Linking Patient Care Ownership and Professional Identity Formation through Simulation.

THEORY: The link between ownership of patient care and professional identity formation (PIF) has not been formally established, yet PIF researchers frequently cite clinical experiences as powerful contributions to PIF. Hypothesis: Using clinical simulation, this study aimed to explore the relationship between patient care ownership and the cognitive processes involved in the creation of a professional identity. Methods: In 2018-2019, 189 third-year students participated in a simulation in which they were placed in the role of a physician treating a patient in respiratory distress. Data were collected from 12 focus groups (n = 84; 44% of the third-year class), each lasting 15-25 minute. Students were asked four questions designed to identify moments when they felt like a physician and experienced feelings of ownership. Each focus group was transcribed and analyzed for the presence of known elements that contribute to feelings of psychological ownership, and then inductively for how students related their feelings of ownership to their professional identity. Results: When students were asked to take ownership of their patient's care, they underwent a three-step process: (1) experiencing disorientation, (2) reconceptualizing roles and responsibilities, and (3) reorientation to professional goals. Patient care ownership was disorienting because it marked a departure from the clinical roles the students had previously experienced. While disoriented, students engaged in a process of reflection during which they asked themselves who they were, who they were becoming, and who they needed to become to effectively serve in the role of a physician. This process prompted students to realize the limitations of their clinical reasoning abilities and that the role of a physician requires new ways of thinking. Conclusions: This study advances a conceptual model of PIF that identifies patient care ownership as a catalyst in developing a professional identity. Assuming responsibility for patients places students into an unfamiliar role, which opens a channel for students to access new perspectives in their development as physicians.

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.

A Comparison of 2 Debriefing Rubrics to Assess Facilitator Adherence to the PEARLS Debriefing Framework.

INTRODUCTION: Many educators have adopted the Promoting Excellence and Reflective Learning in Simulation (PEARLS) model to guide debriefing sessions in simulation-based learning. The PEARLS Debriefing Checklist (PDC), a 28-item instrument, and the PEARLS Debriefing Adherence Rubric (PDAR), a 13-item instrument, assess facilitator adherence to the model. The aims of this study were to collect evidence of concurrent validity and to evaluate their unique strengths. METHODS: A review of 130 video recorded debriefings from a synchronous high-fidelity mannequin simulation event involving third-year medical students was undertaken. Each debriefing was scored utilizing both instruments. Internal consistency was determined by calculating a Cronbach's α. A Pearson correlation was used to evaluate concurrent validity. Discrimination indices were also calculated. RESULTS: Cronbach's α values were 0.515 and 0.714 for the PDAR and PDC, respectively, with ≥0.70 to ≤0.90 considered to be an acceptable range. The Pearson correlation coefficient for the total sum of the scores of both instruments was 0.648, with a values between ±0.60 and ±0.80 considered strong correlations. All items on the PDAR had positive discrimination indices; 3 items on the PDC had indices ≤0, with values between -0.2 and 0.2 considered unsatisfactory. Four items on both instruments had indices >0.4, indicating only fair discrimination between high and low performers. CONCLUSIONS: Both instruments exhibit unique strengths and limitations. The PDC demonstrated greater internal consistency, likely secondary to having more items, with the tradeoff of redundant items and laborious implementation. Both had concurrent validity in nearly all subdomains. The PDAR had proportionally more items with high discrimination and no items with indices ≤0. A revised instrument incorporating PDC items with high reliability and validity and removing those identified as redundant or poor discriminators, the PDAR 2, is proposed.

Small bowel perforation secondary to fish bone ingestion managed non-operatively.

BACKGROUND: The presurgical diagnosis of foreign body (FB)-induced bowel perforation is exceedingly difficult. Perforation most commonly occurs in the ileocecal region and typically mimics diagnoses more common to the right lower quadrant (RLQ), including appendicitis and diverticulitis. OBJECTIVES: This report will discuss the events of this particular case of fish bone ingestion and subsequent small bowel perforation and the epidemiology, diagnosis, and management of FB ingestions. CASE REPORT: This case describes a 28-year-old man who presents with a 4-h history of sharp, stabbing abdominal pain localized to the RLQ. Abdominal computed tomography revealed a 1.5-cm curvilinear foreign body traversing through a loop of small bowel in the RLQ. Upon further questioning, the patient recalled eating northern pike 2 days before. During his hospital stay, the patient noted improvement of his symptoms and thus was managed non-operatively without complication. The patient was discharged after complete resolution of his abdominal pain on hospital day number 2. CONCLUSION: This represents a rare case of small bowel perforation secondary to fish bone ingestion that was managed non-operatively without complication.

Leveraging Medical Simulation for Faculty Development in Interprofessional Education: A Pilot Study.

This mixed-methods pilot study aimed to determine the faculty perceptions and knowledge of interprofessional education (IPE) before and after a faculty development program at a health sciences campus that used medical simulation as the pedagogy. Thirty health professions faculty completed a pre- and post-survey instrument to evaluate their understanding and perceptions of IPE. The survey data were analyzed using paired t-tests. Participants contributed post-training to a semi-structured focus group that used thematic analysis. The pilot study findings included a statistically significant increase in IPE knowledge and perceptions by the participating faculty, corroborated by the focus group responses. The focus group responses emphasized the use of IPE: to teach soft skills in communication to students, to create a new culture of healthcare professionals, to discuss role biases and assumptions, and to create of a new healthcare team which included non-caregivers.

Impact of group size on the effectiveness of a resuscitation simulation curriculum for medical students.

BACKGROUND: Simulation requires involvement from participants. However, it is unknown to what extent simulation effectiveness is a function of the number of participants. PURPOSE: This study assessed the impact of varying group size on medical students' subjective experience of simulation and on postsimulation exam performance. METHODS: Medical students were randomly assigned to groups of 2, 3, or 4. Retrospective assessment was done through a survey assessing confidence and knowledge as it relates to resuscitation and statements related to group size. Performance on a postsimulation exam was analyzed. RESULTS: There were significant increases in students' confidence and knowledge following simulation. There were no significant differences in student perception of the effectiveness or realism of the simulation or in performance on the postsimulation exam as a function of group size. CONCLUSIONS: Students feel that simulation is an effective way to learn medical knowledge. Varying group size had no effect on students' subjective experience or exam performance.

No relationship between measures of clinical efficiency and teaching effectiveness for emergency medicine faculty.

OBJECTIVES: Emergency medicine (EM) doctors affiliated with academic institutions experience professional tension between providing excellent, timely care for patients and high-quality bedside instruction for residents and medical students. The goal of this study was to assess the relationship between measures of faculty clinical efficiency and teaching effectiveness. METHODS: This was a retrospective review of data from a single academic institution with an annual census of 55,000. Faculty clinical efficiency was measured by two variables: the relative value unit (RVU)/h ratio and average 'door to discharge' time. Teaching effectiveness was estimated by determining the average 'overall teaching' scores derived from anonymous EM resident and senior medical student evaluations. Relationships were assessed using the Spearman's correlation coefficient. RESULTS: There was no statistically significant relationship (p>0.050) between measures of faculty clinical efficiency and teaching effectiveness. CONCLUSION: These data replicate previous findings that clinical productivity has no correlation with teaching effectiveness for emergency medicine faculty doctors.

Student Performance During a Simulated Patient Encounter Has No Impact on Debriefer Adherence to PEARLS Debriefing Model.

PURPOSE: Debriefing is necessary for effective simulation education. The PEARLS (Promoting Excellence and Reflective Learning in Simulations) is a scripted debriefing model that incorporates debriefing best practices. It was hypothesized that student simulation performance might impact facilitator adherence to the PEARLS debriefing model. There are no published findings on the effect of student performance on debriefer behavior. METHODS: Third-year medical students participated in a video-recorded, formative simulation to treat a high-fidelity mannequin for an asthma exacerbation. A faculty debriefer trained in the PEARLS model evaluated student performance with a standardized rubric and conducted a recorded debriefing. Debriefing recordings were analyzed for debriefer adherence to the PEARLS model. Debriefers were assigned a debriefing score (DS) from 0 to 13; 13 was perfect adherence to the model. Definitive intervention (DI) for asthma exacerbation was defined as bronchodilator therapy. Critical actions were as follows: a focused history, heart/lung exam, giving oxygen, and giving a bronchodilator. RESULTS: Mean DS for the debriefers of students who provided DI was 8.57; 9.14 for those students who did not (P = 0.25). Mean DS for debriefers of students who completed all critical actions was 8.68; 8.52 for those students who did not (P = 0.62). Analysis of elapsed time to DI showed no relationship between the time DI was provided and DS. CONCLUSIONS: Student performance had no impact on debriefer performance, suggesting the PEARLS model is an effective aid for debriefers, regardless of learner performance. These findings suggest student performance may not bias facilitators' ability to conduct quality debriefings.

Improved medical student satisfaction and test performance with a simulation-based emergency medicine curriculum: a randomized controlled trial.

STUDY OBJECTIVE: We determine the effect of a simulation-based curriculum on fourth-year medical student test performance and satisfaction during an emergency medicine clerkship. METHODS: This was a randomized controlled study using a crossover design for curriculum format and an anonymous end-of-rotation satisfaction survey. Students were randomized into 2 groups. One group started the rotation with simulation and the other with group discussion. Midrotation, they each crossed over to the opposite format. All students subsequently completed the same multiple choice examination. We assessed paired samples of the number of questions missed for material taught in each format. Students rated satisfaction with a 5-point Likert scale framed as attitude toward simulation compared with group discussion. Scores ranged from 5, signifying strong agreement with a statement, to 1, signifying strong disagreement. RESULTS: Ninety students (99%) completed the multiple choice test. Significantly fewer questions were missed for material presented in simulation format compared with group discussion, with a mean difference per student of 0.7 (95% confidence interval [CI] 0.3 to 1.0; P=.006). This corresponds to mean scores of 89.8% for simulation and 86.4% for group discussion. Eighty-eight (97%) students completed the satisfaction survey. Students rated simulation as more stressful (mean 4.1; 95% CI 3.9 to 4.3), but also more enjoyable (mean 4.5; 95% CI 4.3 to 4.6), more stimulating (mean 4.7; 95% CI 4.5 to 4.8), and closer to the actual clinical setting (mean 4.6; 95% CI 4.4 to 4.7) compared with group discussion. CONCLUSION: A simulation-based curriculum yielded measurable benefits. Students demonstrated a small improvement in learning and were more satisfied with the simulation-based curriculum compared with group discussion.

Teaching when Time Is Limited: a Resident and Fellow as Educator Video Module.

BACKGROUND: Research has demonstrated that residents and fellows (hereafter referred to as "residents") play a significant role in the education of medical students. However, residents often feel unprepared to teach effectively and efficiently in busy clinical environments. ACTIVITY: The Residents as Educators Committee at the Medical College of Wisconsin sought to create an online module for residents to promote five key elements of teaching medical students in a busy clinical environment when time is limited. The module includes a narrated presentation highlighting key attributes of excellent clinical teachers as well as video clips presenting teaching pearls from award-winning resident educators. All incoming residents during the 2015-2016 academic year were required to view the module and complete a mandatory post-test, representing over 80 specialties and subspecialties. RESULTS: A total of 325 residents viewed the module and took the required post-test. Of this group, 294 residents (91.4%) completed the optional evaluation. The module was rated highly in terms of content, format, and likelihood to change teaching practices. DISCUSSION: The teaching provided by residents is vital to the success of future generations of medical students. The online module developed at the Medical College of Wisconsin may be useful to a larger audience of residents at other institutions. Additionally, further studies could determine the effectiveness of the module by examining the teaching evaluations of residents before and after viewing the module.

The National Clinical Assessment Tool for Medical Students in the Emergency Department (NCAT-EM).

INTRODUCTION: Clinical assessment of medical students in emergency medicine (EM) clerkships is a highly variable process that presents unique challenges and opportunities. Currently, clerkship directors use institution-specific tools with unproven validity and reliability that may or may not address competencies valued most highly in the EM setting. Standardization of assessment practices and development of a common, valid, specialty-specific tool would benefit EM educators and students. METHODS: A two-day national consensus conference was held in March 2016 in the Clerkship Directors in Emergency Medicine (CDEM) track at the Council of Residency Directors in Emergency Medicine (CORD) Academic Assembly in Nashville, TN. The goal of this conference was to standardize assessment practices and to create a national clinical assessment tool for use in EM clerkships across the country. Conference leaders synthesized the literature, articulated major themes and questions pertinent to clinical assessment of students in EM, clarified the issues, and outlined the consensus-building process prior to consensus-building activities. RESULTS: The first day of the conference was dedicated to developing consensus on these key themes in clinical assessment. The second day of the conference was dedicated to discussing and voting on proposed domains to be included in the national clinical assessment tool. A modified Delphi process was initiated after the conference to reconcile questions and items that did not reach an a priori level of consensus. CONCLUSION: The final tool, the National Clinical Assessment Tool for Medical Students in Emergency Medicine (NCAT-EM) is presented here.

Increasing Completion Rate of an M4 Emergency Medicine Student End-of-Shift Evaluation Using a Mobile Electronic Platform and Real-Time Completion.

INTRODUCTION: Medical students on an emergency medicine rotation are traditionally evaluated at the end of each shift with paper-based forms, and data are often missing due to forms not being turned in or completed. Because students' grades depend on these evaluations, change was needed to increase form rate of return. We analyzed a new electronic evaluation form and modified completion process to determine if it would increase the completion rate without altering how faculty scored student performance. METHODS: During fall 2013, 29 faculty completed paper N=339 evaluations consisting of seven competencies for 33 students. In fall 2014, an electronic evaluation form with the same competencies was designed using an electronic platform and completed N=319 times by 27 faculty using 25 students' electronic devices. Feedback checkboxes were added to facilitate collection of common comments. Data was analyzed with IBM® SPSS® 21.0 using multi-factor analysis of variance with the students' global rating (GR) as an outcome. Inter-item reliability was determined with Cronbach alpha. RESULTS: There was a significantly higher completion rate (p=0.001) of 98% electronic vs. 69% paper forms, lower (p=0.001) missed GR rate (1% electronic. vs 12% paper), and higher mean scores (p=0.001) for the GR with the electronic (7.0±1.1) vs. paper (6.8±1.2) form. Feedback checkboxes were completed on every form. The inter-item reliability for electronic and paper forms was each alpha=0.95. CONCLUSION: The use of a new electronic form and modified completion process for evaluating students at the end of shift demonstrated a higher faculty completion rate, a lower missed data rate, a higher global rating and consistent collection of common feedback. The use of the electronic form and the process for obtaining the information made our end-of-shift evaluation process for students more reliable and provided more accurate, up-to-date information for student feedback and when determining student grades.

Hypothyroidism: mimicker of common complaints.

Hypothyroidism is a common condition presenting a challenge to emergency physicians in diagnosing the underlying etiology of vague complaints. Making the diagnosis of a critically ill patient in myxedema coma allows early treatment with appropriate thyroid hormone replacement and avoids higher patient mortality. To do this, the emergency physician must maintain a high degree of clinical suspicion for thyroid disease.

Hyperthyroidism.

The clinical spectrum of hyperthyroidism varies from asymptomatic,subclinical hyperthyroidism to the life-threatening "thyroid storm". Hyperthyroidism is a common form of thyroid disease that mimics many of the common complaints in the emergency department. The diagnosis of hyperthyroidism is often challenging due to the multitude of physical and even psychiatric complaints. Recognition and treatment by emergency physicians of severe hyperthyroidism is critical and can be life saving.

Correction: Diagnostic Potential of the NMDA Receptor Peptide Assay for Acute Ischemic Stroke.

[This corrects the article DOI: 10.1371/journal.pone.0042362.].

Situation-Background-Assessment-Recommendation (SBAR) and Emergency Medicine Residents' Learning of Case Presentation Skills.

BACKGROUND: To date, no standardized presentation format is taught to emergency medicine (EM) residents during patient handoffs to consulting or admitting physicians. The Situation-Background-Assessment-Recommendation (SBAR) is a common format that provides a consistent framework to communicate pertinent information. OBJECTIVE: The objective of this study was to describe and evaluate the feasibility of using SBAR to teach interphysician communication skills to first-year EM residents to use during patient handoffs. METHODS: An educational study was designed as part of a pilot curriculum to teach first-year EM residents handoff communication skills. A standardized SBAR reporting format was taught during a 1-hour didactic intervention. All residents were evaluated using pretest/posttest simulated cases using a 17-item SBAR checklist initially, and then within 4 months to assess retention of the tool. A survey was distributed to determine resident perceptions of the training and potential clinical utility. RESULTS: There was a statistically significant improvement from the resident scores on the pretest/posttest of the first case (P  =  .001), but there was no difference between posttest of the first case and pretest of the second case (P  =  .34), suggesting retention of the material. There was a statistically significant improvement from the pretest and posttest scores on the second case (P  =  .001). The survey yielded good reliability for both sessions (Cronbach alpha  =  0.87 and 0.89, respectively), demonstrating statistically significant increases for the perceived quality of training, presentation comfort level, and the use of SBAR (P  =  .001). CONCLUSION: SBAR was acceptable to first-year EM residents, with improvements in both the ability to apply SBAR to simulated case presentations and retention at a follow-up session. This format was feasible to use as a training method and was well received by our resident physicians. Future research will be useful in examining the general applicability of the SBAR model for interphysician communications in the clinical environment and residency training programs.