Medical Student Core Clinical Ultrasound Milestones: A Consensus Among Directors in the United States.

OBJECTIVES: Many medical schools are implementing point-of-care ultrasound in their curricula to help augment teaching of the physical examination, anatomy, and ultimately clinical management. However, point-of-care ultrasound milestones for medical students remain unknown. The purpose of this study was to formulate a consensus on core medical student clinical point-of-care ultrasound milestones across allopathic and osteopathic medical schools in the United States. Directors who are leading the integration of ultrasound in medical education (USMED) at their respective institutions were surveyed. METHODS: An initial list of 205 potential clinical ultrasound milestones was developed through a literature review. An expert panel consisting of 34 USMED directors across the United States was used to produce consensus on clinical ultrasound milestones through 2 rounds of a modified Delphi technique, an established anonymous process to obtain consensus through multiple rounds of quantitative questionnaires. RESULTS: There was a 100% response rate from the 34 USMED directors in both rounds 1 and 2 of the modified Delphi protocol. After the first round, 2 milestones were revised to improve clarity, and 9 were added on the basis of comments from the USMED directors, resulting in 214 milestones forwarded to round 2. After the second round, only 90 milestones were found to have a high level of agreement and were included in the final medical student core clinical ultrasound milestones. CONCLUSIONS: This study established 90 core clinical milestones that all graduating medical students should obtain before graduation, based on consensus from 34 USMED directors. These core milestones can serve as a guide for curriculum deans who are initiating ultrasound curricula at their institutions. The exact method of implementation and competency assessment needs further investigation.

The Midline Catheter: A Clinical Review.

BACKGROUND: Venous access in the emergency department (ED) is an often under-appreciated procedural skill given the frequency of its use. The patient's clinical status, ongoing need for laboratory investigation, and intravenous therapeutics guide the size, type, and placement of the catheter. The availability of trained personnel and dedicated teams using ultrasound-guided insertion techniques in technically difficult situations may also impact the selection. Appropriate device selection is warranted on initial patient contact to minimize risk and cost. OBJECTIVE: To compare venous access device indications and complications, highlighting the use of midline catheters as a potentially cost-effective and safe approach for venous access in the ED. DISCUSSION: Midline catheters (MC) offer a comparable rate of device-related bloodstream infection to standard peripheral intravenous catheters (PIV), but with a significantly lower rate than peripherally inserted central catheters (PICC) and central venous catheters (CVC) (PIV 0.2/1000, MC 0.5/1000, PICC 2.1-2.3/1000, CVC 2.4-2.7/1000 catheter days). The average dwell time of a MC is reported as 7.69-16.4 days, which far exceeds PIVs (2.9-4.1 days) and is comparable to PICCs (7.3-16.6 days). Cost of insertion of a MC has been cited as comparable to three PIVs, and their use has been associated with significant cost savings when placed to avoid prolonged central venous access with CVCs or in patients with difficult-to-access peripheral veins. Placement of a MC includes modified Seldinger and accelerated, or all-in-one, Seldinger techniques with or without ultrasound guidance, with a high rate of first-attempt success. CONCLUSION: The MC is a versatile venous access device with a low complication rate, long dwell time, and high rate of first-attempt placement. Its utilization in the ED in patients deemed to require prolonged hospitalization or to have difficult-to-access peripheral vasculature could reduce cost and risk to patients.

Implementing a third-year emergency medicine medical student curriculum.

BACKGROUND: Emergency medicine (EM) is commonly introduced in the fourth year of medical school because of a perceived need to have more experienced students in the complex and dynamic environment of the emergency department. However, there is no evidence supporting the optimal time or duration for an EM rotation, and a number of institutions offer third-year rotations. OBJECTIVE: A recently published syllabus provides areas of knowledge, skills, and attitudes that third-year EM rotation directors can use to develop curricula. This article expands on that syllabus by providing a comprehensive curricular guide for the third-year medical student rotation with a focus on implementation. DISCUSSION: Included are consensus-derived learning objectives, discussion of educational methods, considerations for implementation, and information on feedback and evaluation as proposed by the Clerkship Directors in Emergency Medicine Third-Year Curriculum Work Group. External validation results, derived from a survey of third-year rotation directors, are provided in the form of a content validity index for each content area. CONCLUSIONS: This consensus-derived curricular guide can be used by faculty who are developing or revising a third-year EM medical student rotation and provide guidance for implementing this curriculum at their institution.

Medical student self-assessment narratives: perceived educational needs during fourth-year emergency medicine clerkship.

BACKGROUND: The educational needs of medical students in the 4th-year of training are not well defined in the literature. PURPOSE: The specific aim of this investigation is to characterize the perceived educational needs of 4th-year medical students during an Emergency Medicine clerkship. METHODS: This was a thematic analysis of informed self-assessment narratives. The writings were performed by medical students during an Emergency Medicine clerkship from July 2010 through May 2011. Themes and subthemes that emerged were assessed for frequency of occurrence. RESULTS: Qualitative analysis of 203 narratives revealed 13 themes and 55 subthemes. Patient care (50%), history taking (44%), and physical examination (29%) were the themes most commonly noted as strengths. Medical decision making/plan of care (44%), differential diagnosis (37%), presentation skills (32%), and knowledge base (27%) were the themes most commonly noted as weaknesses. All themes were described as strengths by some students and weaknesses by others; however, trends were apparent in the analysis. CONCLUSIONS: Fourth-year medical students rotating on an Emergency Medicine clerkship perceive an educational need to improve medical decision making/plan of care. Self-assessment narratives reveal trends in strengths and weaknesses but also highlight the importance of recognizing students as unique learners with individualized needs.

A tiered mentorship program improves number of students with an identified mentor.

BACKGROUND: Mentorship is critical to professional development and academic success. Unfortunately, only about 40% of medical students can identify a mentor. While group mentorship has been evaluated - the concept of a specialty specific, tiered group mentorship program (TGMP) has not. In the latter, each member of the group represents a unique education or professional level. PURPOSE: The purpose of this study was to investigate the ability of a specialty-specific, tiered group mentorship program to improve mentorship for students interested in emergency medicine. METHODS: Groups consisted of faculty members, residents, 4th-year students pursuing a career in Emergency Medicine, and junior (MS1, MS2, and MS3) medical students (13 total groups). Students completed confidential electronic surveys before and after completion of the program. RESULTS: Of 126 students, 85 completed the Course Evaluation Survey. At program onset, 11.4% of 1st-year students, 41.7% of 2nd-year students, 50% of 3rd-year students, and 28% of the total students could identify a mentor. After completion, 68.6% of 1st years, 83.3% of 2nd years, 90% of 3rd years, and 77.6% of the total reported they could identify a mentor. Faculty were rated most important members followed by the 4th-year student. CONCLUSION: A tiered group mentorship program improved the ability of students to identify a mentor. Students identified mentoring relationships from individuals at various professional levels.

Faculty prefer continuity with medical students in the emergency department.

INTRODUCTION: The aim of this investigation was to better understand emergency medicine (EM) faculty opinions as they relate to continuity with students. METHODS: This was a prospective cohort study of faculty supervising students completing an EM clerkship. Student schedules were aligned to maximise continuity with faculty. Faculty completed surveys prior to the start of the study and again at the end of the study period. RESULTS: Faculty generally indicated a favourable opinion regarding continuity with students. Significant change was noted in two survey questions from pre- to post-intervention: faculty reported higher motivation to teach and felt the students' learning experience was better with improved continuity. CONCLUSION: EM faculty express theoretical optimism regarding the value of improved continuity between teacher and learner. This positive sentiment persisted after actual experience with students on a shift allocation model that aligns faculty and student schedules.

Adapting Compassionate Conversations for Virtual Mediated Communication.

OBJECTIVE: The Covid-19 pandemic resulted in a shift in communication of difficult, emotionally charged topics from almost entirely in-person to virtual mediated communication (VMC) methods due to restrictions on visitation for safety. The objective was to train residents in VMC and assess performance across multiple specialties and institutions. DESIGN: The authors designed a teaching program including asynchronous preparation with videos, case simulation experiences with standardized patients (SPs), and coaching from a trained faculty member. Three topics were included - breaking bad news (BBN), goals of care / health care decision making (GOC), and disclosure of medical error (DOME). A performance evaluation was created and used by the coaches and standardized patients to assess the learners. Trends in performance between simulations and sessions were assessed. SETTING: Four academic university hospitals - Virginia Commonwealth University Medical Center in Richmond, Virginia, The Ohio State University Wexner Medical Center in Columbus, Ohio, Baylor University Medical Center in Dallas, Texas and The University of Cincinnati in Cincinnati, Ohio- participated. PARTICIPANTS: Learners totaled 34 including 21 emergency medicine interns, 9 general surgery interns and 4 medical students entering surgical training. Learner participation was voluntary. Recruitment was done via emails sent by program directors and study coordinators. RESULTS: A statistically significant improvement in mean performance on the second compared to the first simulation was observed for teaching communication skills for BBN using VMC. There was also a small but statistically significant mean improvement in performance from the first to the second simulation for the training overall. CONCLUSIONS: This work suggests that a deliberate practice model can be effective for teaching VMC and that a performance evaluation can be used to measure improvement. Further study is needed to optimize the teaching and evaluation of these skills as well as to define minimal acceptable levels of competency.

The impact of two clinical shift allocation models on student experiences in an emergency medicine clerkship.

BACKGROUND: Medical students on Emergency Medicine (EM) clerkships are traditionally assigned work shifts in a manner that provides a mix of daytime, evening, overnight, and weekend shifts. Whether or not this shift allocation model provides the optimal educational experience remains unclear. PURPOSE: The purpose of this study was to compare the impact of two different shift allocation models on the student's clerkship experience. Specifically, we set out to compare the traditional shift allocation model to a novel model designed to maximize teacher-learner continuity. METHODS: This was a prospective, crossover, cohort study of medical students participating in an EM clerkship at one institution from January 1 through April 31, 2010. All students completed 2 weeks of shifts under the "traditional shift model" and 2 weeks of shifts under the "continuity-based shift model." In the latter, the guiding principle of student shift allocation was continuity between teacher and learner. Students completed coded surveys after each 2-week block that were later matched and analyzed using 2-way ANOVAs with 1 repeated measure. In addition, all students participated in a semistructured group interview at the completion of both blocks. The interviews were recorded, transcribed, and analyzed using qualitative methods. Themes and subthemes that emerged were assessed for frequency of occurrence. RESULTS: Eighteen medical students consented to participate. Students rated the continuity-based shift model higher on all 10 survey items. However, only the items that asked specifically about "faculty"-faculty teaching, faculty interaction, frequency and quality of faculty feedback-were rated significantly higher when students worked under the continuity-based shift model. Qualitative analysis of group interviews revealed 6 major themes and 16 subthemes. Students described feedback (N = 16/117) and the teacher-learner relationship (N = 21/117) as superior under the continuity-based shift model. CONCLUSIONS: Changes in shift allocation affects student experience in an EM clerkship. A shift allocation model that maximizes the continuity between teacher and learner is perceived by students to improve feedback and the teacher-learner relationship.

Procedural Curriculum to Verify Intern Competence Prior to Patient Care.

INTRODUCTION: Emergency medicine (EM) programs train residents to perform clinical procedures with known iatrogenic risks. Currently, there is no established framework for graduating medical students to demonstrate procedural competency prior to matriculating into residency. Mastery-based learning has demonstrated improved patient-safety outcomes. Incorporation of this framework allows learners to demonstrate procedural competency to a predetermined standard in the simulation laboratory prior to performing invasive procedures on patients in the clinical setting. This study describes the creation and implementation of a competency-based procedural curriculum for first-year EM residents using simulation to prepare learners for supervised participation in procedures during patient care. METHODS: Checklists were developed internally for five high-risk procedures (central venous line placement, endotracheal intubation, lumbar puncture, paracentesis, chest tube placement). Performance standards were developed using Mastery-Angoff methods. Minimum passing scores were determined for each procedure. Over a two-year period, 38 residents underwent baseline assessment, deliberate practice, and post-testing against the passing standard score to demonstrate procedural competency in the simulation laboratory during intern orientation. RESULTS: We found that 37% of residents required more than one attempt to achieve the minimum passing score on some procedures, however, all residents ultimately met the competency standard on all five high-risk procedures in simulation. One critical incident of central venous catheter guideline retention was identified in the simulation laboratory during the second year of implementation. CONCLUSION: All incoming first-year EM residents demonstrated procedural competence on five different procedures using a mastery-based educational framework. A competency-based EM curriculum allowed for demonstration of procedural competence prior to resident participation in supervised clinical patient care.

From chaos to creativity: Designing collaborative communication training for the delivery of bad news.

BACKGROUND: Before the COVID-19 pandemic, teaching communication skills in health care focused primarily on developing skills during face-to-face conversation. Even experienced clinicians were unprepared for the transition in communication modalities necessitated due to physical distancing requirements and visitation restrictions during the COVID-19 pandemic. We aimed to develop and pilot a comprehensive video-mediated communication training program and test its feasibility in multiple institutional settings and medical disciplines. METHODS: The education team, consisting of clinician-educators in general surgery and emergency medicine (EM) and faculty specialists in simulation and coaching, created the intervention. Surgery and EM interns in addition to senior medical students applying in these specialties were recruited to participate. Three 90-minute sessions were offered focusing on 3 communication topics that became increasingly complex and challenging: breaking bad news, goals of care discussions, and disclosure of medical error. This was a mixed-methods study using survey and narrative analysis of open comment fields. RESULTS: Learner recruitment varied by institution but was successful, and most (75%) learners found the experience to be valuable. All of the participants reported feeling able to lead difficult discussions, either independently or with minimal assistance. Only about half (52%) of the participants reported feeling confident to independently disclose medical error subsequent to the session. CONCLUSION: We found the program to be feasible based on acceptability, demand, the ability to implement, and practicality. Of the 3 communication topics studied, confidence with disclosure of medical error proved to be the most difficult. The optimal length and structure for these programs warrants further investigation.

Emergency medicine resident clinical experience vs. in-training examination content: A national database study.

Objectives: Emergency medicine (EM) residents take the In-Training Examination (ITE) annually to assess medical knowledge. Question content is derived from the Model of Clinical Practice of Emergency Medicine (EM Model), but it is unknown how well clinical encounters reflect the EM Model. The objective of this study was to compare the content of resident patient encounters from 2016-2018 to the content of the EM Model represented by the ITE Blueprint. Methods: This was a retrospective cross-sectional study utilizing the National Hospital Ambulatory Medical Care Survey (NHAMCS). Reason for visit (RFV) codes were matched to the 20 categories of the American Board of Emergency Medicine (ABEM) ITE Blueprint. All analyses were done with weighted methodology. The proportion of visits in each of the 20 content categories and 5 acuity levels were compared to the proportion in the ITE Blueprint using 95% confidence intervals (CIs). Results: Both resident and nonresident patient visits demonstrated content differences from the ITE Blueprint. The most common EM Model category were visits with only RFV codes related to signs, symptoms, and presentations regardless of resident involvement. Musculoskeletal disorders (nontraumatic), psychobehavioral disorders, and traumatic disorders categories were overrepresented in resident encounters. Cardiovascular disorders and systemic infectious diseases were underrepresented. When residents were involved with patient care, visits had a higher proportion of RFV codes in the emergent and urgent acuity categories compared to those without a resident. Conclusions: Resident physicians see higher acuity patients with varied patient presentations, but the distribution of encounters differ in content category than those represented by the ITE Blueprint.

Medical student professionalism narratives: a thematic analysis and interdisciplinary comparative investigation.

BACKGROUND: Professionalism development is influenced by the informal and hidden curriculum. The primary objective of this study was to better understand this experiential learning in the setting of the Emergency Department (ED). Secondarily, the study aimed to explore differences in the informal curriculum between Emergency Medicine (EM) and Internal Medicine (IM) clerkships. METHODS: A thematic analysis was conducted on 377 professionalism narratives from medical students completing a required EM clerkship from July 2008 through May 2010. The narratives were analyzed using established thematic categories from prior research as well as basic descriptive characteristics. Chi-square analysis was used to compare the frequency of thematic categories to prior research in IM. Finally, emerging themes not fully appreciated in the established thematic categories were created using grounded theory. RESULTS: Observations involving interactions between attending physician and patient were most abundant. The narratives were coded as positive 198 times, negative 128 times, and hybrid 37 times. The two most abundant narrative themes involved manifesting respect (36.9%) and spending time (23.7%). Both of these themes were statistically more likely to be noted by students on EM clerkships compared to IM clerkships. Finally, one new theme regarding cynicism emerged during analysis. CONCLUSIONS: This analysis describes an informal curriculum that is diverse in themes. Student narratives suggest their clinical experiences to be influential on professionalism development. Medical students focus on different aspects of professionalism depending on clerkship specialty.

Medical School to Residency: How Can We Trust the Process?

Background To say that the transition from undergraduate medical education (UME) to graduate medical education (GME) is under scrutiny would be an understatement. Findings from a panel discussion at the 2018 Association of American Medical Colleges Annual meeting entitled, "Pass-Fail in Medical School and the Residency Application Process and Graduate Medical Education Transition" addressed what and when information should be shared with residency programs, and how and when that information should be shared. Materials and Methods Over 250 participants representing UME and GME (e.g. leadership, faculty, medical students) completed worksheets addressing these questions. During report-back times, verbal comments were transcribed in real time, and written comments on worksheets were later transcribed. All comments were anonymous. Thematic analysis was conducted manually by the research team to analyze the worksheet responses and report back comments. Results Themes based on suggestions of what information should be shared included the following: 1) developmental/assessment benchmarks such as demonstrating the ability/competencies to do clinical work; 2) performance on examinations; 3) grades and class ranking; 4) 360 evaluations; 5) narrative evaluations; 6) failures/remediation/gaps in training; 7) professionalism lapses; 8) characteristics of students such as resiliency/reliability; and 9) service/leadership/participation. In terms of how this information should be shared, the participants suggested enhancements to the current process of transmitting documents rather than alternative methods (e.g., video, telephonic, face-to-face discussions) and information sharing at both the time of the match and again near/at graduation to include information about post-match rotations. Discussion Considerations to address concerns with the transition from medical school to residency include further enhancements to the Medical Student Performance Evaluation, viewing departmental letters as ones of evaluation and not recommendation, a more meaningful educational handoff, and limits on the number of residency applications allowed for each student. The current medical education environment is ready for meaningful change in the UME to GME transition.

Erratum: This Article Corrects: "Assessment of Physician Well-being, Part Two: Beyond Burnout".

This corrects West J Emerg Med. 2019 March;20(2):291-304. Assessment of Physician Well-being, Part Two: Beyond Burnout Lall MD, Gaeta TJ, Chung AS, Chinai SA, Garg M, Husain A, Kanter C, Khandelwal S, Rublee CS, Tabatabai RR, Takayesu JK, Zaher M, Himelfarb NT. Erratum in West J Emerg Med. 2020 May;21(3):727. Author name misspellled. The sixth author, originally published as Abbas Hussain, MD is revised to Abbas Husain, MD. Abstract: Part One of this two-article series reviews assessment tools to measure burnout and other negative states. Physician well-being goes beyond merely the absence of burnout. Transient episodes of burnout are to be expected. Measuring burnout alone is shortsighted. Well-being includes being challenged, thriving, and achieving success in various aspects of personal and professional life. In this second part of the series, we identify and describe assessment tools related to wellness, quality of life, resilience, coping skills, and other positive states.

Does the Emergency Medicine In-training Examination Accurately Reflect Residents' Clinical Experiences?

OBJECTIVE: The American Board of Emergency Medicine Model of the Clinical Practice of Emergency Medicine (ABEM Model) serves as a guide for resident education and the basis for the resident In-training Examination (ITE) and the Emergency Medicine Board Qualification Examinations. The purpose of this study was to determine how closely resident-patient encounters in our emergency departments (EDs) matched the ABEM Model as presented in the specifications of the content outline for the ITE. METHODS: This single-site study of an academic residency program analyzed all documented resident-patient encounters in the ED during a 2.5-year period recorded in the electronic medical record. The chief complaints from these encounters were matched to the 20 categories of the ABEM Model. Chi-square goodness-of-fit tests were performed to compare the proportions of categorized encounters and proportions of patient acuity levels to the proportions of categories as outlined in the content blueprint of the ITE. RESULTS: After the exclusion of encounters with missing data and those not involving EM residents, 125,405 encounters were analyzed. We found a significant difference between the clinical experience of EM residents and the ABEM Model as reflected in the ITE for both case categories (p < 0.01) and patient acuity (p < 0.01). The following categories were the most overrepresented in clinical care: signs, symptoms, and presentations; psychobehavioral disorders; and abdominal and gastrointestinal disorders. The most underrepresented were procedures and skills, systemic infectious disorders, and thoracic-respiratory disorders. CONCLUSION: The clinical experience of EM residents differs significantly from the ITE Content Blueprint, which reflects the ABEM Model. This type of inquiry may help to provide custom education reports to residents about their clinical encounters to help identify clinical knowledge gaps that may require supplemental nonclinical training.

Assessment of Physician Well-being, Part Two: Beyond Burnout.

Part One of this two-article series reviews assessment tools to measure burnout and other negative states. Physician well-being goes beyond merely the absence of burnout. Transient episodes of burnout are to be expected. Measuring burnout alone is shortsighted. Well-being includes being challenged, thriving, and achieving success in various aspects of personal and professional life. In this second part of the series, we identify and describe assessment tools related to wellness, quality of life, resilience, coping skills, and other positive states.

Topical oxygen therapy induces vascular endothelial growth factor expression and improves closure of clinically presented chronic wounds.

1. Chronic wounds, especially in diabetics, represent a serious threat to human health. 2. Correcting a compromised state of tissue oxygenation by the administration of supplemental O(2) is known to benefit wound healing. Beyond its role as a nutrient and antibiotic, O(2) supports wound healing by driving redox signaling. 3. Hyperbaric oxygen (HBO) therapy is widely used and approved by Center for Medicare and Medicaid Services to treat specific ulcerations. The current literature supports the notion that approaches to topically oxygenate wounds may be productive. 4. Here, we present the results of two simultaneous studies testing the effects of HBO and portable topical oxygen (TO) therapies. These two therapeutic approaches have several contrasting features. 5. In total, 1854 patients were screened in outpatient wound clinics for non-randomized enrolments into the HBO (n = 32; 31% diabetic) and TO (n = 25; 52% diabetic) studies. 6. Under the conditions of the present study, HBO treatment seemed to benefit some wounds while not benefiting others. Overall, HBO did not result in statistically significant improvements in wound size in the given population over the time monitored in the present study. 7. However, TO significantly improved wound size. Among the three O(2)-sensitive genes (VEGF, TGFbeta1 and COL1A1) studied in wound edge tissue biopsies, TO treatment was associated with higher VEGF165 expression in healing wounds. Expression of the other genes mentioned was not affected by TO. There was no significant change in the expression levels of any of genes studied in patients in the HBO study. This establishes a link between VEGF gene expression and healing outcome for TO therapy. 8. Taken together, the present study provides evidence demonstrating that TO treatment benefits wound healing in patients suffering from chronic wounds. Treatment with TO is associated with an induction of VEGF expression in wound edge tissue and an improvement in wound size.

Hyperbaric oxygen: applications in infectious disease.

This article reviews the applications of hyperbaric oxygen (HBO) as an adjunctive treatment of certain infectious processes. Infections for which HBO has been studied and is recommended by the Undersea and Hyperbaric Medicine Society include necrotizing fasciitis, gas gangrene, chronic refractory osteomyelitis (including malignant otitis externa), mucormycosis, intracranial abscesses, and diabetic foot ulcers that have concomitant infections. In all of these processes, HBO is used adjunctively along with antimicrobial agents and aggressive surgical debridement. This article describes the details of each infection and the research that supports the use of HBO.

Training in Emergency Obstetrics: A Needs Assessment of U.S. Emergency Medicine Program Directors.

INTRODUCTION: Obstetrical emergencies are a high-risk yet infrequent occurrence in the emergency department. While U.S. emergency medicine (EM) residency graduates are required to perform 10 low-risk normal spontaneous vaginal deliveries, little is known about how residencies prepare residents to manage obstetrical emergencies. We sought to profile the current obstetrical training curricula through a survey of U.S. training programs. METHODS: We sent a web-based survey covering the four most common obstetrical emergencies (pre-eclampsia/eclampsia, postpartum hemorrhage (PPH), shoulder dystocia, and breech presentation) through email invitations to all program directors (PD) of U.S. EM residency programs. The survey focused on curricular details as well as the comfort level of the PDs in the preparation of their graduating residents to treat obstetrical emergencies and normal vaginal deliveries. RESULTS: Our survey had a 55% return rate (n=105/191). Of the residencies responding, 75% were in the academic setting, 20.2% community, 65% urban, and 29.8% suburban, and the obstetrical curricula were 2-4 weeks long occurring in post-graduate year one. The most common teaching method was didactics (84.1-98.1%), followed by oral cases for pre-eclampsia (48%) and PPH (37.2%), and homemade simulation for shoulder dystocia (37.5%) and breech delivery (33.3%). The PDs' comfort about residency graduate skills was highest for normal spontaneous vaginal delivery, pre-eclampsia, and PPH. PDs were not as comfortable about their graduates' skill in handling shoulder dystocia or breech delivery. CONCLUSION: Our survey found that PDs are less comfortable in their graduates' ability to perform non-routine emergency obstetrical procedures.