Educating for adaptive expertise: case examples along the medical education continuum.

Adaptive expertise represents the combination of both efficient problem-solving for clinical encounters with known solutions, as well as the ability to learn and innovate when faced with a novel challenge. Fostering adaptive expertise requires careful approaches to instructional design to emphasize deeper, more effortful learning. These teaching strategies are time-intensive, effortful, and challenging to implement in health professions education curricula. The authors are educators whose missions encompass the medical education continuum, from undergraduate through to organizational learning. Each has grappled with how to promote adaptive expertise development in their context. They describe themes drawn from educational experiences at these various learner levels to illustrate strategies that may be used to cultivate adaptive expertise.At Vanderbilt University School of Medicine, a restructuring of the medical school curriculum provided multiple opportunities to use specific curricular strategies to foster adaptive expertise development. The advantage for students in terms of future learning had to be rationalized against assessments that are more short-term in nature. In a consortium of emergency medicine residency programs, a diversity of instructional approaches was deployed to foster adaptive expertise within complex clinical learning environments. Here the value of adaptive expertise approaches must be balanced with the efficiency imperative in clinical care. At Mayo Clinic, an existing continuous professional development program was used to orient the entire organization towards an adaptive expertise mindset, with each individual making a contribution to the shift.The different contexts illustrate both the flexibility of the adaptive expertise conceptualization and the need to customize the educational approach to the developmental stage of the learner. In particular, an important benefit of teaching to adaptive expertise is the opportunity to influence individual professional identity formation to ensure that clinicians of the future value deeper, more effortful learning strategies throughout their careers.

Creating a better learning environment: a qualitative study uncovering the experiences of Master Adaptive Learners in residency.

BACKGROUND: Adaptive expertise is an important physician skill, and the Master Adaptive Learner (MAL) conceptual model describes learner skills and behaviors integral to the acquisition of adaptive expertise. The learning environment is postulated to significantly impact how MALs learn, but it is unclear how these successful learners experience and interact with it. This study sought to understand the authentic experience of MALs within the learning environment and translate those experiences into practical recommendations to improve the learning environment for all trainees. METHODS: Following a constructivist paradigm, we conducted a thematic analysis of transcripts from focus groups composed of MALs to identify commonalities in experiences and practices of successful postgraduate trainees in the learning environment. Saturation was achieved after seven focus groups, consisting of thirty-eight participants representing fourteen specialties from four institutions. Researchers coded transcripts using constant comparison analysis, which served as the foundation for our thematic analysis. RESULTS: We identified eight themes and situated them within a 4-component model of the learning environment. Four themes were identified within the personal component: (1) patients drive learning; (2) learning has no endpoint; (3) management of emotions is crucial for learning; (4) successful learning requires a structured approach. Two themes were identified in the social component: (5) positive social relationships are leveraged to maximize learning; (6) teaching facilitates personal learning. Two themes were identified in the organizational component: (7) transitions challenge learners to adapt; (8) the learning environment dictates goal setting strategy. No major themes were identified in the physical/virtual component, although participants frequently used technology when learning. CONCLUSIONS: Master Adaptive Learners experience similar facilitators of, and barriers to, success in the learning environment. Overall, our data show that acquisition of many successful strategies and skills that support learning are relegated to the hidden curriculum of residency training. Educators could support a more effective learning environment for all trainees by: (1) highlighting patients as the focal point of learning, (2) building a professional 'learner' identity, (3) teaching learning skills, and (4) creating opportunities for collaborative learning.

Learning to learn: A qualitative study to uncover strategies used by Master Adaptive Learners in the planning of learning.

Background: The ability to adapt expertise to both routine and uncommon situations, termed adaptive expertise, has been suggested as a necessary skill for physicians. The Master Adaptive Learner (MAL) framework proposes four phases necessary to develop adaptive expertise. The first phase, "planning" for learning, includes three stages: identification of gaps, prioritization of gaps, and identification of learning resources. This study explored key strategies used by MALs in "planning" for learning. Methods: Focus groups were used to identify strategies that successful postgraduate trainees use to plan learning. Researchers analyzed transcripts using constant comparison analysis and grounded theory to guide the generation of themes. Results: 38 participants, representing 14 specialties, participated in 7 focus groups. Six key strategies used in the "planning" phase of learning were found. During gap identification, they used performance-driven gap identification and community-driven gap identification. To prioritize gaps, they used the schema of triage and adequacy. To identify resources they used intentional adaptation and weighted curation. Barriers such as lack of time and inexperience were noted. Conclusions: MALs use six strategies to plan learning, using patients, health-care team roles, and clinical questions to guide them. Understanding these strategies can help educators design learning opportunities and overcome barriers.

Aiming Beyond Competent: The Application of the Taxonomy of Significant Learning to Medical Education.

Issue: Competency-Based Medical Education (CBME) focuses on demonstrable outcomes, as well as upholding medical education's accountability to society. Despite calls for a robust, multifaceted approach to competency-based assessment (CBA), lingering critiques exist. These critiques include reductionism, reinforcement of an external locus of control within learners, an loss of focus on learner development. Both CBME and CBA may be strengthened if viewed through the lens of a complementary curriculum design framework that broadens the focus on the learner. Evidence: Researchers and physician organizations have articulated the need for medical practitioners trained to provide optimal care in the rapidly changing care environment. In the drive to ensure accountability to patients and society, CBME may overlook the duty of educators to foster the necessary intrinsic development of learners as holistic professionals. The focus of CBA on outcomes may reward memorization and rote performance but may fail to ensure the underlying comprehension or critical thinking necessary to adapt to the variability of real-life patient care. Learners focus on tasks chosen for assessment; thus, areas less easily assessed may be overlooked or deemed unimportant. Reinforcement for learner motivation becomes externalized in CBA, as opposed to being driven by the desire for self-improvement and self-actualization. A recently proposed framework that views learner development as a process-based improvement cycle, the "Master Adaptive Learner," may help remedy this issue. L. Dee Fink's Taxonomy of Significant Learning aims to create meaningful learning experiences in higher education. This taxonomy consists of six interwoven domains: (a) Learning How to Learn, (b) Foundational Knowledge, (c) Application, (d) Integration, (e) Human Dimension, and (f) Caring. Each domain encompasses a unique perspective on the learning process, and when collectively applied to curriculum design, significant learning occurs. This taxonomy has not been widely applied to medical education but may offer an important counterbalance to the outcomes-based focus of CBME. Implications: The outcomes-based focus of CBME is well suited for skill-based tasks, such as procedures, that are observable and measurable. However, other essential physician skills-such as critical thinking, reflection, empathy, and self-directed learning-are not easily assessed, and thus may receive little focus in an outcomes-based model. A holistic approach, such as the Taxonomy of Significant Learning, can counter the deficits of CBME and provide a balanced approach to education program design and assessment.

Selecting a Medical School Advisor.

Having an advisor offers medical students many advantages, including increased likelihood of matching into their top choices. Interestingly, students who choose emergency medicine (EM) as a specialty are more likely to seek advising. However, finding and optimally utilizing an EM faculty advisor is often challenging for the medical student. In this article, we tackle the different ways to seek advising, including the 'virtual advisor program' implemented by the Society for Academic Emergency Medicine, the 'e-Advisor Program' instigated by the Clerkship Director in EM Group, the 'member exclusive mentorship program' of the Emergency Medicine Residency Association, as well as peer-based mentoring. More so, we discuss the consensus recommendations developed by the Student Advising Task Force to guide both students planning to apply to EM and their advisors to ensure high-caliber advising.

What's the Evidence: Self-Assessment Implications for Life-Long Learning in Emergency Medicine.

BACKGROUND: The 2012 Academic Emergency Medicine Consensus Conference, "Education Research in Emergency Medicine: Opportunities, Challenges, and Strategies for Success" noted that emergency medicine (EM) educators often rely on theory and tradition when molding their approaches to teaching and learning, and called on the EM education community to advance the teaching of our specialty through the performance and application of research in teaching and assessment methods, cognitive function, and the effects of education interventions. OBJECTIVE: The purpose of this article was to review the research-based evidence for the effectiveness of self-assessment and to provide suggestions for its use in clinical teaching and practice in EM. DISCUSSION: This article reviews hypothesis-testing research related to self-assessment behaviors and learning. Evidence indicates that self-assessment is inherently flawed when used in isolation. We review a multi-dimensional approach to informed self-assessment that can serve as the basis for life-long learning and development. CONCLUSIONS: Advancing EM education will require that high-quality education research results be translated into actual curricular, pedagogical, assessment, and professional development changes. The informed self-assessment framework is a method that is applicable to teaching and practice in EM.

Racial/Ethnic Differences in Emotional Health: A Longitudinal Study of Immigrants' Adolescent Children.

First, discrimination was conceptualized as a major source of stress for immigrants' adolescent children. Next, such children's emotional health (indicated by measures of self-esteem and depression) was examined for possible associations with discrimination, psychosocial supports, and social structure; additionally, race/ethnicity's possible moderating role in such associations was evaluated. Data from the first 2 waves of the Children of Immigrants Longitudinal Study (1991-2006) were employed, focusing on 3 groups: Asians, Hispanics, and Whites. Linear regression analyses were used to weigh how discrimination, psychosocial supports, and social structure measured at Wave 1 and Wave 2 related to self-esteem and depression measured at Wave 2. Asians exhibited the highest level of depression and were most likely to perceive discrimination; Asians' self-esteem was also low, compared to other groups'. Discrimination and psychosocial supports appeared to operate differentially in explaining the 3 groups' emotional health.

What's the Evidence: A Review of the One-Minute Preceptor Model of Clinical Teaching and Implications for Teaching in the Emergency Department.

BACKGROUND: The 2012 Academic Emergency Medicine Consensus Conference, "Education Research in Emergency Medicine: Opportunities, Challenges, and Strategies for Success" noted that emergency medicine (EM) educators often rely on theory and tradition in molding their approaches to teaching and learning, and called on the EM education community to advance the teaching of our specialty through the performance and application of research in teaching and assessment methods, cognitive function, and the effects of education interventions. OBJECTIVE: The purpose of this article is to review the research-based evidence for the effectiveness of the one-minute preceptor (OMP) teaching method, and to provide suggestions for its use in clinical teaching and learning in EM. DISCUSSION: This article reviews hypothesis-testing education research related to the use of the OMP as a pedagogical method applicable to clinical teaching. Evidence indicates that the OMP prompts the teaching of higher level concepts, facilitates the assessment of students' knowledge, and prompts the provision of feedback. Students indicate satisfaction with this method of clinical case-based discussion teaching. CONCLUSION: Advancing EM education will require that high quality education research results be translated into actual curricular, pedagogical, assessment, and professional development changes. The OMP is a pedagogical method that is applicable to teaching in the emergency department.

PROGNOSTIC VALUE OF THE MULTIPLE MINI-INTERVIEW FOR EMERGENCY MEDICINE RESIDENCY PERFORMANCE.

BACKGROUND: The Multiple Mini-Interview (MMI) uses short, structured contacts, and is known to predict medical school success better than traditional interviews and application materials. Its utility in Emergency Medicine residency selection is untested. OBJECTIVES: We investigate whether it provides additional information regarding future first-year resident performance that can be useful in resident selection. METHODS: From three Emergency Medicine residency programs, 71 interns in their first month completed an MMI developed to focus on desirable resident characteristics. Application data were reviewed. First-year resident performance assessments covering the American Council for Graduate Medical Education (ACGME) core competencies, along with professionalism and performance concerns, were obtained. Multiple logistic regressions were employed and MMI correlations were compared with program rank lists and typical selection factors. RESULTS: An individual's score on the MMI correlated with overall performance (p < 0.05) in single logistic regression. MMI correlated with ACGME individual competencies patient care and procedural skills at a less robust level (p < 0.1), but not with any other outcomes. Rank list position correlated with the diagnostic skill competency (p < 0.05), but no others. Traditional selection factors correlated with overall performance, disciplinary action, patient care, medical knowledge, and diagnostic skills (p < 0.05). MMI was not correlated significantly with the outcomes when included in multiple ordinal logistic regression with other selection factors. CONCLUSIONS: MMI scores correlate with overall performance, but are not statistically significant when other traditional selection factors were considered. The MMI process seems potentially superior to program rank list at correlating with first-year performance. The MMI may provide additional benefit when examined using a larger and more diverse sample.

The multiple mini-interview for emergency medicine resident selection.

BACKGROUND: The Multiple Mini-Interview (MMI) uses multiple, short-structured contacts to evaluate communication and professionalism. It predicts medical school success better than the traditional interview and application. Its acceptability and utility in emergency medicine (EM) residency selection are unknown. OBJECTIVE: We theorized that participants would judge the MMI equal to a traditional unstructured interview and it would provide new information for candidate assessment. METHODS: Seventy-one interns from 3 programs in the first month of training completed an eight-station MMI focused on EM topics. Pre- and post-surveys assessed reactions. MMI scores were compared with application data. RESULTS: EM grades correlated with MMI performance (F[1, 66] = 4.18; p < 0.05) with honors students having higher scores. Higher third-year clerkship grades were associated with higher MMI performance, although this was not statistically significant. MMI performance did not correlate with match desirability and did not predict most other components of an application. There was a correlation between lower MMI scores and lower global ranking on the Standardized Letter of Recommendation. Participants preferred a traditional interview (mean difference = 1.36; p < 0.01). A mixed format (traditional interview and MMI) was preferred over a MMI alone (mean difference = 1.1; p < 0.01). MMI performance did not significantly correlate with preference for the MMI. CONCLUSIONS: Although the MMI alone was viewed less favorably than a traditional interview, participants were receptive to a mixed-methods interview. The MMI does correlate with performance on the EM clerkship and therefore can measure important abilities for EM success. Future work will determine whether MMI performance predicts residency performance.

Evidence for Site-Specific, Systematic Adaptation of Substance Prevention Curriculum With High Risk Youth in Community and Alternative School Settings.

The problem of substance use among older youth is of great concern, but has received little attention in prevention research. This may be due to the perception that prevention programming is developmentally inappropriate for older youth who are actively experimenting with substances. This project examined the differential effectiveness of youth-driven adaptations of the evidence-based prevention program, keepin' it REAL (KiR). The participating sites included a juvenile justice day program, a homeless shelter, four alternative high schools, low-income housing programs, an LGBTQ youth center, and a youth group on the Texas-Mexico border. In the project's first phase, high risk youth in community settings tailored KiR workbooks and videos to increase the relevance for their peers, older adolescents who are likely to have already initiated drug use. The second phase of the study, discussed here in detail, evaluates the effectiveness of the adapted versions of KiR compared with the original version and a comparison condition. The study employed a quasi-experimental pretest posttest design with a 6-week follow-up. Youth also participated in focus groups. Both qualitative and quantitative data suggest that participants receiving the adapted version of the curriculum experienced greater improvement in acceptance and use of substances than youth in the other two groups.

Training for Adaptive Expertise: Why, What, and How.

BACKGROUND: Routine expertise is the efficient use of mastered skills at a high level of competency in familiar situations. PROBLEM: Novel case variation and continuous scientific advances preclude reliance on routine expertise alone. SOLUTION: Medical training programs must prepare learners to solve unfamiliar problems by cultivating adaptive expertise. Adaptive expertise is the ability to transfer existing knowledge to innovate a solution for an unfamiliar problem.

What the experts see: A qualitative analysis of the behaviors of master adaptive learners in emergency medicine.

Objectives: The Master Adaptive Learner (MAL) model postulates that learners develop adaptive expertise through cycles of self-regulated learning. Despite a robust theoretical basis, the actual observable behaviors of MALs are not well characterized. We sought to define behaviors that characterize MALs within emergency medicine (EM) training. Methods: Using a constructivist grounded theory approach, we analyzed semistructured interviews with expert EM educators. These experts reflected on observable behaviors as well as factors in the clinical learning environment that may modulate these behaviors. We recruited using purposive sampling until thematic saturation. Results: We identified four overall themes, of which three described groups of learner behaviors and a fourth described modifiers of these behaviors. Learner behaviors include: (1) critical interrogation of practice, (2) intellectual risk-taking, and (3) intentional curation of a learning network. Critical interrogation of practice encompasses several observable behaviors including learner-driven feedback conversations, independent synthesis of clinical information, appropriate deviation from algorithms based on their conceptual understanding of core principles, intentional use of case variation and hypothetical questioning, and continuous refinement of decisions. MALs also engage in intellectual risk-taking for their development by communicating clinical decision-making processes even at the risk of being wrong, openly addressing errors and gaps, and intentionally seeking out uncomfortable experiences. Intentional curation of a learning network is the deliberate development of a consortium of trusted individuals who serve as mentors and sounding boards. We also identified a fourth theme related to the expression of learner behaviors: learning environment modulates behaviors. Active promotion of psychological safety is necessary for learners to express these behaviors. This safety is mediated through trusting relationships and expert supervisors who serve as colearners and role models. Conclusions: We present several behaviors that allow identification of MALs among EM trainees. These data expand our understanding of MALs and the critical influence of the learning environment. Identification of these behaviors may allow for more precise categorization of targeted curricular interventions and meaningful learning outcomes.

Understanding clerkship experiences in emergency medicine and their potential influence on specialty selection: A qualitative study.

Objectives: The specialty of emergency medicine (EM) is experiencing a significant decrease in student interest. In addition, women are historically underrepresented within the specialty at all levels of training and practice. We sought to understand how clinical experiences and perceptions of EM influence specialty selection by medical students, particularly women. Methods: Using a constructivist grounded theory approach, we analyzed semistructured interviews with senior medical students who considered EM as a specialty. We used purposive sampling to recruit from diverse learning environments and represent a variety of experiences. Participants reflected on their specialty selection process and experiences in EM including their perceived acceptance in the work environment. Results: Twenty-five medical students from 11 geographically diverse schools participated. A total of 68% (17/25) identified as women. The majority (21/25, 84%) planned on applying to EM residency. We identified four major themes: (1) distressing interpersonal interactions with patients and the ED care team negatively affect students; (2) EM culture includes behaviors that are perceived as exclusionary; (3) beliefs about the attributes of an ideal EM physician and the specialty itself have a gendered nature; and (4) ease of access to mentors, representation, and early exposure to EM environment increased interest in specialty. Conclusions: Our participants express that EM causes challenges for students to accept the norms of behavior in the field, which is an essential element in joining a group and professional identity formation. In addition, we raise concern that gendered perceptions and language may send exclusionary environmental cues that may negatively impact recruitment of a diverse physician workforce.

Staffing Patterns of Non-ACGME Fellowships with 4-Year Residency Programs: A National Survey.

Introduction: Emergency medicine (EM) is one of few specialties with variable training lengths. Hiring a three-year graduate to continue fellowship training in a department that supports a four-year residency program can lead to conflicts around resident supervision. We sought to understand hiring and clinical supervision, or staffing, patterns of non-Accreditation Council for Graduate Medical Education (ACGME) fellowships hosted at institutions supporting four-year residency programs. Methods: We performed a web-based, cross-sectional survey of non-ACGME fellowship directors (FD) hosted at institutions supporting four-year EM residency programs. We calculated descriptive statistics. Our primary outcome was the proportion of programs with four-year EM residencies that hire non-ACGME fellows graduating from three-year EM residencies. Results: Of 119 eligible FDs, 88 (74%) completed the survey. Seventy FDs (80%) indicated that they hire graduates of three-year residencies. Fifty-six (80%) indicated that three-year graduates supervise residents. Most FDs (74%) indicated no additional requirements exist to supervise residents outside of being hired as faculty. The FDs cited department policy, concerns about quality and length of training, and resident complaints as reasons for not hiring three-year graduates. A majority (10/18, 56%) noted that not hiring fellows from three-year programs negatively impacts recruitment and gives them access to a smaller applicant pool. Conclusion: Most non-ACGME fellowships at institutions with four-year EM programs recruit three-year graduates and allow them to supervise residents. This survey provides programs information on how comparable fellowships recruit and staff their departments, which may inform policies that fit the needs of their learners, the fellowship, and the department.

Oh, the places you'll go! A qualitative study of resident career decisions in emergency medicine.

Objectives: Postresidency career choices are complex decisions that involve personal, professional, and financial preferences and may be influenced by training programs. It is unknown how residents navigate these decisions during emergency medicine (EM) residency. We explored EM residents' perspectives on career decision making and how residency programs can support career planning. Methods: We conducted semistructured interviews at seven accredited EM residency programs from diverse locations and training formats. We used purposive sampling to reflect the diversity of trainees with regard to gender, level of training, and career plans. Two researchers independently coded the transcripts. We used a constructivist-interpretivist paradigm to guide our thematic analysis. Results: We interviewed 11 residents and identified major themes in three categories. Residents described being exposed to career options through formalized curricula such as required rotations, career fairs, and subspeciality tracks, highlighting the importance of access to faculty with diverse areas of clinical and academic expertise. Many noted that exposure was often self-driven. We identified three major themes regarding career decisions: instrumental factors, people involved, and processes of decision making. Instrumental factors included personal interests, goals, and values as well as practice characteristics, financial considerations, timing, and opportunity costs. Mentors and family were highly involved in resident career decisions. Residents often utilized reflection and conversations with mentors and peers in their decision-making process. Participants recommended that programs provide exposure to diverse career options early in training, protect time for career education, and ensure adequate mentorship and a supportive community. Participants suggested specific curricular content and strategies to support career decisions. Conclusions: This study illuminates important factors involved in resident career decision making and how programs can support their trainees. Essential components include diverse experiences and building a reflective mentorship environment.

Impact of drone-specific dispatch instructions on the safety and efficacy of drone-delivered emergency medical treatments: A randomized simulation pilot study.

Introduction: Medical drones have potential for improving the response times to out-of-hospital emergencies. However, widespread adoption is hindered by unanswered questions surrounding medical dispatch and bystander safety. This study evaluated the impact of novel drone-specific dispatch instructions (DSDI) on bystanders' ability to interact effectively with a medical drone and provide prompt, safe, and high-quality treatment in a simulated emergency scenario. We hypothesized DSDI would improve bystanders' performance and facilitate safer bystander-drone interactions. Methods: Twenty-four volunteers were randomized to receive either DSDI and standard Medical Priority Dispatch (MPD) instructions or MPD alone in a simulated out-of-hospital cardiac arrest (OHCA) or pediatric anaphylaxis.,3 Participants in the DSDI group received detailed instructions on locating and interacting with the drone and its enclosed medical kit. The simulations were video recorded. Participants completed a semi-structured interview and survey. Results: The addition of DSDI did not lead to statistically significant changes to the overall time to provide care in either the anaphylaxis or OHCA simulations. However, DSDI did have an impact on bystander safety. In the MPD only group, 50% (6/12) of participants ignored the audio and visual safety cues from the drone instead of waiting for it to be declared safe compared to no DSDI participants ignoring these safety cues. Conclusions: All participants successfully provided patient care. However, this study indicates that DSDI may be useful to ensure bystander safety and should be incorporated in the continued development of emergency medical drones.

Bystander interaction with a novel multipurpose medical drone: A simulation trial.

Intro: Medical drones are an emerging technology which may facilitate rapid treatment in time-sensitive emergencies. However, drones rely on lay rescuers, whose interactions with multipurpose medical drones have not been studied, and the optimal drone design remains unclear. Methods: We conducted 24 simulations of adult out-of-hospital cardiac arrest (OHCA) and pediatric anaphylaxis with a prototype drone equipped with spoken and visual cues and a multipurpose medical kit. 24 layperson volunteers encountered one of the two scenarios and were supported through administering treatment by a simulated 911 dispatcher. Bystander-drone interactions were evaluated via a convergent parallel mixed methods approach using surveys, video event review, and semi-structured interviews. Results: 83% (20/24) of participants voiced comfort interacting with the drone. 96% (23/24) were interested in future interaction. Participants appreciated the drone's spoken instructions but found visual cues confusing. Participants retrieved the medical kit from the drone in a mean of 5 seconds (range 2-14) of drone contact; 79% (19/24) found this step easy or very easy. The medical kit's layered design caused difficulty in retrieving appropriate equipment. Participants expressed a wide range of reactions to the unique drone design. Conclusions: Laypeople can effectively and comfortably interact with a medical drone with a novel design. Feedback on design elements will result in further refinements and valuable insights for other drone designers. A multipurpose medical kit created more challenges and indicates the need for further refinement to facilitate use of the equipment.

Deciphering a Changing Match Environment in Emergency Medicine and Identifying Residency Program Needs.

INTRODUCTION: The Match in emergency medicine (EM) is historically competitive for applicants; however, the 2022 residency Match had a large number of unfilled positions. We sought to characterize the impact of and response to the Match on programs and determine programs' needs for successful recruitment strategies. METHODS: We conducted a web-based survey of EM residency program leadership during March-April 2022. Program characteristics were generated from publicly available data, and descriptive statistics were generated. We analyzed free-text responses thematically. RESULTS: There were 133/277 (48%) categorical EM residency programs that responded. Of those, 53.8% (70/130) reported a negative impression of their Match results; 17.7% (23/130) positive; and the remainder neutral (28.5%; 37/130). Three- and four-year programs did not differ in their risk of unfilled status. Hybrid programs had a higher likelihood of going unfilled (odds ratio [OR] 4.52, confidence interval [CI] 1.7-12.04) vs community (OR 1.62, CI 0.68-3.86) or university programs (0.16, 0.0-0.49). Unfilled programs were geographically concentrated. The quality of applicants was perceived the same as previous years and did not differ between filled and unfilled programs. Respondents worried the expansion of EM residency positions and perceptions of the EM job market were major factors influencing the Match. They expressed interest in introducing changes to the interview process, including caps on applications and interviews, as well as a need for more structural support for programs and the specialty. CONCLUSION: This survey identifies impacts of the changed match environment on a broad range of programs and identifies specific needs. Future work should be directed toward a deeper understanding of the factors contributing to changes in the specialty and the development of evidence-based interventions.