The integrative feedback tool: assessing a novel feedback tool among emergency medicine residents.

OBJECTIVE: Feedback is critical to the growth of learners. However, feedback quality can be variable in practice. Most feedback tools are generic, with few targeting emergency medicine. We created a feedback tool designed for emergency medicine residents, and this study aimed to evaluate the effectiveness of this tool. METHODS: This was a single-center, prospective cohort study comparing feedback quality before and after introducing a novel feedback tool. Residents and faculty completed a survey after each shift assessing feedback quality, feedback time, and the number of feedback episodes. Feedback quality was assessed using a composite score from seven questions, which were each scored 1 to 5 points (minimum total score, 7 points; maximum, 35 points). Preintervention and postintervention data were analyzed using a mixed-effects model that took into account the correlation of random effects between study participants. RESULTS: Residents completed 182 surveys and faculty members completed 158 surveys. The use of the tool was associated with improved consistency in the summative score of effective feedback attributes as assessed by residents (P=0.040) but not by faculty (P=0.259). However, most of the individual scores for attributes of good feedback did not reach statistical significance. With the tool, residents perceived that faculty spent more time providing feedback (P=0.040) and that the delivery of feedback was more ongoing throughout the shift (P=0.020). Faculty felt that the tool allowed for more ongoing feedback (P=0.002), with no perceived increase in the time spent delivering feedback (P=0.833). CONCLUSION: The use of a dedicated tool may help educators provide more meaningful and frequent feedback without impacting the perceived required time needed to provide feedback.

Racial and Ethnic Differences in Hospital Admissions of Emergency Department COVID-19 Patients.

BACKGROUND: Several studies have found that among patients testing positive for COVID-19 within a health care system, non-Hispanic Black and Hispanic patients are more likely than non-Hispanic White patients to be hospitalized. However, previous studies have looked at odds of being admitted using all positive tests in the system and not only those seeking care in the emergency department (ED). OBJECTIVE: This study examined racial/ethnic differences in COVID-19 hospitalizations and intensive care unit (ICU) admissions among patients seeking care for COVID-19 in the ED. RESEARCH DESIGN: Electronic health records (n=7549) were collected from COVID-19 confirmed patients that visited an ED of an urban health care system in the Chicago area between March 2020 and February 2021. RESULTS: After adjusting for possible confounders, White patients had 2.2 times the odds of being admitted to the hospital and 1.5 times the odds of being admitted to the ICU than Black patients. There were no observed differences between White and Hispanic patients. CONCLUSIONS: White patients were more likely than Black patients to be hospitalized after presenting to the ED with COVID-19 and more likely to be admitted directly to the ICU. This finding may be due to racial/ethnic differences in severity of disease upon ED presentation, racial and ethnic differences in access to COVID-19 primary care and/or implicit bias impacting clinical decision-making.

Consensus Development of a Core Content for a Standardized Medical Toxicology Curriculum for Medical Students.

BACKGROUND: Currently, no standardized core content in medical toxicology exists for medical students. The goals of this study were to (1) assess the current state and needs of medical toxicology clerkships and (2) develop a consensus-derived list of core topics that should be covered during a medical toxicology clerkship. METHODS: We assembled a task force established by the American College of Medical Toxicology (ACMT) of nine experts in medical toxicology or emergency medicine. We developed a needs assessment survey that was sent to all medical student clerkship directors in medical toxicology. Based on their responses, we used a modified Delphi process to develop a consensus of core topics that should be covered during a medical student clerkship. RESULTS: Nineteen out of 42 (45%) clerkship directors completed the survey; 18 met inclusion criteria. The majority of clerkships were 4 weeks in duration with an average of 15 students/year. The three most common teaching methods used were bedside teaching (n = 17/18), classroom teaching (n = 17/18), and journal club (n = 14/18). All the clerkship directors (n = 18/18) reported they would use a standardized curriculum as well as educational content developed by ACMT. There was overwhelming consensus on the core topics which included, but were not limited to, pharmacology/toxicology; drugs; drugs of abuse; natural products; pharmacological basis of antidote use; toxicologic syndromes; vital sign abnormalities; initial management; supportive and other care; withdrawal syndrome management; industrial, household, and environmental toxins; differential diagnosis by clinical findings; and ABCs-resuscitation. CONCLUSION: The ACMT task force developed a medical toxicology clerkship core content. The task force also identified a need for shared resources among clerkships.

The Performance and Trajectory of Medical Students With Disabilities: Results From a Multisite, Multicohort Study.

PURPOSE: To conduct a post-Americans with Disabilities Act Amendments Act of 2008 multisite, multicohort study called the Pathways Project to assess the performance and trajectory of medical students with disabilities (SWDs). METHOD: From June to December 2020, the authors conducted a matched cohort study of SWDs and nondisabled controls from 2 graduating cohorts (2018 and 2019) across 11 U.S. MD-granting medical schools. Each SWD was matched with 2 controls, one from their institution and, whenever possible, one from their cohort for Medical College Admission Test score and self-reported gender. Outcome measures included final attempt Step 1 and Step 2 Clinical Knowledge scores, time to graduation, leave of absence, matching on first attempt, and matching to primary care. RESULTS: A total of 171 SWDs and 341 controls were included; the majority of SWDs had cognitive/learning disabilities (118/171, 69.0%). Compared with controls, SWDs with physical/sensory disabilities had similar times to graduation (88.6%, 95% confidence interval [CI]: 77.0, 100.0 vs 95.1%, 95% CI: 90.3, 99.8; P = .20), Step 1 scores (229.6 vs 233.4; P = .118), and match on first attempt (93.9%, 95% CI: 86.9, 100.0 vs 94.6%, 95% CI: 91.8, 97.4; P = .842), while SWDs with cognitive/learning disabilities had lower Step 1 scores (219.4; P < .001) and were less likely to graduate on time (81.2%, 95% CI: 69.2, 93.2; P = .003) and match on first attempt (85.3%, 95% CI: 78.0, 92.7; P = .009). Accommodated SWDs had Step 1 scores that were 5.9 points higher than nonaccommodated SWDs (95% CI: -0.7, 12.5; P = .08). CONCLUSIONS: Structural barriers remain for SWDs with cognitive/learning disabilities, which could be partially mitigated by accommodations on high-stakes exams.

Using a Diagnostic OSCE to Discern Deficit From Disability in Struggling Students.

PROBLEM: When medical students with disabilities fail, identifying the underlying cause is challenging. Faculty unfamiliar with disability-related barriers or accommodations may falsely attribute academic struggles to disability. Fear of legal action may prompt inappropriate promotion of students with disabilities who are struggling to meet competencies. Therefore, a clear understanding of the origin of difficulty is critical to determining an appropriate response to the student's failure, including revision of accommodations, academic remediation, probation, and dismissal. APPROACH: A large Midwestern medical college created an innovative approach to differentiate between disability-related barriers and academic deficits by creating a diagnostic objective structured clinical examination (OSCE). The goal of this OSCE was to determine the need for additional or refined accommodations versus clinical remediation, and to guide future decision making about a student on academic probation. Using 3 simulated cases that drew on a cross section of clinical knowledge, a team of clinical and disability specialists observed a disabled student to determine the origin of that student's difficulties in a clinical rotation. OUTCOMES: Using the diagnostic OSCE, the team quickly identified clinical reasoning and fund of knowledge deficits, and need for further accommodations. As a result, the team was able to remediate the clinical deficits, augment the current accommodations in vivo, and determine the potential impact on performance. The team approach was documented and facilitated the legally required interactive process for determining additional barriers, efficacy of existing accommodations, and need for additional reasonable accommodations. All parties reported a positive experience. The collective knowledge and expertise of the team helped confirm the origin of the deficit: a fundamental lack of knowledge and reasoning skills versus a disability-related barrier. NEXT STEPS: The next step is to formalize this process to ensure appropriate evaluation of students with disabilities.

Medical Student Documentation in the Electronic Medical Record: Patterns of Use and Barriers.

INTRODUCTION: Electronic health records (EHR) have become ubiquitous in emergency departments. Medical students rotating on emergency medicine (EM) clerkships at these sites have constant exposure to EHRs as they learn essential skills. The Association of American Medical Colleges (AAMC), the Liaison Committee on Medical Education (LCME), and the Alliance for Clinical Education (ACE) have determined that documentation of the patient encounter in the medical record is an essential skill that all medical students must learn. However, little is known about the current practices or perceived barriers to student documentation in EHRs on EM clerkships. METHODS: We performed a cross-sectional study of EM clerkship directors at United States medical schools between March and May 2016. A 13-question IRB-approved electronic survey on student documentation was sent to all EM clerkship directors. Only one response from each institution was permitted. RESULTS: We received survey responses from 100 institutions, yielding a response rate of 86%. Currently, 63% of EM clerkships allow medical students to document a patient encounter in the EHR. The most common reasons cited for not permitting students to document a patient encounter were hospital or medical school rule forbidding student documentation (80%), concern for medical liability (60%), and inability of student notes to support medical billing (53%). Almost 95% of respondents provided feedback on student documentation with supervising faculty being the most common group to deliver feedback (92%), followed by residents (64%). CONCLUSION: Close to two-thirds of medical students are allowed to document in the EHR on EM clerkships. While this number is robust, many organizations such as the AAMC and ACE have issued statements and guidelines that would look to increase this number even further to ensure that students are prepared for residency as well as their future careers. Almost all EM clerkships provided feedback on student documentation indicating the importance for students to learn this skill.