Development of an integrated milestone assessment tool across multiple early-adopter programs for breaking bad news: a pilot project.

BACKGROUND: The transition of the Accreditation Council for Graduate Medical Education (ACGME) to milestone assessment creates opportunities for collaboration and shared assessments across graduate medical programs. Breaking bad news is an essential communication skill that is a common milestone across almost every medical specialty. The purpose of this study was to develop and pilot an integrated milestone assessment (IMA) tool for breaking bad news using ACGME milestone criteria and to compare the IMA tool with the existing SPIKES protocol. METHODS: The IMA tool was created using sub-anchors in professionalism and interpersonal communication skills that are applicable to every specialty and to the ability to break bad news. Two cases of breaking bad news, designed to be "easy" and "intermediate" in difficulty, were used to assess basic skills in breaking bad news in first-year medical residents from six residency specialties. Eight standardized patients were trained to portray the cases in sessions held in November 2013 and May 2014. Standardized patients completed an assessment checklist to evaluate each resident's performance in breaking bad news based on their use of the SPIKES protocol and IMA tool. Residents answered post-encounter questions about their training and comfort in breaking bad news. The association between SPIKES and IMA scores was investigated by simple linear regression models and Spearman rank correlations. RESULTS: There were 136 eligible medical residents: 108 (79.4%) participated in the first session and 97 (71.3%) participated in the second session, with 96 (70.6%) residents participating in both sessions. Overall, we were able to identify residents that performed at both extremes of the assessment criteria using the integrated milestone assessment (IMA) and the SPIKES protocol. Interestingly, residents rated themselves below "comfortable" on average. CONCLUSION: We developed an integrated milestone assessment (IMA) that was better than the SPIKES protocol at assessing the skill of breaking bad news. This collaborative assessment tool can be used as supplement tool in the era of milestone transformation. We aim assess our tool in other specialties and institutions, as well as assess other shared milestones across specialties.

Twelve tips on creating and using custom GPTs to enhance health professions education.

The custom GPT is the latest powerful feature added to ChatGPT. Non-programmers can create and share their own GPTs ("chat bots"), allowing Health Professions Educators to apply the capabilities of ChatGPT to create administrative assistants, online tutors, virtual patients, and more, to support their clinical and non-clinical teaching environments. To achieve this correctly, however, requires some skills, and this 12-Tips paper provides those: we explain how to construct data sources, build relevant GPTs, and apply some basic security.

Educator's blueprint: A guide for clinician-educators to achieve promotion in emergency medicine.

Promotion and tenure (P&T) can be a complex process, which many junior faculty in academic emergency medicine may struggle navigating. This paper presents perspectives and key considerations to guide faculty through the promotions process. We explore tips through three key phases: plotting the course for a successful academic career, collecting data to support academic advancement, and packaging materials into a compelling application portfolio. This resource can inform faculty and faculty developers when planning for P&T.

"I'd rather see action": Application and recruitment experiences of underrepresented in emergency medicine trainees.

Objectives: The emergency medicine (EM) physician workforce is largely composed of white men. Despite recruitment efforts over the past decade, there has not been a significant increase of trainees with underrepresented racial and ethnic identities in EM (URM). Prior studies have focused on institutional strategies to improve diversity, equity, and inclusion (DEI) in EM residency recruitment but have been limited in describing URM trainees' perspectives. We sought to assess URM trainees' perspectives on DEI in the EM residency application and selection process. Methods: This study was conducted at an urban academic medical center in the United States from November 2021 to March 2022. Junior residents were invited to participate in individual semistructured interviews. We used a combined deductive-inductive approach to categorize responses in predetermined areas of interest then elicit dominant themes within each category through consensus discussions. Thematic saturation was reached after eight interviews, indicating adequate sample size. Results: Ten residents participated in semistructured interviews. All identified as racial or ethnic minorities. Three dominant themes emerged relating to authenticity, representation, and being treated as a learner first. Participants assessed the authenticity of a program's DEI efforts by evaluating the time frame and scope of DEI efforts. Participants reported a desire for representation of other URM colleagues in a residency program and training environment. While participants wanted their lived experience as URM trainees acknowledged, they were wary of being viewed solely through the lens of future DEI leaders rather than as learners first. Conclusions: URM residents value multifaceted commitment to DEI efforts, representation, and being seen as learners first when assessing residency programs. Programs seeking to recruit URM residents should develop a department-wide, multipronged, comprehensive DEI plan and showcase how their program will contribute to an applicant's professional development.

Reconceptualizing the emergency medicine resident scholarly requirement: Proposed framework and rubric.

Background: The completion of a scholarly project is a common program requirement by the Accreditation Council for Graduate Medical Education (ACGME) for all residency training programs. However, the implementation can vary significantly between programs. Lack of generalizable standards for scholarly projects required of all trainees within ACGME-accredited residencies has led to a large range of quality and effort put forth to complete these projects. Our goal is to introduce a framework and propose a corresponding rubric for application to resident scholarship to quantify and qualify the components of scholarship to better measure resident scholarly output across the graduate medical education (GME) continuum. Methods: Eight experienced educators and members of the Society for Academic Emergency Medicine Education Committee were selected to explore the current scholarly project guidelines and propose a definition that can be universally applied to diverse training programs. Following a review of the current literature, the authors engaged in iterative, divergent, and convergent discussions via meetings and asynchronous dialogue to develop a framework and associated rubric. Results: The group proposes that emergency medicine (EM) resident scholarship should (1) involve a structured process, (2) generate outcomes, (3) be disseminated, and (4) be peer reviewed. These components of resident scholarly activity are achieved whether this is a single project encompassing all four domains, or multiple smaller projects that sum to the whole. To assist residency programs in assessing a given individual resident's achievement of the standards set forth, a rubric is proposed. Conclusion: Based on current literature and consensus, we propose a framework and rubric for tracking of resident scholarly project achievement in an effort to elevate and advance EM scholarship. Future work should explore the optimal application of this framework and define minimal scholarship goals for EM resident scholarship.

Perceptions of Communication Between Emergency Medicine and Internal Medicine physicians.

As part of an institutional effort to develop an atmosphere of communication and encourage mutual appreciation of respective viewpoints, we used a cross-sectional survey to investigate the perceptions of emergency (EM) and internal medicine (IM) residents and faculty, particularly, their attitudes about collaboration, mutual respect, and mistreatment. This cross-sectional survey was administered to the EM and IM faculty and residents of a county, academic hospital with a Level 1 Trauma Center to evaluate each specialty's current perception of professional behavior and observations of unprofessional behavior in order to identify areas for improvement. The survey items were answered using a 5-point Likert scale and was analyzed using the unpaired t-test. A total of 68 residents and faculty completed the survey, 32 (59.4% residents) from EM and 36 (94.4% residents) from IM. Among all EM and IM clinicians, 48.6% felt that there was a culture of clinical collaboration. Approximately half of the respondents (51.5%) felt that the state of professionalism between the two departments was below that of other departments. About 10% (11.8%) of all respondents reported experiencing unprofessional behaviors from the other department at least once a month. Challenges identified by EM faculty and residents included time to consult, recommendations, and disposition. Challenges identified by IM included difficulty contacting EM providers and lack of communication regarding patient's clinical status changes. Both specialties emphasized the importance of improved patient care transitional processes. This study is an important first look at the prevalence of negative attitudes and misperceptions between EM and IM providers. These perspectives can occur due to breakdown of communication and differing expectations. Such asynchronies can cause a toxic workplace environment, diminished performance, and poor patient outcomes.

Overcoming barriers to promotion for women and underrepresented in medicine faculty in academic emergency medicine.

Equity in the promotion of women and underrepresented minorities (URiM) is essential for the advancement of academic emergency medicine and the specialty as a whole. Forward-thinking healthcare organizations can best position themselves to optimally care for an increasingly diverse patient population and mentor trainees by championing increased diversity in senior faculty ranks, leadership, and governance roles. This article explores several potential solutions to addressing inequities that hinder the advancement of women and URiM faculty. It is intended to complement the recently approved American College of Emergency Physicians (ACEP) policy statement aimed at overcoming barriers to promotion of women and URiM faculty in academic emergency medicine. This policy statement was jointly released and supported by the Society for Academic Emergency Medicine (SAEM), American Academy of Emergency Medicine (AAEM), and the Association of Academic Chairs of Emergency Medicine (AACEM).

Let's Escape Didactics: Virtual Escape Room as a Didactic Modality in Residency.

Audience: The virtual escape room is a didactic activity for emergency medicine residents (interns, junior residents, senior residents). Introduction: Residency programs are employing a wide variety of active learning techniques to engage their learners, including large-group discussion, small-group activities, team-based learning, gamification, problem-based learning, role-playing and case studies. In recent years, educators have drawn their attention to educational escape rooms, a new type of learning activity that utilizes collaborative learning activities to foster creating thinking, communication, teamwork and leadership.1-3 There have been a number of cases in medicine, 4,5 but there have been limited works published on the use of virtual educational escape rooms in residency education.Unfortunately, the COVID pandemic has made participation in an escape room more difficult. In lieu of social distancing during the COVID pandemic, participation in a virtual escape room is an effective and flexible learning modality for resident didactics that appears to promote participant satisfaction, competency, learning, and engagement. Educational Objectives: By the end of the activity, learners should be able to:Identify the hazardous chemicals associated with house firesClassify burn injury according to depth, extent and severity based on established standardsRecall the actions to take in response to fire emergencies (R.A.C.E. and P.A.S.S. acronyms)Recall key laboratory features of cyanide and carbon monoxide poisoningsIdentify appropriate management strategies for smoke inhalation injuriesRecite the treatment for cyanide and carbon monoxide poisoningsDescribe the management of the burn injuriesCommunicate and collaborate as a team to arrive at solutions of problemsDisplay task-switching and leadership skills during exerciseEvaluate virtual escape room experience. Educational Methods: Emergent care of burns, a popular and shared topic in both Emergency Medicine and Family Medicine literature, was chosen and educational objectives were developed. The website Deck.Toys was utilized to formulate the escape room along with puzzles around the educational objectives. Students congregated remotely on Zoom, and after instructions, were separated into teams to solve content-specific puzzles in order to escape the room. Teams which solve all the puzzles in the allotted time were considered to have successfully escaped the room. After the allotted time, the faculty led debriefing, and topic discussion occurred. Research Methods: Sixty-three participants composed of residents (24 emergency [EM], 29 family medicine [FM], 4 combined emergency and family medicine [EM/FM]), advanced practice practitioner trainees (2 EM), and faculty member participants (4 FMP) partook in the virtual escape room experience. At the end of the activity, a 17-item survey using Likert-scale questions was embedded in order to obtain feedback regarding satisfaction, engagement, learning, and medical competency in communication, collaboration, task-switching, and leadership skills. Results: Eighteen out of 63 participants filled out the survey. This was the first virtual escape room experience for 94% of the respondents. A majority (88.9%) of respondents enjoyed the virtual escape room, finding it fun, interesting, engaging, and interactive. None of the respondents preferred traditional didactics over the virtual escape room activity, and 72% were either just as or equally as satisfied with virtual compared to in-person escape rooms. Nearly all respondents agreed that the activity encouraged collaboration, communication skills, task-switching, and leadership skills (94.4%, 88.9%, 72.2%, 72.2%, respectively). Discussion: Participation in a virtual escape room is an effective and flexible learning modality for resident didactics that appears to promote learner satisfaction and engagement. The escape room also promoted important competencies encouraged during residency, such as interpersonal and communication skills and practice-based learning and improvement, and is an effective addition to virtual learning tools. Topics: Small group activity, team-building exercise, remote learning, virtual learning, educational games, gamification, medical education, escape room, millennials, student engagement, adult learning theory, emergency medicine residents, family medicine residents, chemicals in house fires, smoke inhalation injuries, burn classification, burn injury management, carbon monoxide poisoning, cyanide poisoning, R.A.C.E. acronym, P.A.S.S. acronym, fluid resuscitation in burn patients, burn referrals.

Using a Resuscitation-Based Simulation Activity to Create an Interprofessional Education Activity for Medical, Nursing, and Pharmacy Students.

Introduction: To achieve high-quality, patient-centered care, teaching programs across health professions must prepare their learners to work in effective teams. We created a simulation activity to formatively assess interprofessional objectives in graduating medical, nursing, and pharmacy students. This simulation also gave learners an opportunity to practice clinical airway resuscitation skills. Methods: The simulation featured a decompensating adult asthmatic with a chief complaint of shortness of breath and a final diagnosis of severe asthma exacerbation and respiratory failure. Students completed a prebrief to formulate a plan and then interacted with a mannequin. Faculty led a debriefing and completed assessments of the team's performance. The students completed a questionnaire assessing their own and the team's performance. Results: Four sessions were held over a 2-year period. A total of 91 graduating students participated in the activity: 33 from Baylor College of Medicine, 26 from University of Houston College of Pharmacy, and 28 from Texas Woman's University Nelda C. Stark College of Nursing. Postsession questionnaire data demonstrated very good overall team performance and good individual performance. Student comments demonstrated an understanding of the importance of teamwork and thoughtful reflection on their own areas for improvement. All students rated the activity as valuable and effective. Multirater assessments of the students found that most met three of the four objectives. Discussion: This activity allows for real-time formative assessment with a focus on roles, communication, and managing difficult situations. The debriefing demonstrates the students' understanding of interprofessional goals in providing effective patient-centered care.

A Critical Disconnect: Residency Selection Factors Lack Correlation With Intern Performance.

BACKGROUND: Emergency medicine (EM) residency programs want to employ a selection process that will rank best possible applicants for admission into the specialty. OBJECTIVE: We tested if application data are associated with resident performance using EM milestone assessments. We hypothesized that a weak correlation would exist between some selection factors and milestone outcomes. METHODS: Utilizing data from 5 collaborating residency programs, a secondary analysis was performed on residents trained from 2013 to 2018. Factors in the model were gender, underrepresented in medicine status, United States Medical Licensing Examination Step 1 and 2 Clinical Knowledge (CK), Alpha Omega Alpha (AOA), grades (EM, medicine, surgery, pediatrics), advanced degree, Standardized Letter of Evaluation global assessment, rank list position, and controls for year assessed and program. The primary outcomes were milestone level achieved in the core competencies. Multivariate linear regression models were fitted for each of the 23 competencies with comparisons made between each model's results. RESULTS: For the most part, academic performance in medical school (Step 1, 2 CK, grades, AOA) was not associated with residency clinical performance on milestones. Isolated correlations were found between specific milestones (eg, higher surgical grade increased wound care score), but most had no correlation with residency performance. CONCLUSIONS: Our study did not find consistent, meaningful correlations between the most common selection factors and milestones at any point in training. This may indicate our current selection process cannot consistently identify the medical students who are most likely to be high performers as residents.

Medical and Physician Assistant Student Competence in Basic Life Support: Opportunities to Improve Cardiopulmonary Resuscitation Training.

INTRODUCTION: Medical and physician assistant (PA) students are often required to have Basic Life Support (BLS) education prior to engaging in patient care. Given the potential role of students in resuscitations, it is imperative to ensure that current BLS training prepares students to provide effective cardiopulmonary resuscitation (CPR). The objective of this study was to assess whether current BLS training produces student providers who can deliver BLS in an American Heart Association (AHA) guideline-adherent manner. METHODS: Students at a US medical school were recruited by convenience sampling. BLS performance immediately following a standard AHA BLS training course was evaluated during a two-minute CPR cycle using manikins. We also collected information on demographics, previous BLS training attendance, perceived comfort in providing CPR, and prior experiences in healthcare and providing or observing CPR. RESULTS: Among 80 participants, we found that compression rate, depth, and inter-compression recoil were AHA guideline-adherent for 90.0%, 68.8%, and 79.3% of total compression time, respectively. Mean hands-off time was also within AHA guidelines. Mean number of unsuccessful ventilations per cycle was 2.2. Additionally, 44.3% of ventilations delivered were of adequate tidal volume, 12.2% were excessive, and 41.0% were inadequate. Past BLS course attendance, prior healthcare certification, and previous provision of real-life CPR were associated with improved performance. CONCLUSION: Following BLS training, medical and PA students met a majority of AHA compressions guidelines, but not ventilations guidelines, for over 70% of CPR cycles. Maintaining compression depth and providing appropriate ventilation volumes represent areas of improvement. Conducting regular practice and involving students in real-life CPR may improve performance.

A Cross-Specialty Examination of Resident Error Disclosure and Communication Skills Using Simulation.

BACKGROUND: Disclosure of medical errors is important to patients and physicians, but formal disclosure training during the graduate medical education curriculum is limited. OBJECTIVE: We examined resident competence related to error disclosure, using standardized patient (SP) ratings of resident communication skills. METHODS: All first-year residents from medicine, radiology, emergency medicine, orthopedic surgery, and neurological surgery completed a 20-minute simulated session in which they were provided background information on a medical error they had made and were asked to disclose the error to an SP acting as a family member. Residents were then debriefed and completed a postscenario questionnaire. The SPs completed an 11-item communication assessment and 3 milestone rating tools on professionalism (PROF-1, PROF-3) and interpersonal and communication skills (ICS-1). RESULTS: Ninety-six residents from a single institution participated toward the end of the intern year. Communication assessment scores ranged from 23% to 100% (mean [SD], 80.6 [17.0]). Mean (SD) milestone ratings across specialties were 2.80 ± 0.92 for PROF-1, 2.48 ± 0.92 for PROF-3, and 2.45 ± 0.92 for ICS-1. One-way analysis of variance revealed no significant differences among specialties on milestone or communication ratings. Residents who accepted personal responsibility for the error (84.55 [14.06]) received significantly higher communication ratings from SPs compared with residents who did not (66.67 [19.52], P < .001). CONCLUSIONS: This SP assessment of error disclosure by first-year residents from multiple specialties was feasible and acceptable. It revealed areas of improvement as well as considerable variation in communication skills and professionalism among residents.

Informing the Revolution: A Needs Assessment of Ultrasound Knowledge and Skills Among Graduating Physician Assistant Students.

PURPOSE: We performed a needs assessment to understand how existing physician assistant (PA) program curricula and clinical training affect students' ultrasound knowledge, skills, and competence and prepare students for performing ultrasound techniques in clinical practice. METHODS: Students graduating from a PA program completed a 23-item questionnaire examining their ultrasound training experiences, their self-assessment of competency, and their demographics. Students also completed a 15-item ultrasound knowledge assessment. RESULTS: Thirty-eight of 39 students (97%) completed the survey. Students received little hands-on ultrasound training, with the most hands-on training being offered during emergency medicine (44.7%), obstetrics and gynecology (42.1%), and inpatient internal medicine (39.5%) rotations. This lack of preparedness was reflected in a mean score of 47.1% (±16.4%) on the ultrasound knowledge assessment. Most students (84.2%) indicated that the ultrasound instruction they received during clinical rotations was insufficient to prepare them for clinical practice, and 84.2% desired a formal ultrasound training program in the PA program curriculum. CONCLUSIONS: Existing PA program curricula are insufficient for developing critical skills related to ultrasonography.

Survey of Individual and Institutional Risk Associated with the Use of Social Media.

INTRODUCTION: Residents and faculty in emergency medicine (EM) residency programs might be unaware of the professional and legal risks associated with the use of social media (SM). The objective of this study was to identify and characterize the types and reported incidence of unprofessional SM behavior by EM residents, faculty, and nurses and the concomitant personal and institutional risks. METHODS: This multi-site study used an 18-question survey tool that was distributed electronically to the leaders of multiple EM residency programs, members of the Council of Emergency Medicine Residency Directors (CORD), and the residents of 14 EM programs during the study period May to June 2013. RESULTS: We received 1,314 responses: 772 from residents and 542 from faculty. Both groups reported encountering high-risk-to-professionalism events (HRTPE) related to SM use by residents and non-resident providers (NRPs), i.e., faculty members and nurses. Residents reported posting of one of the following by a resident peer or nursing colleague: identifiable patient information (26%); or a radiograph, clinical picture or other image (52%). Residents reported posting of images of intoxicated colleagues (84%), inappropriate photographs (66%), and inappropriate posts (73%). Program directors (PDs) reported posting one of the following by NRPs and residents respectively: identifiable patient information (46% and 45%); a radiograph, clinical picture or other image (63% and 58%). PDs reported that NRPs and residents posted images of intoxicated colleagues (64% and 57%), inappropriate photographs (63% and 57%), or inappropriate posts (76% and 67%). The directors also reported that they were aware of or issued reprimands or terminations at least once a year (30% NRPs and 22% residents). Residents were more likely to post photos of their resident peers or nursing colleagues in an intoxicated state than were NRPs (p=0.0004). NRPs were more likely to post inappropriate content (p=0.04) and identifiable patient information (p=0.0004) than were residents. CONCLUSION: EM residents and faculty members cause and encounter HRTPE frequently while using SM; these events present significant risks to the individuals responsible and their associated institution. Awareness of these risks should prompt responsible SM use and consideration of CORD's Social Media Task Force recommendations.

Unintended adverse consequences of electronic health record introduction to a mature universal HIV screening program.

Early HIV detection and treatment decreases morbidity and mortality and reduces high-risk behaviors. Many Emergency Departments (EDs) have HIV screening programs as recommended by the Centers for Disease Control and Prevention. Recent federal legislation includes incentives for electronic health record (EHR) adoption. Our objective was to analyze the impact of conversion to EHR on a mature ED-based HIV screening program. A retrospective pre- and post-EHR implementation cohort study was conducted in a large urban, academic ED. Medical records were reviewed for HIV screening rates from August 2008 through October 2013. On 1 November 2010, a comprehensive EHR system was implemented throughout the hospital. Before EHR implementation, labs were requested by providers by paper orders with HIV-1/2 automatically pre-selected on every form. This universal ordering protocol was not duplicated in the new EHR; rather it required a provider to manually enter the order. Using a chi-squared test, we compared HIV testing in the 6 months before and after EHR implementation; 55,054 patients presented before, and 50,576 after EHR implementation. Age, sex, race, acuity of presenting condition, and HIV seropositivity rates were similar pre- and post-EHR, and there were no major patient or provider changes during this period. Average HIV testing rate was 37.7% of all ED patients pre-, and 22.3% post-EHR, a 41% decline (p < 0.0001), leading to 167 missed new diagnoses after EHR. The rate of HIV screening in the ED decreased after EHR implementation, and could have been improved with more thoughtful inclusion of existing human processes in its design.

Approach to metabolic acidosis in the emergency department.

Acid-base disorders should be considered a process with the goal being to treat the patient and the underlying condition, not the numbers. A good understanding of the normal acid-base regulation in the body, as well as the most common derangements can prepare the emergency physician for this very common disorder that presents on every shift.

Neonatal endocrine emergencies: a primer for the emergency physician.

The resuscitation principles of securing the airway and stabilizing hemodynamics remain the same in any neonatal emergency. However, stabilizing endocrine disorders may prove especially challenging. Several organ systems are affected simultaneously and the clinical presentation can be subtle. Although not all-inclusive, the implementation of newborn screening tests has significantly reduced morbidity and mortality in neonates. Implementing routine screening tests worldwide and improving the accuracy of present tests remains the challenge for healthcare providers. With further study of these disorders and best treatment practices we can provide neonates presenting to the emergency department with the best possible outcomes.

Phenytoin-induced drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome: a case report from the emergency department.

BACKGROUND: Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome is an uncommon but serious hypersensitivity drug reaction most frequently associated with antiepileptics. Clinical manifestations include rash, fever, and visceral organ involvement, most commonly hepatitis. The mortality rate associated with DRESS syndrome is approximately 10%, the majority due to fulminant liver failure. OBJECTIVES: We report one case of phenytoin-induced DRESS syndrome in a patient who presented to the Emergency Department (ED). Our objectives for this case report include: 1) to learn the importance of DRESS syndrome; 2) to recognize the signs and symptoms of DRESS syndrome; 3) to know what diagnostic studies are indicated; and 4) to learn the appropriate treatment. CASE REPORT: We report one case of phenytoin-induced DRESS syndrome in a 34-year-old man, previously on phenytoin for seizure prophylaxis, who presented to the ED with 5 days of worsening symptoms including generalized rash, fever, tongue swelling, and dysphagia. Laboratory results revealed an eosinophilia and elevated liver enzymes. With initiation of steroids, the transaminitis improved despite increasing eosinophilia and development of an atypical lymphocytosis. Fever and angioedema resolved with improvement of the rash, and the patient was discharged on hospital day 3. CONCLUSION: Given the significant mortality related to DRESS syndrome, ED staff should have a low threshold for suspecting the condition in patients who present with unusual complaints and skin findings after starting any antiepileptic drug. Early diagnosis and prompt treatment with corticosteroids is imperative.