scale. Absolute agreement between editors was low to moderate, while relative consistency between editor's rubric ratings was high. Finally, we showed that recommendations of higher rated peer reviews were more likely to concur with the editor's formal decision. Conclusion: Early evidence regarding the HESR supports the use of this instrument in determining the quality of peer reviews as well as its relative importance in informing editorial decision-making.

The Impact of a Medical Education Research Faculty Development Program on Career Development, Through the Lens of Social Cognitive Career Theory.

OBJECTIVES: The Medical Education Research Certificate at the Council of Residency Directors in Emergency Medicine (MERC at CORD), a specialized adaptation of the Association of American Medical Colleges MERC program, provides faculty development in education research in emergency medicine. However, its long-term influence on career development remains unknown. Our study explored the impact of MERC at CORD on career development through the lens of social cognitive career (SCC) theory. METHODS: This was a prospective qualitative study using a constructivist/interpretivist paradigm to assess long-term career development outcomes. A purposeful randomized stratified sampling strategy of MERC at CORD graduates (2011-2014) ensured diversity of representation (sex, region, number of research publications, and project group leadership). Subjects were invited by e-mail to participate in semistructured phone interviews. Thematic analysis by two independent reviewers followed an iterative process until saturation was reached. RESULTS: Twelve graduates were interviewed. All engaged with MERC at CORD early in their careers with minimal previous education research experience. Currently, all hold medical education leadership positions. Graduates had a mean of 19.3 publications (range = 9-43). Themes explaining reasons for participating in MERC at CORD include: desire for education research skills, recommendation of mentors/colleagues, and accessibility. Themes citing the program's value to career development include networking/collaboration, mentorship, informational framework to build upon, and the application of theoretical knowledge through experiential learning. MERC at CORD impacted career development aligning with the core domains of SCC theory including self-efficacy, outcome expectations, and goals. CONCLUSION: MERC at CORD enhanced the long-term career development of participants by providing a core knowledge framework in a mentored, experiential learning environment. Participants identified themes aligned with SCC theory as influential in their long-term career advancement in medical education including the development of education research skills, successful completion of education research, career acceleration, promotion, niche development, and formulation of professional goals.

Freiberg's disease in the Emergency Department.

Freiberg's disease is an avascular necrosis affecting the second, third, or, rarely, the fourth metatarsal head. It is typically a chronic, progressive process, eventually causing pain and loss of normal function of the metatarsophalangeal joint. Normally, patients present to the Emergency Department with atraumatic foot pain, however, as we illustrate with this case, an acute fracture may occur, requiring recognition and appropriate treatment. Our patient presented with acute pain, swelling, and point tenderness of the forefoot after a minor fall. Radiographs revealed a fracture through the head of the second metatarsal and underlying avascular necrosis consistent with Freiberg's disease. Identifying the underlying chronic process was important in understanding how minor trauma resulted in a fracture in this patient.

A Social Network Analysis of the Western Journal of Emergency Medicine Special Issue in Educational Research and Practice.

INTRODUCTION: Scholarship and academic networking are essential for promotion and productivity. To develop education scholarship, the Council of Emergency Medicine Directors (CORD) and Clerkship Directors of Emergency Medicine (CDEM) created an annual Special Issue in Educational Research and Practice of the Western Journal of Emergency Medicine. The objective of this study was to evaluate the network created by the special Issue, and explore changes within the network over time. METHODS: Researchers used bibliometric data from Web of Science to create a social network analysis of institutions publishing in the first four years of the special issue using UCINET software. We analyzed whole-network and node-level metrics to describe variations and changes within the network. RESULTS: One hundred and three (56%) Accreditation Council for Graduate Medical Education-accredited emergency medicine programs were involved in 136 articles. The majority of institutions published in one or two issues. Nearly 25% published in three or four issues. The network analysis demonstrated that the mean number of connections per institution increased over the four years (mean of 5.34; standard deviation [SD] 1.27). Mean degree centralization was low at 0.28 (SD 0.05). Network density was low (mean of 0.09; SD 0.01) with little change across four issues. Five institutions scored consistently high in betweenness centrality, demonstrating a role as connectors between institutions within the network and the potential to connect new members to the network. CONCLUSION: Network-wide metrics describe a consistently low-density network with decreasing degree centralization over four years. A small number of institutions within the network were persistently key players in the network. These data indicate that, aside from core institutions that publish together, the network is not widely connected. There is evidence that new institutions are coming into the network, but they are not necessarily connected to the core publishing groups. There may be opportunities to intentionally increase connections across the network and create new connections between traditionally high-performing institutions and newer members of the network. Through informal discussions with authors from high-performing institutions, there are specific behaviors that departments may use to promote education scholarship and forge these new connections.

The Emergency Medicine Group Standardized Letter of Evaluation as a Workplace-based Assessment: The Validity Is in the Detail.

INTRODUCTION: Interest is growing in specialty-specific assessments of student candidates based on clinical clerkship performance to assist in the selection process for postgraduate training. The most established and extensively used is the emergency medicine (EM) Standardized Letter of Evaluation (SLOE), serving as a substitute for the letter of recommendation. Typically developed by a program's leadership, the group SLOE strives to provide a unified institutional perspective on performance. The group SLOE lacks guidelines to direct its development raising questions regarding the assessments, processes, and standardization programs employ. This study surveys EM programs to gather validity evidence regarding the inputs and processes involved in developing group SLOEs. METHODS: A structured telephone interview was administered to assess the input data and processes employed by United States EM programs when generating group SLOEs. RESULTS: With 156/178 (87.6%) of Accreditation Council of Graduate Medical Education-approved programs responding, 146 (93.6%) reported developing group SLOEs. Issues identified in development include the following: (1) 84.9% (124/146) of programs limit the consensus process by not employing rigorous methodology; (2) several stakeholder groups (nurses, patients) do not participate in candidate assessment placing final decisions at risk for construct under-representation; and (3) clinical shift assessments don't reflect the task-specific expertise of each stakeholder group nor has the validity of each been assessed. CONCLUSION: Success of the group SLOE in its role as a summative workplace-based assessment is dependent upon valid input data and appropriate processes. This study of current program practices provides specific recommendations that would strengthen the validity arguments for the group SLOE.

Emergency Medicine Standardized Letter of Evaluation (SLOE): Findings From the New Electronic SLOE Format.

BACKGROUND: Emergency medicine (EM) uses a standardized template for residency application letters of recommendations. In 1997, the Standardized Letter of Recommendation was developed with categories for applicant comparison. Now named the Standardized Letter of Evaluation (SLOE), it is a universal requirement in the EM residency application process. In 2016, a website called "eSLOE" was launched for credentialed academic EM faculty to enter applicant data, which generates a SLOE. OBJECTIVE: This article outlines website creation for the eSLOE and its successful national implementation in the 2016-2017 EM residency application cycle. We analyzed current trends in applicant assessments from the eSLOE data and compared them to prior data. METHODS: Data from 2016-2017 were sorted and analyzed for each question on the eSLOE. An analysis of Global Assessment and Qualifications for EM rankings, clerkship grade, and comparison with prior SLOE data was performed. RESULTS: Analysis of 6715 eSLOEs for 3138 unique applicants revealed the following Global Assessment rankings: top 10%, top one-third, middle one-third, and lower one-third. There was less spread with the distribution for clerkship grade and Qualifications for EM. The 2011-2012 standard letter of recommendation global assessment data, with top 10%, top one-third, middle one-third, and lower one-third, also revealed top-clustered results with less spread compared with the ranking usage in 2016-2017. CONCLUSIONS: Results indicate an improved spread of all rank categories for Global Assessment, enhancing the eSLOE's applicant discrimination. There has been an overall improvement in rank designation when compared with previously published data.

Use of the "Step-back" Method for Education Research Consultation at the National Level: A Pilot Study.

BACKGROUND: There are a limited number of emergency medicine (EM) physicians with expertise in education research. The Harvard Macy "step-back" method is an emerging model utilized to gather group feedback. Despite its use in multiple educational settings, there are little published data demonstrating effectiveness. OBJECTIVES: Our objective was to create and evaluate a national faculty development session providing consultation in education research utilizing the step-back method. METHODS: This was a pilot study. EM experts in education research from across the country served as facilitators for a faculty development session held at the 2018 Council of Emergency Medicine Residency Directors Academic Assembly. Small groups consisting of two or three facilitators and one or two participants were formed and each participant underwent a step-back consultation for their education research study. Participants wrote their study question before and after the session. After the session, facilitators and participants completed an evaluative survey consisting of multiple-choice, Likert-type, and free-response items. Descriptive statistics were reported. Qualitative analysis using a thematic approach was performed on free-response data. Participant study questions were assessed by the PICO (population, intervention, comparison, outcome) and FINER (feasible, interesting, novel, ethical, relevant) criteria. Both scales were evaluated using a two-way random-consistency intraclass correlation. Before and after scores were evaluated with a paired t-test. RESULTS: Twenty-four facilitators and 13 participants completed the step-back session. Evaluations from 20 facilitators and nine participants were submitted and analyzed. Sixteen of 20 facilitators felt that the step-back method "greatly facilitated" their ability to share their education research expertise. All facilitators and participants recommended that the session be provided at a future academic assembly. Regarding suggestions for improvement, qualitative analysis revealed three major themes: praise for the session, desire for additional time, and a room set up more conducive to small group work. Seven of nine responding participants felt that the session was "very valuable" for improving the strength of their study methods. Qualitative analysis regarding change in study as a result of the step-back session yielded four major themes: refinement of study question, more specific outcomes and measurements, improvement in study design, and greater understanding of study limitations. Both FINER and PICO scale comparisons showed improvement pre- and postintervention (PICO 60% relative increase; FINER 16% relative increase). Neither achieved statistical significance (PICO t(5) = -1.835, p = 0.126; and FINER t(5) = -1.305, p = 0.249). CONCLUSION: A national-level education research consultation utilizing the step-back method was feasible to implement and highly valued by facilitators and participants. Potential positive outcomes include refinement of study question, more specific outcomes and measurements, improvement in study design, and greater understanding of limitations. These results may inform others who want to utilize this method.

Early Impact of the Western Journal of Emergency Medicine CDEM/CORD Special Issue in Educational Research & Practice.

INTRODUCTION: In 2015, with a stated goal of disseminating best teaching practices and developing a community of educational scholars, the Council of Emergency Medicine Directors (CORD) and the Clerkship Directors of Emergency Medicine (CDEM) created an annual Special Issue in Educational Research and Practice (Special Issue) in cooperation with the Western Journal of Emergency Medicine. The intention of this study was to analyze the impact of this effort to date. METHODS: Bibliometric data was gathered on all four special issues, 2015-2019, from the Web of Science and then verified with the eScholarship website. Authorship, academic affiliation, date published, article type, and format were tabulated for descriptive analysis. Using metrics from Google Scholar, alternative scholarly impact metrics (altmetrics), and the eScholarship website, the authors identified top articles and grouped them into themes. RESULTS: Of the 136 articles included in the first four years of the Special Issue, 126 represented peer-reviewed publications with an overall acceptance rate of 25.0% (126/505). Authors from this cohort represented 103 of the 182 (56.6%) Accreditation Council for Graduate Medical Education (ACGME) programs in existence at the time of the inaugural issue. Multi-institutional studies represented 34.9% (44/126) of the peer-reviewed publications. Traditional and alternative publication metrics are reported to assess the impact of articles from the Special Issues. CONCLUSION: The Special Issue is a proven outlet to share best practices, innovations, and research related to education. Additionally, the infrastructure of this process promotes the development of individual faculty and a community of teaching scholars.

Professionalism Milestones Assessments Used by Emergency Medicine Residency Programs: A Cross-sectional Survey.

INTRODUCTION: Professionalism is a vital component of quality patient care. While competency in professionalism is Accreditation Council for Graduate Medical Education (ACGME)-mandated, the methods used to evaluate professionalism are not standardized, calling into question the validity of reported measurements. We aimed to determine the type and frequency of methods used by United States (US) -based emergency medicine (EM) residencies to assess accountability (Acc) and professional values (PV), as well as how often graduating residents achieve competency in these areas. METHODS: We created a cross-sectional survey exploring assessment and perceived competency in Acc and PV, and then modified the survey for content and clarity through feedback from emergency physicians not involved in the study. The final survey was sent to the clinical competency committee (CCC) chair or program director (PD) of the 185 US-based ACGME-accredited EM residencies. We summarized results using descriptive statistics and Fisher's exact testing. RESULTS: A total of 121 programs (65.4%) completed the survey. The most frequently used methods of assessment were faculty shift evaluation (89.7%), CCC opinion (86.8%), and faculty summative evaluation (76.4%). Overall, 37% and 42% of residency programs stated that nearly all (greater than 95%) of their graduating residents achieve mastery of Acc and PV non-technical skills, respectively. Only 11.2% of respondents felt their programs were very effective at determining mastery of non-technical skills. CONCLUSION: EM residency programs relied heavily on faculty shift evaluations and summative opinions to determine resident competency in professionalism, with feedback from peers, administrators, and other staff less frequently incorporated. Few residency programs felt their current methods of evaluating professionalism were very effective.

Time to Reevaluate the Away Rotation: Improving Return on Investment for Students and Schools.

Away rotations are common among senior medical students preparing to apply for residency. For competitive specialties, multiple away rotations may be viewed as a de facto requirement for a strong application. Although away rotations are often valuable learning experiences, a variety of noneducational factors motivate students to enroll, including the need for letters of recommendation, students' uncertainty regarding their strength as applicants, perceived competitiveness of residency applications, and conflicting guidance from advisors.Students who enroll in away rotations often benefit from a novel educational environment, opportunities for career exploration, and the chance to assess "fit" with a program. Yet away rotations also come at a significant cost. Students must deal with the time and expenses of rotating at multiple institutions. The application process for away rotations is expensive, disjointed, and inefficient. Students must work hard to make an impression on host institution faculty, and risk hurting their residency applications with a negative letter of recommendation.To reduce the burden of away rotations, future research should assess the impact of multiple away rotations on success in the Match. Allowing students limited access to letters of recommendation content would allow students and advisors to make informed decisions regarding additional rotations. Students would benefit from greater standardization of the application process for away rotations, with uniform dates, timely acceptances and rejections, and a cap for the number of applications per student. Students can maximize their returns by targeting away rotations that provide the most diverse educational experiences and valuable letters of recommendation.

Are one or two dangerous? Diphenoxylate-atropine exposure in toddlers.

Lomotil (Pfizer Inc., New York, NY) (diphenoxylate-atropine) is said to be potentially toxic to toddlers with exposure to as little as one to two tablets. A review of the data on diphenoxylate-atropine poisonings from the American Association of Poison Control Centers annual reports, review articles, and case series disputes this view. Fatalities associated with diphenoxylate-atropine have been reported in toddlers after repetitive or incorrect dosages. Fortunately, trends in pediatric diphenoxylate-atropine ingestions are decreasing. We review the management, trends, and current concepts regarding pediatric diphenoxylate-atropine ingestions.

Autonomic pathways regulating pancreatic exocrine secretion.

The parasympathetic (PNS) and sympathetic (SNS) and nervous systems densely innervate the exocrine pancreas. Efferent PNS pathways, consisting of central dorsal motor nucleus of the vagus (DMV) and peripheral pancreatic neurons, stimulate exocrine secretion. The DMV integrates cortical (olfactory, gustatory) and gastric, and intestinal vagal afferent input to determine central PNS outflow during cephalic, gastric and intestinal phases of exocrine secretion. Pancreatic neurons integrate DMV input with peripheral enteric, sympathetic, and, possibly, afferent axon reflexes to determine final PNS input to all exocrine effectors. Gut and islet hormones appear to modulate both central and peripheral PNS pathways. Preganglionic sympathetic neurons in the intermediolateral (IML) column of the spinal cord receive inputs from brain centers, some shared with the PNS, and innervate postganglionic neurons, mainly in prevertebral ganglia. Sympathetic innervation of the exocrine pancreas is primarily indirect, and inhibits secretion by decreasing blood flow and inhibiting transmission in pancreatic ganglia. Interactions between SNS and PNS pathways appear to occur in brain, spinal cord, pancreatic and prevertebral ganglia, and at neuroeffector synapses. Thus, the PNS and SNS pathways regulating the exocrine pancreas are directly or indirectly antagonistic at multiple sites: the state of exocrine secretion reflects the balance of these influences. Despite over a century of study, much remains to be understood about the connections of specific neurons forming pancreatic pathways, their processes of neurotransmission, and how disruption of these pathways contributes to pancreatic disease.

Spontaneous intracranial hypotension: case report and relevant review of the literature.

Spontaneous intracranial hypotension (SIH) is a well-defined clinical entity that is frequently misdiagnosed because little information regarding this type of headache exists in the Emergency Medicine literature. This report presents a case and relevant review of the literature on SIH. An understanding of the characteristic symptomatology, appropriate evaluation, treatment options, and prognosis is essential if the emergency physician is to provide the most appropriate care to these patients.

Malingering in toxic exposure: classification accuracy of reliable digit span and WAIS-III Digit Span scaled scores.

This study examined the sensitivity and false-positive error rate of reliable digit span (RDS) and the WAIS-III Digit Span (DS) scaled score in persons alleging toxic exposure and determined whether error rates differed from published rates in traumatic brain injury (TBI) and chronic pain (CP). Data were obtained from the files of 123 persons referred for neuropsychological evaluation related to alleged exposure to environmental and industrial substances. Malingering status was determined using the criteria of Slick, Sherman, and Iverson (1999). The sensitivity and specificity of RDS and DS in toxic exposure are consistent with those observed in TBI and CP. These findings support the use of these malingering indicators in cases of alleged toxic exposure and suggest that the classification accuracy data of indicators derived from studies of TBI patients may also be validly applied to cases of alleged toxic exposure.

Do Emergency Medicine Residency Graduates Feel Prepared to Manage Closed Fractures After Training?

OBJECTIVES: Fractures comprise 3% of all emergency department (ED) visits. Although emergency physicians are often responsible for managing most of the initial care of these patients, many report a lack of proficiency and comfort with these skills. The primary objective was to assess how prepared recent emergency medicine (EM) residency graduates felt managing closed fractures upon completion of residency. Secondary objectives included whether residency training or independent practice contributed most to the current level of comfort with these procedures and which fractures were most commonly reduced without orthopedic consultation. METHODS: An anonymous online survey was sent to graduates from seven EM residency programs over a 3-month period to evaluate closed fracture reduction training, practice, and comfort level. Each site primary investigator invited graduates from 2010 to 2014 to participate and followed a set schedule of reminders. RESULTS: The response rate was 287/384 (74.7%) and included 3-year (198/287, 69%) and 4-year (89/287, 31%) programs. Practice in community, academic, and hybrid ED settings was reported by 150/287 (52.3%), 64/287 (22.3%), and 73/287 (25.4%), respectively. It was indicated by 137/287 (47.7%) that they reduce closed fractures without a bedside orthopedic consultation greater than 75% of the time. The majority of graduates felt not at all prepared (35/287, 12.2%) or somewhat prepared (126/287, 43.9%) upon residency graduation. Postresidency independent practice contributed most to the current level of comfort for 156/287 (54.4%). The most common fractures requiring reduction were wrist/distal radius and/or ulna, next finger/hand, and finally, ankle/distal tibia and/or fibula. CONCLUSIONS: Although most recent graduates feel at least "somewhat" prepared to manage closed fractures in the ED, most felt that independent practice was a greater contributor to their current level of comfort than residency training. Recent graduates indicate that fracture reduction without orthopedic consultation is common in today's clinical practice. This survey identifies common fractures requiring reduction which EM residencies may wish to consider prioritizing in their emergency orthopedic curricula to better prepare their residents for independent clinical practice.

The prevalence of cognitive malingering in persons reporting exposure to occupational and environmental substances.

OBJECTIVE: Directly estimate the prevalence of cognitive malingering in persons claiming exposure to occupational and environmental substances. METHODS: Retrospective review of 128 neuropsychological cases with financial incentive. Estimates were based on two methods: (1) clinical identification using the Slick, Sherman and Iverson criteria for malingered neurocognitive dysfunction (MND), and (2) statistical modeling based on patient performance on several individual psychometric indicators of malingering. RESULTS: The prevalence based on the clinical method was 40%. The statistically based estimates ranged from 30% to more than 45% depending on model parameters. Different incentive parameters may influence prevalence. CONCLUSIONS: Cognitive malingering in toxic exposure is common and must be adequately addressed in the clinical neuropsychological assessment of toxic exposure and in research on its neurocognitive effects or findings will likely over-estimate the degree of cognitive impairment and related disability.