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.

Diabetic ketoacidosis.

Diabetic ketoacidosis (DKA) is an acute metabolic complication of diabetes characterized by hyperglycemia, ketosis and acidosis. The pathophysiology of DKA is reviewed and diagnostic and therapeutic modalities are discussed in the context of the currently available evidence. Complications associated with DKA are often a result of the treatment itself, and these issues are also discussed.

Estimating the degree of emergency department overcrowding in academic medical centers: results of the National ED Overcrowding Study (NEDOCS).

OBJECTIVES: No single universal definition of emergency department (ED) overcrowding exists. The authors hypothesize that a previously developed site-sampling form for academic ED overcrowding is a valid model to quantify overcrowding in academic institutions and can be used to develop a validated short form that correlates with overcrowding. METHODS: A 23-question site-sampling form was designed based on input from academic physicians at eight medical schools representative of academic EDs nationwide. A total of 336 site-samplings at eight academic medical centers were conducted at 42 computer-generated random times over a three-week period by independent observers at each site. These sampling times ranged from very slow to severely overcrowded. The outcome variable was the degree of overcrowding as assessed by the charge nurse and ED physicians. The full model consisted of objective data that were obtained by counting the number of patients, determining patients' waiting times, and obtaining information from registration, triage, and ancillary services. Specific objective data were indexed to site-specific demographics. The outcome and objective data were compared using a multiple linear regression to determine predictive validity of the full model. A five-question reduced model was calculated using a backward stepdown procedure. Predictive validity and relationships between the outcome and objective data were assessed using a mixed-effects linear regression model, treating center as random effect. RESULTS: Overcrowding occurred 12% to 73% of the time (mean, 35%), with two hospitals being overcrowded more than 50% of the time. Comparison of objective and outcome data resulted in an R(2) of 0.49 (p < 0.001), indicating a good degree of predictive validity. A reduced five-question model predicted the full model with 88% accuracy. CONCLUSIONS: Overcrowding varied widely between academic centers during the study period. Results of a five-question reduced model are valid and accurate in predicting the degree of overcrowding in academic centers.

Social media guidelines and best practices: recommendations from the Council of Residency Directors Social Media Task Force.

Social media has become a staple of everyday life among over one billion people worldwide. A social networking presence has become a hallmark of vibrant and transparent communications. It has quickly become the preferred method of communication and information sharing. It offers the ability for various entities, especially residency programs, to create an attractive internet presence and "brand" the program. Social media, while having significant potential for communication and knowledge transfer, carries with it legal, ethical, personal, and professional risks. Implementation of a social networking presence must be deliberate, transparent, and optimize potential benefits while minimizing risks. This is especially true with residency programs. The power of social media as a communication, education, and recruiting tool is undeniable. Yet the pitfalls of misuse can be disastrous, including violations in patient confidentiality, violations of privacy, and recruiting misconduct. These guidelines were developed to provide emergency medicine residency programs leadership with guidance and best practices in the appropriate use and regulation of social media, but are applicable to all residency programs that wish to establish a social media presence.

Inaccuracy of the global assessment score in the emergency medicine standard letter of recommendation.

OBJECTIVES: The standard letter of recommendation (SLOR) is used by most emergency medicine (EM) faculty to submit evaluations for medical students applying for EM residency programs. In the global assessment score (GAS) section, there is a crucial summative question that asks letter writers to estimate the applicant's rank order list (ROL) position in their own program. The primary aim of the study was to determine if these estimated global assessment tiers agreed with the actual ROL, using the criteria recommended by the Council of Emergency Medicine Residency Directors (CORD). METHODS: Data from SLORs written by EM faculty from five California institutions were retrospectively collected from the 2008-2009 residency application year. Descriptive and comparative statistical analyses were performed using the documented GAS tiers and actual ROL positions. RESULTS: A total of 105 SLORs were reviewed from the five participating institutions. Three SLORs were excluded and 102 were analyzed. Only 27 (26%) SLORs documented a GAS tier that accurately predicted the applicant's actual ROL position. The GAS tier overestimated the applicant's position on the ROL in 67 (66%) SLORs, whereas it underestimated the position in eight (8%) SLORs. Accuracy was poor regardless of the number of letter writers on the SLOR (p = 0.890), the writer's administrative title (p = 0.326), whether the student was a home or visiting student (p = 0.801), or if the student had prior EM rotation experience (p = 0.793). CONCLUSIONS: Standard letter of recommendation writers are inaccurate in estimating the ROL position of the applicant using the GAS tier criteria. The GAS tiers were accurate only 26% of the time. Because of the valuable role that the SLOR plays in determining an applicant's competitiveness in the National Resident Matching Program (NRMP) in EM, future discussion should focus on improving the consistency and accuracy of the GAS section. Furthermore, there needs to be a national dialogue to reassess the utility of the criterion-based GAS within the SLOR.

A bedside ultrasound curriculum for medical students: prospective evaluation of skill acquisition.

OBJECTIVE: We conducted a study to evaluate the efficacy of an introductory ultrasound (US) curriculum for medical students rotating through our emergency department. MATERIALS AND METHODS: Third- and 4th-year medical students indicated their previous US experience and were given a pretest consisting of static US images to assess baseline interpretation skills. They participated in a 45-min interactive didactic session followed by a 45-min session of hands-on experience practicing real-time US image acquisition on a normal model. After this session, we tested the timing and quality of their image acquisition skills on a separate normal model. Quality of images was based on a point value from 0 to 2 per image. This was followed by a posttest of static US images, which was graded in the same manner as the pretest. RESULTS: Thirty-one students participated in the study. Median time to acquire 2 images was 112.5 sec (range = 15420 sec). Acquisition time was unaffected by previous experience (p = .97). The mean score on the quality of 2 images (maximum score = 4) was 3.84; median was 4 (range = 14). Image quality was significantly better in participants with previous US experience (p = .014). Scores on interpretation of static images improved significantly from pretest to posttest by a median of 8.25 points (p = .0001). CONCLUSION: Our introductory US course is effective at significantly improving medical students' interpretation of static US images. The majority of students were able to acquire high quality images in a short period of time after this session.